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.

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.

An examination of illicit drug use and sexual risk behaviours among a cohort of street-involved youth in Vancouver

Injection drug use has significant health consequences, including high rates of HIV and hepatitis C transmission. These problems have been exacerbated in recent years by the use of crystal methamphetamine (commonly called crystal meth), particularly in BC. Methamphetamine use is becoming increasingly common among marginalized youth, particularly those whose social and economic environment is the street. It is estimated there are between 45,000 to 150,000 street-involved youth in Canada, most of whom live in the large urban centres of Toronto, Montreal and Vancouver. Illicit drug use and unsafe sexual practices, including unprotected sex and sex trade work, increase susceptibility to HIV infection among street-involved youth. Brandon Marshall is one of the few researchers investigating the relationship between illicit drug use and sexual risk behaviours among street-involved youth. Using data collected from the B.C. Centre for Excellence in HIV/AIDS At-Risk Youth Study, he will examine how different social, structural, and environmental factors impact sexual practices. Specific factors include the age of first sexual experience, sexual orientation, illicit drug use, sexual relationships with older partners, access to health services, and involvement in the Downtown Eastside community of Vancouver, where drug use and poverty are prominent. This research will improve our understanding of illicit drug use and sexual activity in marginalized youth and will play an important role in developing sexual health education and prevention programs for youth at-risk.