Melanie Rusch

Mapping violence and policing as an environmental-structural barrier to health service and syringe availability among substance-using women in street-level sex work

BACKGROUND Within street-based sex work and substance-using populations, there is growing evidence to support the role of place, both physical setting and social meanings attached to place, in mediating the effectiveness and reach of health and harm reduction services. METHODS Social mapping was used to explore how health service and syringe availability may be impacted at the geographic level by avoidance of physical settings due to violence and policing among women in street-level sex work. Through a community-based research partnership and extensive peer-led outreach over a 6-month period, women were invited to participate in interview-questionnaires and mapping of their community, working conditions, and access to resources. Results were compiled used ArcGIS software and GIS street maps. In secondary analysis, logistic regression was used to model the geographic association (using likelihood ratio and significance at p<0.05) and stratified models were run to assess differential patterns of avoidance based on age, ethnicity and drug use. RESULTS The findings reveal a significant geographic relationship between a heavily concentrated core area of health and syringe availability and avoidance of physical settings due to violence and policing by 198 women in street-level sex work in Vancouver, Canada. Of particular concern, this correlation is significantly elevated among younger and Aboriginal women, active injection drug users, and daily crack cocaine smokers, suggesting significant environmental-structural barriers to interventions among these vulnerable populations. CONCLUSIONS The resultant displacement of sex work to primarily industrial settings and side streets pushes women further from health and social supports and reduces access to safer injection and drug use paraphernalia. This study offers important evidence for environmental-structural level prevention and safer environment interventions, supported by legal reforms, that facilitate safer sex work environments, including spatial programming, peer-based prevention, outreach and mobile resources, and peer-supervised safer sex work settings.

Impairments, activity limitations and participation restrictions: Prevalence and associations among persons living with HIV/AIDS in British Columbia

BackgroundTo measure the prevalence of and associations among impairments, activity limitations and participation restrictions in persons living with HIV in British Columbia to inform support and care programs, policy and research.MethodsA cross-sectional population-based sample of persons living with HIV in British Columbia was obtained through an anonymous survey sent to members of the British Columbia Persons With AIDS Society. The survey addressed the experience of physical and mental impairments, and the experience and level of activity limitations and participation restrictions. Associations were measured in three ways: 1) impact of types of impairment on social restriction; 2) impact of specific limitations on social restriction; and 3) independent association of overall impairments and limitations on restriction levels. Logistic regression was used to measure associations with social restriction, while ordinal logistic regression was used to measure associations with a three-category measure of restriction level.ResultsThe survey was returned by 762 (50.5%) of the BCPWA participants. Over ninety percent of the population experienced one or more impairments, with one-third reporting over ten. Prevalence of activity limitations and participation restrictions was 80.4% and 93.2%, respectively. The presence of social restrictions was most closely associated with mental function impairments (OR: 7.0 for impairment vs. no impairment; 95% CI: 4.7 – 10.4). All limitations were associated with social restriction. Among those with ≤ 200 CD4 cells/mm3, odds of being at a higher restriction level were lower among those on antiretrovirals (OR: 0.3 for antiretrovirals vs. no antiretrovirals; 95% CI: 0.1–0.9), while odds of higher restriction were increased with higher limitation (OR: 3.6 for limitation score of 1–5 vs. no limitation, 95%CI: 0.9–14.2; OR: 24.7 for limitation score > 5 vs. no limitation, 95%CI: 4.9–125.0). Among those with > 200 CD4 cells/mm3, the odds of higher restriction were increased with higher limitation (OR: 2.7 for limitation score of 1–5 vs. no limitation, 95%CI: 1.4–5.1; OR: 8.6 for limitation score > 5 vs. no limitation, 95%CI: 3.9–18.8), as well as by additional number of impairments (OR:1.2 for every additional impairment; 95% CI:1.1–1.3).ConclusionsThis population-based sample of people living with HIV has been experiencing extremely high rates of impairments, activity limitations and participation restrictions. Furthermore, the complex inter-relationships identified amongst the levels reveal lessons for programming, policy and research in terms of the factors that contribute most to a higher quality of life.

Unprotected anal intercourse associated with recreational drug use among young men who have sex with men depends on partner type and intercourse role.

Objective: The objective of this study was to measure associations of unprotected anal intercourse (UAI) and substance use by sexual partner (regular vs. casual) and role [insertive (I) vs. receptive (R)]. Goal: The goal of this study was to identify determinants of the association of specific drugs and UAI. Study: We conducted a prospective study of young men who have sex with men (MSM), 1997–2002. Odds ratios (ORs) for association of substance use and UAI during the previous year were adjusted for age and calendar year. Results: UAI was significantly associated with sexual situation-specific use of marijuana (OR, 1.43), crystal methamphetamine (OR, 1.75), ecstasy (OR, 1.88), and ketamine (OR, 2.17); global use associations were similar. Situation-specific associations with alcohol (OR, 1.93) and &ggr;-hydroxybutyrate (GHB; OR, 1.98) were not seen with global measures. GHB and ketamine were specifically associated with IUAI with regular partners, and methamphetamine with RUAI with casual partners. Conclusion: Type of drug use measure, partner, and role are important determinants of the association of specific substances and UAI.

Associations between Migrant status and sexually transmitted infections among female sex workers in Tijuana, Mexico

Objective: To examine associations between migration and sexually transmitted infection (STI) prevalence among Mexican female sex workers (FSW). Methods: FSW aged 18 years and older in Tijuana, Baja California (BC) underwent interviews and testing for HIV, syphilis, gonorrhoea and chlamydia. Multivariate logistic regressions identified correlates of STI. Results: Of 471 FSW, 79% were migrants to BC. Among migrant FSW, prevalence of HIV, syphilis, gonorrhoea, chlamydia and any STI was 6.6%, 13.2%, 7.8%, 16.3% and 31.1% compared with 10.9%, 18.2%, 13.0%, 19.0% and 42.4% among FSW born in BC. A greater proportion of migrant FSW were registered with local health services and were ever tested for HIV. Migrant status was protective for any STI in unadjusted models (unadjusted odds ratio 0.61, 95% CI 0.39 to 0.97). In multivariate models controlling for confounders, migrant status was not associated with an elevated odds of STI acquisition and trended towards a protective association. Conclusions: Unexpectedly, migrant status (vs native-born status) appeared protective for any STI acquisition. It is unclear which social or economic conditions may protect against STI and whether these erode over time in migrants. Additional research is needed to inform our understanding of whether or how geography, variations in health capital, or social network composition and information-sharing attributes can contribute to health protective behaviours in migrant FSW. By capitalising on such mechanisms, efforts to preserve protective health behaviours in migrant FSW will help control STI in the population and may lead to the identification of strategies that are generalisable to other FSW.

HIV and HCV prevalence and gender-specific risk profiles of crack cocaine smokers and dual users of injection drugs.

The present analysis compares HIV and HCV prevalence and associated gender-specific risk patterns of dual users (i.e., crack smokers who inject drugs) and never injectors. Two logistic models, one restricted to female and the other to male crack smokers, were constructed to identify gender-specific risk factors associated with dual use (p < 0.05). Of 437 crack smokers, 246 (56%) were dual users while 191 (44%) were never injectors. In a fitted logistic regression model, dual use among female crack smokers was associated with HCV infection (adjusted OR = 4.65, 95% CI: 1.92–9.70), exchanging sex for money, drugs, or shelter while using crack (aOR = 4.47, 95% CI: 1.56–12.80), having a casual partner who injects (aOR = 4.13, 95% CI: 1.05–16.26), having equipment broken or confiscated by police without being arrested (aOR = 3.66, 95% CI: 1.43–9.34), and HIV infection (aOR = 2.07, 95% CI: 1.18–5.96). Among male crack smokers, dual use was associated with HCV infection (aOR = 5.34, 95% CI: 2.10–13.18), exchanging sex for money, drugs, or shelter (aOR = 3.25, 95% CI: 1.59–6.65), crack use history ≥ 5 years (aOR = 2.16, 95% CI: 1.29–3.63), and smoking in a group of unknown people (such as crack houses, alleys; aOR = 1.70, 95% CI: 1.10–2.81). These findings highlight the need for evidence-based prevention and harm reduction initiatives that directly targeting crack cocaine smokers, with particular attention given to female dual users of injection drugs.

Nonadherence increases the risk of hospitalization among HIV-infected antiretroviral naive patients started on HAART.

Background. Since the advent of highly active antiretroviral therapy (HAART), AIDS-related hospitalizations have decreased. The objective of this study was to assess the impact of adherence on hospitalization among antiretroviral-naïve HIV-infected persons initiating HAART. Methods. Analysis was based on a cohort of individuals initiating HAART between 1996 and 2001. The primary outcome was hospitalization for one or more days. Survival methods were used to assess the impact of adherence on hospitalization. Results. Of 1605 eligible participants, 672 (42%) were hospitalized for one or more days after initiating HAART. Median adherence levels were 92 (IQR: 58, 100) and 100 (IQR: 83, 100) among those ever and never hospitalized, respectively. After controlling for confounders, those with <95% adherence had 1.88 times (95% CI: 1.60, 2.21) higher risk for hospitalization. Conclusions. Suboptimal adherence among HIV-infected patients taking HAART predicts hospitalization. Identifying and addressing factors contributing to poor adherence early in treatment could improve patient care and lower hospitalization costs.

Distribution of sexually transmitted diseases and risk factors by work locations among female sex workers in Tijuana, Mexico.

Background: Sex work is regulated in the Zona Roja (red light district) in Tijuana, Mexico, where HIV and sexually transmitted disease (STD) prevalence is high among female sex workers (FSWs). We examined the spatial distribution of STDs by work venue among FSWs in Tijuana. Methods: FSWs aged 18 years and older who reported unprotected sex with ≥1 client in the past 2 months underwent testing for HIV, syphilis, gonorrhea, and Chlamydia. HIV/STDs were mapped by venue (i.e., bar, hotel) and Getis-Ord Gi statistics were used to identify geographic hotspots. High-risk venues were then identified using a standardized STD ratio (high risk defined as a ratio ≥1.25). Logistic regression was used to assess correlates of working at a high risk venue. Results: Of 474 FSWs, 176 (36.4%) had at least 1 bacterial sexually transmitted infection (STI); 36 (7.6%) were HIV-positive. Within the Zona Roja, 1 venue was identified as a geographic “hotspot,” with a higher than expected number of HIV/STD-positive FSW (P < 0.05) as compared to neighboring venues. Using the STD ratio definition, 11 venues were identified as high-risk; FSWs working in these locations had higher education, were more likely to report always using drugs with sex, and having mostly US clients. They were less likely to be registered FSWs or to live at their work venue. Conclusions: A relatively few number of sex work venues accounted for a large proportion of the HIV/STI burden among FSWs in Tijuana. Structural interventions that focus on sex work venues could help increase STI diagnosis, prevention, and treatment among FSWs in Tijuana.

Spatial Epidemiology of HIV among Injection Drug Users in Tijuana, Mexico

The northwest border city of Tijuana is Mexicos fifth largest and is experiencing burgeoning drug use and human immunodeficiency virus (HIV) epidemics. Because local geography influences disease risk, we explored the spatial distribution of HIV among injection drug users (IDUs). From 2006–2007, 1,056 IDUs were recruited using respondent-driven sampling and then followed for eighteen months. Participants underwent semiannual surveys, mapping, and testing for HIV, tuberculosis, and syphilis. Using average nearest neighbor and Getis-Ord Gi* statistics, locations where participants lived, worked, bought drugs, and injected drugs were compared with HIV status and environmental and behavioral factors. Median age was thirty-seven years; 85 percent were male. Females had higher HIV prevalence than males (10.2 percent vs. 3.4 percent; p = 0.001). HIV cases at baseline (n = 47) most strongly clustered by drug injection sites (Z score = –6.173, p < 0.001), with a 16-km2 hotspot near the Mexico–U.S. border, encompassing the red-light district. Spatial correlates of HIV included syphilis infection, female gender, younger age, increased hours on the street per day, and higher number of injection partners. Almost all HIV seroconverters injected within a 2.5-block radius of each other immediately prior to seroconversion. Only history of syphilis infection and female gender were strongly associated with HIV in the area where incident cases injected. Directional trends suggested a largely static epidemic until July through December 2008, when HIV spread to the southeast, possibly related to intensified violence and policing that spiked in the latter half of 2008. Although clustering allows for targeting interventions, the dynamic nature of epidemics suggests the importance of mobile treatment and harm reduction programs.

Prevalence of Activity Limitation Among Persons Living with HIV/AIDS in British Columbia

BACKGROUND As antiretrovirals increase the life expectancy of persons living with HIV, quality of life issues become more important. Little research has examined the types and levels of activity limitations among HIV-positive populations. The objective of this report is to compare the levels of limitations among HIV-positive persons to the general population. METHODS The BC Persons With AIDS (BCPWA) Society consists of approximately 3,500 HIV-positive members. A recent survey conducted among BCPWA members included a section assessing activity limitations. Prevalence of limitations in this group was compared to the general population of BC using the National Population Health Survey (NPHS) to calculate standardized prevalence ratios (SPR). RESULTS Compared to the general BC population, BCPWA members were more likely to be male, aged over 30 years, not to have graduated from high school, unemployed, living alone and having a household income less than

Changes in prevalence of girl child marriage in South Asia.

10,000 per year. The SPR for activity limitations among male participants applying the rates of limitation among the general population of BC was 9.4 (8.4-10.6). The SPR for women was 9.9 (7.2-11.1). Using an NPHS rate restricted to individuals who reported a chronic condition, the SPR for males was 6.0 (5.9-6.5) and for females was 7.0 (5.8-8.2). INTERPRETATION Limitations on activity are prevalent, even when comparing those with high CD4 counts and restricting the standard to those with chronic conditions. These findings suggest that implementation of programs offering support with everyday tasks would be of value in this population.