Towards evidence-based public health for sex workers in British Columbia

Youth and women working in Vancouver’s sex industry are among the most marginalized and vulnerable in Canadian society. The persistently high rates of health-related issues, violence, and mortality among sex workers, both in Canada and globally, highlights a desperate need for renewed public health interventions targeting the reduction of harms in this industry. Dr. Kate Shannon is working to investigate the different factors influencing the health and safety of youth and women working in the sex industry in Vancouver. Her team is studying the social (violence, work conditions) and structural (laws, regulations, urban renewal) contexts of sexually transmitted infection (STI) in this population. Specifically, her team is examining the different factors that influence the worker’s negotiating power during transactions and how this influences the risk of HIV/STI acquisition. Her research will involve the study and long-term follow-up of two groups of women: (1) 500 existing and new adult women working in both the street and indoor sex industry; and (2) 250 female youth aged 14 to 20 years who have exchanged sex for money, drugs, gifts, shelter, or other commodities in the previous 30 days. By evaluating and integrating different types of data, including individual mapping and neighborhood environment data (including violence and housing) from publicly available sources, she hopes to identify policies and harm-reducing interventions for this population. This study is among the first prospective studies of sex work in North America. Dr. Shannon’s team possesses a wealth of expertise in observational and intervention research, policy, and sex work. They are uniquely positioned to conduct this study, which aims to directly improve the health of some of the most marginalized youth and women in Canadian society.

Impact of structural and environmental factors on risk for HIV/sexually transmitted infections and barriers to accessing prevention, treatment and care among women involved in sex work

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.

An ethno-epidemiological investigation of social and environmental contexts of HIV vulnerability among injection drug users

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.

Place and experiences of risk among young drug users in downtown Vancouver

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.

Examining the interplay between adherence and antiretroviral treatment on disease outcomes over time in HIV/AIDS-infected patients

HIV therapy has evolved tremendously due to the development of new drugs, new technologies to measure viral response and drug resistance, and an improved understanding of how the virus progresses in the body. Modern highly active antiretroviral therapies (HAART) suppress the amount of virus circulating in the blood to nearly undetectable levels for long periods, enabling the immune system to rebound, reducing HIV drug resistance and preventing this otherwise fatal disease from progressing. Clinicians have identified that many people on HAART therapies do not fully adhere to the prescribed therapy, and that their level of adherence typically changes over time. This lack of adherence is known to increase the risk of illness and death, but the specifics remain unclear. More information is needed to determine how adherence dynamically affects disease progression and outcomes, so those at higher risk of treatment failure can be identified in advance and helped with their treatment. Dr. Viviane Lima is exploring the relationship between regimen-specific adherence for key HAART therapies and the disease outcomes for patients. She will determine the levels of adherence required at each stage to reduce or prevent a number of disease outcomes: viral rebound, immune cell loss, HIV drug resistance, the emergence of AIDS-related conditions, and death. She hypothesizes that for each disease outcome, there is a distinct, clinically-significant interaction between adherence and type of HAART therapy. Long-term management of HIV/AIDS requires a long-term commitment from patients to adhere to therapy, a high level of expertise among practitioners to deal with complex and rapidly evolving treatments, and the development of clinically meaningful tools to enhance adherence over time and across varied treatments. Lima’s study will provide an evidence base to identify best treatment practices.

Exploring the social structural dynamics of health barriers and determinants of women in Vancouver's survival sex trade: an ethnographic study

A decade ago, HIV infection among downtown eastside residents exceeded those in any other part of the “developed” world. Current neighbourhood HIV prevalence estimates range between 19 and 22 per cent, and is reported higher amongst individuals who inject drugs. Risk of HIV infection is particularly profound for women who are young, coping with violence and multiple addictions, and whose survival necessitates work in the commercial sex industry. Women and girls are politically, socially and biologically more vulnerable to HIV infection. Many women in the community, including the majority of those who are part of the sex work economy, do access various health and social services, such as clinics, point-of-care and emergency services, as well as needle exchange programs. The use of condoms is also prevalent. Despite this, the rates of HIV infection remain high, particularly among sex workers who are also less likely to be treated for HIV/AIDS. Regardless of income generating strategies, HIV infected women in the community face multiple barriers to continuity of care. Suze Berkhout was previously funded by MSFHR for her early PhD work in HIV risk behaviours and health service needs among women in Vancouver’s inner city. Employing qualitative research methods and philosophical analysis, her research critically examines the impact of common stereotypes, life histories, and institutional norms and values on women’s health care experiences, in order to unravel the paradox surrounding the health and well-being of vulnerable women. Rather than suggest that women who appear to systematically “”choose”” poor health are irrational or irresponsible, Berkhout’s study seeks to understand what health trade-offs women may make in the context of their lives. For example, day-to-day concerns such as housing, food or caring for others may take precedence over health concerns. Likewise, women’s previous experiences in the health system may themselves perpetuate mistrust toward health providers, leading to delays and discontinuation of medical care. Berkhout’s findings will enable health care providers to better reflect on and respond to the experiences of patients within the health care system. Ultimately, her work could lead to more appropriate and responsive care for socially and economically disadvantaged women.

Optimizing the impact of antiretroviral treatment as an HIV prevention intervention in marginalized populations

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.

An investigation of the impact of crystal methamphetamine use on sexual and injection-related risk behaviour among street youth and injection drug users in Vancouver

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.

Assessing the impacts of social, sexual and drug-use networks on HIV-positive Aboriginals receiving highly active anti-retroviral therapy (HAART) in British Columbia

58,000 people live with HIV/AIDS in Canada. British Columbia houses 20% of national infections. The BC Centre for Excellence in HIV/AIDS (BCCfE) estimates that there are 2,000 HIV+ people in BC who are eligible for HIV treatment and not accessing it, either because they are unaware of their infection or not appropriately linked to care. It is believed that a large percentage of these individuals may be Aboriginal, given their disproportionate risk of acquiring HIV, and limited access to treatment. As HAART access is expanded to HIV-positive communities throughout BC, additional research is necessary to understand Aboriginal risk factors for acquiring HIV, to explain their limited access to HIV treatment and care, and to understand their elevated mortality while receiving HAART. Overall, my PhD research seeks to answer the question: How do social, sexual and drug-using networks influence Aboriginal risk for HIV acquisition, HIV treatment access and HAART outcomes. I will explore three hypotheses: 1) Socio-demographic and economic status, injection drug use and risky sexual behavior, are primary risk factors for HIV infection among Aboriginals in BC; 2) Socio-cultural beliefs and drug addiction perpetuate limited treatment access among Aboriginals in BC; 3) Lifestyle issues influence poor treatment outcomes among Aboriginals on HAART in BC. I intend to employ social, sexual and drug-use networking techniques that have been pre-validated for HIV/AIDS epidemiological study. An initial pool of consenting HIV-positive Aboriginal adults on HAART (n=30) will be asked to recruit up to 10 people from their sexual and/or drug use network, defined as someone with whom they have had sex and/or done injection drugs with, within the preceding 2 months. A maximum of 300 participants will be recruited through this technique (n=300). Mathematical modelling techniques will be used to analyze the impacts of sexual and drug use networks on Aboriginals’ HIV risk behavior, treatmenta access and treatment outcomes. This research will be coordinated from the British Columbia Centre for Excellence in HIV/AIDS, and carried out at the Vancouver Native Health Society.

Investigating syringe-sharing among at-risk youth, and analyzing coverage of and access to youth-targeted needle exchange programs

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.