Research Location: BC Centre for Excellence in HIV/AIDS

Sex workers in Vancouver have been found to be highly vulnerable to a variety of negative health and safety outcomes, including high rates of occupational and historical violence, a high prevalence of HIV (approximately 25 percent within street-based sex workers in Vancouver), and limited access and use of health services. In order to mitigate some of the HIV and sexually transmitted infection (STI) risk in this population, researchers at the Gender and Sexual Health Initiative at the BC Centre for Excellence in HIV/AIDS are looking into understanding some of the larger structural and environmental determinants of HIV/STI risk. Dr. Kathleen Deering is studying a sample of sex workers in Metropolitan Vancouver to investigate the intersecting relationships between different social, environmental and structural factors, such as the availability and access to health services, neighbourhood of residence, and locations and venues of sex work. She will be measuring health and safety outcomes of these women (such as HIV/STI risks, including inconsistent condom use, number of sex partners and sex partnering patterns, and occupational and intimate partner violence) and the geographic distribution of these outcomes over time. This project will access data from a five-year longitudinal cohort of women in sex work in Vancouver, including 500 women and 250 youth sex workers who are 14 to 24 years of age. Participants will fill out a detailed survey and be asked to provide blood and urine samples for HIV and STI testing at the start and every six months for the five-year duration of the study. Dr. Deering will be using these data, combined with social epidemiology methods and Geographic Information Systems (GIS) mapping technology to help understand how social, structural and environmental factors impact risk patterns for HIV/STI and health services use and access. She will also be exploring the use of complex adaptive systems approaches as a novel and key methodological/analytical approach for examining multiple intersecting levels of risk. The results of this research will lead to important recommendations relating to changes in public health policy and the development of effective safer-environment interventions to improve the health and safety of women in sex work in Canadian settings. Results will be communicated to community members, the local and provincial government, and the study population through ongoing partnerships.

Illicit drug use is associated with severe harms and immense social suffering among youth. Previous ethnographic work has shown how social-structural and cultural processes present within specific urban locales intersect to push young people who engage in drug use towards ‘risk’, until it becomes difficult or impossible for them to avoid transitioning into increasingly ‘risky’ behaviours. However, there have been relatively few in-depth investigations of drug-using contexts or ‘scenes’ that focus exclusively on the meanings, understandings and everyday lived experiences of young drug users themselves. Danya Fast’s research explores young people’s understandings of the social-structural and physical landscapes of the downtown Vancouver drug scene, and how various locales (e.g. neighbourhoods, alleyways, service locations, residences), shape experiences of ‘safety’ and ‘risk’ among drug-using youth. Her approach emphasizes the influence of place on health, where place is understood to encompass both physical and social spaces. An important goal of this research will be the identification of elements in the physical and social environment that shape risk and structural interventions that alter context and, by consequence, facilitate safer spaces for work, rest and recreation for youth. Ms. Fast’s project will result in a more comprehensive and culturally sensitive account of young drug users’ everyday experiences in the context of the downtown Vancouver drug scene, and will also be used to inform ongoing epidemiological research with drug-using youth. Moreover, Ms. Fast’s project will contribute to the development of an ongoing ethno-epidemiological research program that has been identified as an important emergent area within Human Immunodeficiency Virus research, due to its unique ability to inform the development of interventions designed to reduce drug-related harms.

Outside of Africa, an estimated two-thirds of new Human Immunodeficiency virus (HIV), infections are believed to occur among people who inject illicit drugs. While an urgent need exists for tailored interventions to address HIV risk behaviour within vulnerable groups such as adult injection drug users (IDU), there are major knowledge gaps that must first be addressed if interventions are to be successful. Innovative approaches to examine how participation in particular social contexts and environments foster vulnerability to HIV are crucial to the development of effective intervention strategies among highly vulnerable populations of IDUs. William Small is conducting research to address this need using ethnographic methods to develop empirical information regarding transitions into particular high-risk social contexts, including drug markets and sex trade activities. Specifically, his research focuses on the risk environments in two different geographical settings, Vancouver, Canada and Sydney, Australia. The results will provide critical insight regarding how participation in these high-risk settings influences HIV risks as well as an individual’s ability to engage in risk reduction in the context of injection drug use. The information will be integrated with findings from ongoing epidemiological studies in the same locales to test socially-oriented hypotheses regarding the relationship between HIV vulnerabilities and particular social contexts. Ultimately, the findings from Mr. Smalls’ research will help advance the study of HIV risks among IDUs, and inform the development of social and community interventions designed to reduce HIV transmission.

It is estimated that 269,000 Canadians have injected drugs in the past year; statistics reveal that almost 20 per cent of all newly-recorded HIV infections are associated with injection drug use. High risk behaviours associated with injection drug use have made injection drug user populations especially vulnerable to HIV infection. This is particularly evident in Vancouver’s Downtown Eastside, which has experienced an explosive HIV epidemic among local injection drug users. For several years, this neighbourhood has felt the effects of new developments squeezing out older, low-income housing. This ongoing revitalization of Canada’s poorest postal code will soon be coupled with the upcoming 2010 Olympics. It is also expected that targeted policy interventions will be initiated to reduce the appearance of public disorder, particularly open illicit drug scenes. The implications for current residents are significant. The coming years have the potential to bring a massive displacement of injection drug users out of the Downtown Eastside, away from where most of their health and social services are currently situated. Kora DeBeck is monitoring how public policy changes related to urban revitalization affect risky behaviours and health among injection drug users. She is analyzing data from established cohort studies, which currently follow more than 2,000 injection drug users. Not only will DeBeck’s work help local policy makers respond to changing health service needs within Vancouver, it will also inform other cities experiencing similar urban transitions.

Street youth often carry a heavy burden: trauma, sexual and physical violence, lack of education, homelessness, and mental illness all contribute to the difficulties that many young street people face. Studies have shown that street youth are also one of the groups at most risk of progressing from non-injection drug use to injection drug use, including crystal methamphetamine use. Because they often engage in high-risk sexual activities and drug use, street youth are also particularly susceptible to being infected with and spreading blood-borne diseases like HIV and Hepatitis C. Young women in this group, some of whom are involved in the sex trade, are at particularly high risk of contracting these diseases. Health authorities in Vancouver have recognized this problem and responded by expanding and decentralizing needle exchange programs that target street youth. However, little is currently known about the effect that these programs have had on the risk behaviours and drug use patterns of street-based youth. Given that street youth who inject are often hard to reach, there are concerns that this population may not have adequate access to critical HIV prevention programs such as needle exchange. Daniel Werb is investigating the factors associated with syringe sharing among street youth, such as crystal methamphetamine use, unstable housing, involvement in sex trade work, historical sexual abuse, and depression. He will also investigate the reach of youth-oriented needle exchange programs in Vancouver and determine their effectiveness in harm reduction. Werb’s findings will help health authorities understand this at-risk population better, and contribute to the development of effective programs that support the health of street youth who inject drugs.

Illicit drug use is a major public health concern in British Columbia, most notably the high rates of HIV and Hepatitis C transmission among injection drug users. Additionally, in Vancouver and elsewhere in British Columbia, there is concern regarding escalating rates of crystal methamphetamine (CM) use. The prevalence of CM use is rising internationally, and has been associated with unsafe sexual and injecting practices among specific subpopulations at risk for HIV. However, the potential associations between CM use and sexual and injection-related risk behaviour among marginalized populations in Vancouver have not been thoroughly investigated. Brandon Marshall was previously funded by MSFHR for his Master’s work studying the interactions between drug use and sexual risk behaviour among street youth in Vancouver. He is now continuing his examination of a number of social, environmental, and structural factors that predict frequent CM use and subsequent health-related harms among young injection drug users. He hypothesizes that social disadvantage, impoverished living conditions, frequent exposure to law enforcement, and poor access to health and harm reduction services will be associated with higher frequency and intensity of CM use. This research will help inform evidence-based public health policy and interventions for marginalized populations. Marshall’s findings may be used to develop strategies that seek to reduce the harms associated with CM use, prevent further transmission of HIV and Hepatitis C, and provide better support for youth and injection drug users who are already infected.

The introduction in the mid-1990s of highly active antiretroviral therapy (HAART) helped HIV become a manageable disease in industrialized settings such as Canada. Mortality and morbidity associated with HIV have been dramatically reduced with the increased use of these drug regimens and are associated with reduced transmission probability of HIV within sexual relationships. It has been proposed that HAART be integrated into HIV-prevention activities as a means of helping curb epidemic growth. Evaluating the impact of HAART is complex. For example, while the effect of reduced symptoms and increased lifespan is beneficial to the individual, modelling studies have shown that unless infectiousness of individuals is sufficiently reduced by antiretrovirals, the negative impact of an increased incubation period (leading to increased number of opportunities for transmitting infection and a larger population of transmitters) can actually increase how fast the infection spreads. Using mathemathical modelling methods, Kathleen Deering is comparing the impacts of HAART in Vancouver (where HIV-infected individuals have free access to treatment), and in southwest India (where only about 10 per cent of HIV-infected people have access). Her studies, which consider infection biology, behavioural and demographic characteristics of the population, and the spread of infection over time, will be used to compare different treatment strategies for HAART, and to project disease outcomes. Deering’s research will provide evidence for developing HIV treatment and care recommendations that will help maximize the effectiveness of HAART among marginalized groups in Canada and India.