HIV incidence among street youth in Montreal, Canada

Enabling Adherence to Treatment (EAT): a pilot study of a combination intervention to improve HIV treatment outcomes among street-connected individuals in western Kenya

BACKGROUND

Street-connected individuals (SCI) in Kenya experience barriers to accessing HIV care. This pilot study provides proof-of-concept for Enabling Adherence to Treatment (EAT), a combination intervention providing modified directly observed therapy (mDOT), daily meals, and peer navigation services to SCI living with HIV or requiring therapy for other conditions (e.g. tuberculosis). The goal of the EAT intervention was to improve engagement in HIV care and viral suppression among SCI living with HIV in an urban setting in Kenya.

METHODS

This pilot study used a single group, pre/post-test design, and enrolled a convenience sample of self-identified SCI of any age. Participants were able to access free hot meals, peer navigation services, and mDOT 6 days per week. We carried out descriptive statistics to characterize participants' engagement in EAT and HIV treatment outcomes. We used McNemar's chi-square test to calculate unadjusted differences in HIV outcomes pre- and post-intervention among participants enrolled in HIV care prior to EAT. We compared unadjusted time to initiation of antiretroviral therapy (ART) and first episode of viral load (VL) suppression among participants enrolled in HIV care prior to EAT vs. concurrently with EAT using the Wilcoxon rank sum test. Statistical significance was defined as p < 0.05. We calculated total, fixed, and variable costs of the intervention.

RESULTS

Between July 2018 and February 2020, EAT enrolled 87 participants: 46 (53%) female and 75 (86%) living with HIV. At baseline, 60 out of 75 participants living with HIV (80%) had previously enrolled in HIV care. Out of 60, 56 (93%) had initiated ART, 44 (73%) were active in care, and 25 (42%) were virally suppressed (VL < 1000 copies/mL) at their last VL measure in the 19 months before EAT. After 19 months of follow-up, all 75 participants living with HIV had enrolled in HIV care and initiated ART, 65 (87%) were active in care, and 44 (59%) were virally suppressed at their last VL measure. Among the participants who were enrolled in HIV care before EAT, there was a significant increase in the proportion who were active in HIV care and virally suppressed at their last VL measure during EAT enrollment compared to before EAT enrollment. Participants who enrolled in HIV care concurrently with EAT had a significantly shorter time to initiation of ART and first episode of viral suppression compared to participants who enrolled in HIV care prior to EAT. The total cost of the intervention over 19 months was USD $57,448.64. Fixed costs were USD $3623.04 and variable costs were USD $63.75/month/participant.

CONCLUSIONS

This pilot study provided proof of concept that EAT, a combination intervention providing mDOT, food, and peer navigation services, was feasible to implement and may support engagement in HIV care and achievement of viral suppression among SCI living with HIV in an urban setting in Kenya. Future work should focus on controlled trials of EAT, assessments of feasibility in other contexts, and cost-effectiveness studies.

Causes of death among street-connected children and youth in Eldoret, Kenya

BACKGROUND

Street-connected young people carry a disproportionate burden of morbidities, and engage in a variety of practices that may heighten their risk of premature mortality, yet there are currently no reports in the literature on the rates or risk factors for mortality among them, nor on their causes of death. In low- and middle-income countries they are frequently in situations that violate their human rights, likely contributing to their increased burden of morbidities and vulnerability to mortality. We thus sought to describe the number of deaths annually, causes of death, and determine the number of deaths attributable to HIV among street-connected young people aged 0 to 30 years in Eldoret, Kenya.

METHODS

Eldoret, Kenya has approximately 1900 street-connected young people. We collected data on deaths occurring from October 2009 to December 2016 from Moi Teaching and Referral Hospital records, Academic Model Providing Access to Healthcare HIV program records, and utilized verbal autopsies when no records were available. Descriptive analyses were conducted stratified by sex and age category, and frequencies and proportions were calculated to provide an overview of the decedents. We used logistic regression to assess the association between underlying cause of death and sex, while controlling for age and location of death.

RESULTS

In total there were 100-recorded deaths, 66 among males and 34 among females; 37% of were among those aged ≤18 years. HIV/AIDS (37%) was the most common underlying cause of death, followed by assault (36%) and accidents (10%) for all decedents. Among males, the majority of deaths were attributable to assault (49%) and HIV/AIDS (26%), while females primarily died due to HIV/AIDS (59%).

CONCLUSION

Our results demonstrate a high number of deaths due to assault among males and HIV/AIDS among males and females. Our findings demonstrate the need for studies of HIV prevalence and incidence among this population to characterize the burden of HIV, particularly among young women given the higher number of deaths attributed to HIV/AIDS among them. Most deaths were preventable and require the urgent attention of service providers and policymakers to implement programs and services to prevent premature mortality and uphold children's rights.

Social-structural factors influencing periods of injection cessation among marginalized youth who inject drugs in Vancouver, Canada: an ethno-epidemiological study

BACKGROUND

Injection drug use is associated with HIV and hepatitis C transmission, overdose, and other preventable harms. These harms are heightened for structurally vulnerable injection drug-using populations, as their social conditions pose barriers to safer injecting. Previous research on injection cessation has largely focused on adult drug-using populations. Little qualitative work has examined the social, structural, and environmental factors that shape periods of injection cessation among youth and young adults. Such research is essential to understanding how we can best reduce harms among this vulnerable population as they move in and out of periods of injection cessation.

METHODS

We conducted 22 semi-structured, qualitative interviews with street-involved young people who use drugs (SY), focused on characterizing their transitions into periods of injection cessation and perceived barriers to injection cessation. Adopting an ethno-epidemiological approach, participants who had experienced at least 6 months of injection cessation were purposively recruited from an ongoing prospective cohort study of SY in Vancouver, Canada to participate in qualitative interviews. Qualitative interview findings were triangulated with the findings of a longitudinal program of ethnographic research with SY in this setting. This ethno-epidemiological approach allowed for a more robust exploration of contextual factors surrounding drug use patterns than would be possible through traditional epidemiological methods alone.

RESULTS

Findings indicate that periods of injection cessation were influenced by access to harm reduction-informed youth-focused services, transitions in route of administration (e.g., from injecting methamphetamine to the smoking of methamphetamine), and the provision of housing and social supports (e.g., from friends, family, and care providers). Conversely, participants indicated that inadequate social supports and, for some, abstinence-focused treatment methods (e.g., 12-step programs), impeded efforts to cease injecting.

CONCLUSIONS

To reduce harms, it is imperative to reorient attention toward the social, structural, and spatial contexts that surround injection drug use and shape periods of injection cessation for SY. There is an urgent need for more comprehensive youth-focused services for those engaged in injection drug use, and further study of innovative means of engaging youth.

Unsafe sexual behaviour associated with hazardous alcohol use among street-involved youth

While risky sexual behaviours related to illicit drug use among street youth have been explored, the impacts of alcohol use have received less attention. This longitudinal study examined hazardous alcohol use among a population of street-involved youth, with particular attention to sexual and drug-related risk behaviours. Data were derived from the At-Risk Youth Study, a prospective cohort of street-involved youth in Vancouver, Canada. The outcome of interest was hazardous alcohol use defined by the US National Institute on Alcohol Abuse and Alcoholism. We used generalized estimating equations (GEEs) analyses to identify factors associated with hazardous alcohol use. Between 2005 and 2014, 1149 drug-using youth were recruited and 629 (55%) reported hazardous alcohol use in the previous 6 months during study follow-up. In multivariable GEE analyses, unprotected sex (adjusted odds ratio [AOR] = 1.28, 95% confidence interval [95% CI] = 1.12-1.46) and homelessness (AOR = 1.35, 95% CI = 1.19-1.54) were independently associated with hazardous alcohol use (all p < .001). Older age (AOR = 0.95, 95% CI = 0.92-0.99), Caucasian ethnicity (AOR = 0.74, 95% CI = 0.61-0.90), daily heroin use (AOR = 0.53, 95% CI = 0.42-0.67), daily crack cocaine smoking (AOR = 0.73, 95% CI = 0.59-0.91), and daily crystal methamphetamine use (AOR = 0.52, 95% CI = 0.42-0.64) were negatively associated with hazardous alcohol use (all p < .05). In sub-analysis, consistent dose-response patterns were observed between levels of alcohol use and unprotected sex, homelessness, and daily heroin injection. In sum, hazardous alcohol use was positively associated with unsafe sexual behaviour and negatively associated with high-intensity drug use. Interventions to address hazardous alcohol use should be central to HIV prevention efforts for street-involved youth.

Epidemiology of Injection Drug Use: New Trends and Prominent Issues

After more than 30 years of research, numerous studies have shown that injection drug use is associated with a wide range of adverse health outcomes such as drug overdoses, drug-related suicidal behaviours, comorbid psychiatric disorders, bloodborne pathogens and other infectious diseases, and traumas. This review explores new trends and prominent issues associated with injection drug use. The dynamic nature of injection drug use is underlined by examining its recent trends and changing patterns in Canada and other "high-income countries." Three research topics that could further contribute to the development of comprehensive prevention and intervention strategies aimed at people who inject drugs are also discussed: risk behaviours associated with the injection of prescription opioids, binge injection drug use, and mental health problems as determinants of injection risk behaviours.

Estimating the size of the population of persons who inject drugs in the island of Montréal, Canada, using a six-source capture-recapture model

BACKGROUND

To plan and implement services to persons who inject drugs (PWID), knowing their number is essential. For the island of Montréal, Canada, the only estimate, of 11,700 PWID, was obtained in 1996 through a capture-recapture method. Thirteen years later, this study was undertaken to produce a new estimate.

METHODS

PWID were defined as individuals aged 14-65 years, having injected recently and living on the island of Montréal. The study period was 07/01/2009 to 06/30/2010. An estimate was produced using a six-source capture-recapture log-linear regression method. The data sources were two epidemiological studies and four drug dependence treatment centres. Model selection was conducted in two steps, the first focusing on interactions between sources and the second, on age group and gender as covariates and as modulators of interactions.

RESULTS

A total of 1480 PWID were identified in the six capture sources. They corresponded to 1132 different individuals. Based on the best-fitting model, which included age group and sex as covariates and six two-source interactions (some modulated by age), the estimated population was 3910 PWID (95% confidence intervals (CI): 3180-4900) which represents a prevalence of 2.8 (95% CI: 2.3-3.5) PWID per 1000 persons aged 14-65 years.

CONCLUSIONS

The 2009-2010 estimate represents a two-third reduction compared to the one for 1996. The multisource capture-recapture method is useful to produce estimates of the size of the PWID population. It is of particular interest when conducted at regular intervals thus allowing for close monitoring of the injection phenomenon.

Inability to access addiction treatment among street-involved youth in a Canadian setting

From Sept 2005 to May 2012, 1015 street-involved youth were enrolled into the At-Risk Youth Study, a prospective cohort of youth aged 14-26 who use illicit drugs in Vancouver, Canada. Data were collected through semiannual interviewer administered questionnaires. Generalized estimating equation logistic regression was used to identify factors independently associated with being unable to access addiction treatment. The enclosed manuscript notes the implications and limitations of this study, as well as possible directions for future research. This study was funded by the US National Institutes of Health (NIH) and Canadian Institutes of Health (CIHR).

Rapid point-of-care HIV testing in youth: a systematic review

PURPOSE

This review examines the literature surrounding acceptability of, and preference for, rapid point-of-care (POC) human immunodeficiency virus (HIV) testing in youth, documents notification rates when youth were offered rapid POC testing, and identifies the sociodemographic factors associated with testing.

METHODS

The reviewers searched the scholarly literature indexed in MEDLINE, Embase, CINAHL, and PsycInfo using a set of keywords related to youth and rapid POC HIV testing. A total of 14 articles were included in the review.

RESULTS

Four themes were identified: (1) Youth will accept rapid POC testing, particularly if offered; (2) youth prefer rapid POC testing to traditional testing; (3) youth receive their rapid POC HIV test results; and (4) older youth and those with HIV risk factors or a concurrent genitourinary diagnosis are more likely to accept rapid POC HIV testing when it is offered.

CONCLUSIONS

Evidence shows that youth accept and prefer rapid POC HIV tests when offered. The routine use of rapid POC HIV tests in emergency departments and adolescent primary care clinics should be considered because of higher uptake in these environments. Youth receive their rapid POC test results more frequently and sooner than traditional test results. However, further work is needed to develop HIV testing programs that target younger adolescents.

Homeless youth's overwhelming health burden: A review of the literature

Homelessness has reached epidemic proportions in Canada. Canadian children and adolescents are the most vulnerable because youth comprise the fastest growing segment of the homeless population. A systematic literature review was undertaken using MEDLINE, Web of Science and the Homeless Hub (www.homelesshub.ca) to encompass the time frame from January 1990 to June 2009. The following terms were used as key words: 'homelessness', 'homeless youth', 'poverty', 'street youth' and 'runaway'. The present review identified an intersection among education deficits, social service insufficiencies, and poor mental and physical health in homeless youth. Health care delivery to homeless youth was often nonanticipatory, inconsistent and perceived as discriminatory. However, street youth were identified as requiring health care for pregnancy, mental health concerns, sexually transmitted illnesses, respiratory conditions, substance abuse and a myriad of other illnesses. Plenty of work is still required to reduce health inequalities and improve the daily living conditions of Canadian youth living in poverty.

Frequent methamphetamine injection predicts emergency department utilization among street-involved youth

OBJECTIVES

Methamphetamine (MA) use has been associated with health problems that commonly present in the emergency department (ED). This study sought to determine whether frequent MA injection was a risk factor for ED utilization among street-involved youth.

STUDY DESIGN

Prospective cohort study.

METHODS

Data were derived from a street-involved youth cohort known as the 'At Risk Youth Study'. Behavioural data including MA use were linked to ED records at a major inner-city hospital. Kaplan-Meier and Cox proportional hazards methods were used to determine the risk factors for ED utilization.

RESULTS

Between September 2005 and January 2007, 427 eligible participants were enrolled, among whom the median age was 21 (interquartile range 19-23) years and 154 (36.1%) were female. Within 1 year, 163 (38.2%) visited the ED, resulting in an incidence density of 53.7 per 100 person-years. ED utilization was significantly higher among frequent (i.e. ≥daily) MA injectors (log-rank P = 0.004). In multivariate analysis, frequent MA injection was associated with an increased hazard of ED utilization (adjusted hazard ratio = 1.84, 95% confidence interval 1.04-3.25; P = 0.036).

CONCLUSIONS

Street-involved youth who frequently inject MA appear to be at increased risk of ED utilization. The integration of MA-specific addiction treatment services within emergency care settings for high-risk youth is recommended.

Difficulty accessing syringes mediates the relationship between methamphetamine use and syringe sharing among young injection drug users

Injection drug users (IDU) who use methamphetamine (MA) are at an increased risk of HIV infection due to engagement in injection-related risk behavior including syringe sharing. In this cohort study of young IDU aged 18-30, we investigated the relationship between injection MA use and syringe sharing, and whether difficulty accessing sterile syringes mediated this association. Behavioral questionnaires were completed by 384 IDU in Vancouver, Canada between October 2005 and May 2008. Generalized estimating equations were used to estimate direct and indirect effects. The median age of participants was 24 (IQR: 22–27) and 214 (55.7%) were male. Injecting MA was independently associated with syringe sharing. Mediation analyses revealed that difficulty accessing sterile syringes partially mediated the association between injecting MA and syringe sharing. Interventions to reduce syringe sharing among young methamphetamine injectors must address social and structural barriers to accessing HIV prevention programs.

Trajectories of injection drug use over 20 years (1988-2008) in Baltimore, Maryland

The objective of this study was to identify longitudinal patterns of injection drug use over 20 years in the AIDS Linked to the Intravenous Experience (ALIVE) Study, a community-based cohort of injection drug users (IDUs) in Baltimore, Maryland, with a focus on injection cessation. Starting in 1988, persons over 18 years of age with a history of injection drug use were recruited into the study. Participants provided information on their injection drug use semiannually through 2008. The analysis was restricted to 1,716 IDUs with at least 8 study visits. Finite mixture models were used to identify trajectories and predictors of injection patterns over time. The mean age of participants was 35 years; 75% were male, and 95% were African-American. Five distinct patterns were identified: 2 usage patterns (32% engaged in persistent injection and 16% had frequent relapse) and 3 cessation patterns (early cessation (19%), delayed cessation (16%), and late cessation (18%)). A history of drug treatment, no recent use of multiple substances, and less frequent injection distinguished the early cessation group from the other groups. This study demonstrated multiple trajectories of drug injection behaviors, with a substantial proportion of IDUs stopping injection over extended time frames. For maximum effectiveness, public health programs for IDUs should be long-term, comprehensive, and targeted toward individual patterns of use.

Initiation to drug injection among street youth: a gender-based analysis

OBJECTIVE(S)

To estimate the incidence rate of initiation into drug injection and to identify predictors of initiation into drug injection separately among street girls and boys.

DESIGN

Data from two consecutive prospective street youth cohort studies (1995-2001 and 2001-2005) were used to conduct these analyses, stratified by gender.

METHODS

Data were collected using semi-annual interviewer-administered questionnaires. Variables from the following domains were considered in Cox regression models: socio-demographic characteristics, early and current substance abuse, marginalization, childhood traumatic sexual events and injection exposure.

RESULTS

Of the 946 youth who had never injected drugs at study entry, 86.4% completed at least two questionnaires representing 243 girls and 574 boys. Incidence rates of injection of 7.0 and 5.9 per 100 person-years were observed among these girls and boys respectively. Among girls, cocaine or crack use (adjusted hazard ratio (AHR)=1.97), heroin use (AHR=2.86), homelessness (AHR=2.49) and hanging out regularly with people who inject (AHR=4.46) all independently increased risk of first injection. Among boys, age decreased risk of initiating injection (AHR=0.90/year), while cocaine or crack use (AHR=2.14), heroin use (AHR=3.56), homelessness before age 16 (AHR=1.68), incest or rape before age 14 (AHR=1.98) and hanging out regularly with people who inject (AHR=1.66) all independently increased this risk.

CONCLUSIONS

Our findings suggest similar rates of initiation among girls and boys; however, factors associated with initiation vary by gender. This might lead to the design of more effective programs to prevent initiation into drug injection.

Interventions to modify sexual risk behaviours for preventing HIV in homeless youth

BACKGROUND

Homeless youth are at high risk for HIV infection as a consequence of risky sexual behaviour. Interventions for homeless youth are challenging. Assessment of the effectiveness of interventions to modify sexual risk behaviours for preventing HIV in homeless youth is needed.

OBJECTIVES

To evaluate and summarize the effectiveness of interventions for modifying sexual risk behaviours and preventing transmission of HIV among homeless youth.

SEARCH STRATEGY

We searched electronic databases (CENTRAL, MEDLINE, EMBASE, AIDSearch, Gateway, PsycInfo, LILACS), reference lists of eligible articles, international health agency publication lists, and clinical trial registries. The search was updated January 2010. We contacted authors of published reports and other key role players.

SELECTION CRITERIA

Randomised studies of interventions to modify sexual risk behaviour (biological, self-reporting of sexual-risk behaviour or health-seeking behaviour) in homeless youth (12-24 years).

DATA COLLECTION AND ANALYSIS

Data from eligible studies were extracted by two reviewers. We assessed risk of bias per the Cochrane Collaborations tool. None of the eligible studies reported any primary biological outcomes for this review. Reports of self-reporting sexual risk behaviour outcomes varied across studies precluding calculation of summary measures of effect; we present the outcomes descriptively for each study. We contacted authors for missing or ambiguous data.

MAIN RESULTS

We identified three eligible studies after screening a total of 255 unique records. All three were performed in the United States of America and recruited substance-abusing male and female adolescents (total N=615) through homeless shelters into randomised controlled trials of independent and non-overlapping behavioural interventions. The three trials differed in theoretical background, delivery method, dosage (number of sessions,) content and outcome assessments. Overall, the variability in delivery and outcomes precluded estimation of summary of effect measures. We assessed the risk of bias to be high for each of the studies. Whilst some effect of the interventions on outcome measures were reported, heterogeneity and lack of robustness in these studies necessitate caution in interpreting the effectiveness of these interventions. 

AUTHORS' CONCLUSIONS

The body of evidence does not permit conclusions on the impact of interventions to modify sexual risk behaviour in homeless youth; more research is required. While the psychosocial and contextual factors that fuel sexual risk behaviours among homeless youth challenge stringent methodologies of RCT's, novel ways for program delivery and trial retention are in need of development. Future trials should comply with rigorous methodology in design, delivery, outcome measurement and reporting.

Public injecting and HIV risk behaviour among street-involved youth

BACKGROUND

Although street-involved youth who inject illicit drugs are known to be at an increased risk of HIV and other adverse health outcomes, little is known about public injecting among this population and how injecting in public environments may impact HIV risk behaviour.

METHODS

We used data derived from a study of 560 street-involved youth in Vancouver, Canada to examine the factors associated with injecting in public environments among youth who reported injecting drugs in the past 6 months.

RESULTS

At baseline, 162 (28.9%) reported injecting drugs in the past 6 months. Among injectors, the 124 (76.5%) participants who reported injecting in public were more likely to be homeless (odds ratio [OR]=6.39, p<0.001), engage in unprotected intercourse (OR=3.09, p=0.004), deal drugs (OR=2.26, p=0.032), smoke crack cocaine (OR=3.00, p=0.005), inject heroin (OR=3.48, p=0.001), drop used syringes outdoors (OR=8.44, p<0.001), share syringes (OR=4.43, p=0.004), and were less likely to clean injection sites >75% of the time (OR=0.36, p=0.008). The majority (62.1%) reported feeling rushed while injecting in public.

CONCLUSIONS

Youth who inject in public are significantly more likely to engage in sexual and injection-related risk behaviour. Given the known elevated rates of HIV infection and other harms among this population, youth-focused interventions that target both sexual and drug-related risks associated with public drug-using environments are in urgent need of evaluation.

Involving vulnerable populations of youth in HIV prevention clinical research

Adolescents continue to be at high risk for HIV infection, with young men who have sex with men and youth with drug abuse and/or mental health problems at particularly high risk. Multiple factors may interact to confer risk for these youth. Engaging vulnerable youth in HIV prevention research can present unique challenges in the areas of enrollment, retention, and trial adherence. Examples of successful engagement with vulnerable youth offer encouraging evidence for the feasibility of including these youth in clinical trials. Ethical challenges must be taken into consideration before embarking on biomedical HIV prevention studies with vulnerable youth, especially in the global context. Given the many individual and contextual factors that contribute to their high-risk status, it is essential that vulnerable youth populations be included in HIV prevention clinical research studies.

Survival sex work and increased HIV risk among sexual minority street-involved youth

OBJECTIVES

Exchanging sex for money, drugs, or other commodities for survival is associated with an array of HIV risks. We sought to determine if street-involved drug-using sexual minority youth are at greater risk for survival sex work and are more likely to engage in risk behaviors with clients.

METHODS

We examined factors associated with survival sex work among participants enrolled in the At Risk Youth Study using logistic regression. Self-reported risk behaviors with clients were also examined.

RESULTS

Of 558 participants eligible for this analysis, 75 (13.4%) identified as a sexual minority and 63 (11.3%) reported survival sex work in the past 6 months. Sexual minority males (adjusted odds ratio = 16.1, P < 0.001) and sexual minority females (adjusted odds ratio = 6.87, P < 0.001) were at significantly greater risk for survival sex work. Sexual minority youth were more likely to report inconsistent condom use with clients (odds ratio = 4.30, P= 0.049) and reported a greater number of clients in the past 6 months (median = 14 vs. 3, P = 0.008).

CONCLUSIONS

Sexual minority street youth are not only more likely to engage in survival sex work but also demonstrate elevated HIV risk behavior. These findings suggest that harm reduction and HIV prevention programs for sexual minority youth who exchange sex are urgently required.

'I guess my own fancy screwed me over': transitions in drug use and the context of choice among young people entrenched in an open drug scene

Background

There is growing interest in describing the broader risk trajectories experienced by young people who use drugs - that is, in describing the sequences of drug use transitions experienced by youth in relation to evolving understandings of risk and harm. This study sought to examine young people's perspectives regarding the evolution of their drug use in the context of a local drug scene in Vancouver, Canada.

Methods

Semi-structured qualitative interviews with 38 individuals recruited from a cohort of young drug users known as the At-risk Youth Study (ARYS) were supplemented by ongoing ethnographic fieldwork (e.g., observations and informal conversations with youth) conducted within the same cohort population. Interviews were transcribed verbatim and a thematic analysis was conducted.

Results

The majority of youth characterized past transition events as non-exceptional, largely 'spur-of-the-moment' decisions motivated by evolving feelings of curiosity. At the same time, participants' reflections indicated that the social, structural and material contexts of drug scene entrenchment play a powerful role in shaping these decisions and transition experiences.

Conclusions

Importantly, as young people become increasingly entrenched in the local drug scene, drug use transitions seem to constitute increasingly relevant (and even 'inevitable') choices congruent with everyday lived experience. The implications of these findings for the development of meaningful interventions for youth are discussed.

Coming 'down here': young people's reflections on becoming entrenched in a local drug scene

Recent research has highlighted the ways in which social structural processes and physical environments operate to push young drug users towards risk. We undertook this study in order to explore how young people who were currently street-entrenched characterized and understood their initiation into the local drug scene in downtown Vancouver, Canada. Semi-structured qualitative interviews were conducted with 38 individuals recruited from a cohort of young drug users known as the At-Risk Youth Study (ARYS). Participant narratives reflected an understanding among young people that they are simultaneously pulled and pushed towards the local scene. Push factors were understood as circumstances that propelled young people towards this setting, in some cases because of proximity to it from a very early age, and in other cases because of adverse situations experienced elsewhere and the need to find a new place to live that was both affordable and safe. Interwoven with accounts of how youth were pushed towards the local scene were stories that emphasized a high degree of autonomy and the factors that initially attracted them to this scene, including a desire for excitement, independence and belonging. Once young people were more permanently based in downtown Vancouver, participants identified several factors that accelerated their entrenchment in this locale, including increasingly 'problematic' drug use, an intensified need to generate income, experiences of chronic homelessness, and unstable social relationships. Our findings stress the need for early intervention with youth, before they are initiated into the social networks and processes that rapidly propel young people towards risk within these contexts. Once initiation has occurred, the boundary between safety and risk quickly becomes difficult to navigate, and young people become highly vulnerable to numerous harms.

Injection drug use among street-involved youth in a Canadian setting

Background

Street-involved youth contend with an array of health and social challenges, including elevated rates of blood-borne infections and mortality. In addition, there has been growing concern regarding high-risk drug use among street-involved youth, in particular injection drug use. We undertook this study to examine the prevalence of injection drug use and associated risks among street-involved youth in Vancouver, Canada.

Methods

From September 2005 to November 2007, baseline data were collected for the At-Risk Youth Study (ARYS), a prospective cohort of street-recruited youth aged 14 to 26 in Vancouver, Canada. Using multiple logistic regression, we compared youth with and without a history of injection.

Results

The sample included 560 youth among whom the median age was 21.9 years, 179 (32%) were female, and 230 (41.1%) reported prior injection drug use. Factors associated with injection drug use in multivariate analyses included age ≥ 22 years (adjusted odds ratio [AOR] = 1.18, 95% CI: 1.10–1.28); sex work involvement (AOR = 2.17, 95% CI: 1.35–3.50); non-fatal overdose (AOR = 2.10, 95% CI: 1.38–3.20); and hepatitis C (HCV) infection (AOR = 22.61, 95% CI: 7.78–65.70).

Conclusion

These findings highlight an alarmingly high prevalence of injection drug use among street-involved youth and demonstrate its association with an array of risks and harms, including sex work involvement, overdose, and HCV infection. These findings point to the need for a broad set of policies and interventions to prevent the initiation of injection drug use and address the risks faced by street-involved youth who are actively injecting.

Social influences upon injection initiation among street-involved youth in Vancouver, Canada: a qualitative study

BACKGROUND

Street-involved youth are a population at risk of adopting injection as a route of administration, and preventing the transition to injection drug use among street youth represents a public health priority. In order to inform epidemiological research and prevention efforts, we conducted a qualitative study to investigate the initiation of injection drug use among street-involved youth in Vancouver, Canada.

METHODS

Qualitative interviews with street youth who inject drugs elicited descriptions of the adoption of injection as a route of administration. Interviewees were recruited from the At-Risk Youth Study (ARYS), a cohort of street-involved youth who use illicit drugs in Vancouver, Canada. Audio recorded interviews were transcribed verbatim and a thematic analysis was conducted.

RESULTS

26 youth aged 16 to 26 participated in this study, including 12 females. Among study participants the first injection episode frequently featured another drug user who facilitated the initiation of injecting. Youth narratives indicate that the transition into injecting is influenced by social interactions with drug using peers and evolving perceptions of injecting, and rejecting identification as an injector was important among youth who did not continue to inject. It appears that social conventions discouraging initiating young drug users into injection exist among established injectors, although this ethic is often ignored.

CONCLUSION

The importance of social relationships with other drug users within the adoption of injection drug use highlights the potential of social interventions to prevent injection initiation. Additionally, developing strategies to engage current injectors who are likely to initiate youth into injection could also benefit prevention efforts.

Homelessness and unstable housing associated with an increased risk of HIV and STI transmission among street-involved youth

The role that environmental factors play in driving HIV and STI transmission risk among street-involved youth has not been well examined. We examined factors associated with number of sex partners using quasi-Poisson regression and consistent condom use using logistic regression among participants enroled in the At Risk Youth Study (ARYS). Among 529 participants, 253 (47.8%) reported multiple partners while only 127 (24.0%) reported consistent condom use in the past 6 months. Homelessness was inversely associated with consistent condom use (adjusted odds ratio [aOR]=0.47, p=0.008), while unstable housing was positively associated with greater numbers of sex partners (adjusted incidence rate ratio [aIRR]=1.44, p=0.010). These findings indicate the need for interventions which modify environmental factors that drive risk among young street-involved populations.

Incidence and predictors of onset of injection drug use in a San Francisco cohort of homeless youth

Few studies document incidence of injection drug use among homeless youth. We followed a cohort of 70 street-recruited homeless youth in San Francisco, California who had never injected drugs for six months in 2004-5. We examined initiation of injection drug use and its predictors, informed by prior ethnographic findings. Data were analyzed using exact logistic regression. 11.4% of youth initiated injection drug use. Having no high school education, being over 21 years old, and being in disequilibrium predicted initiation. Limitations, implications and suggestions for future research are noted. Funding was provided by the National Institute for Child Health and Development.

Transition to injection drug use among street youth--a qualitative analysis

OBJECTIVES

To examine social contexts and processes influencing transition to drug injection among street youth.

METHODS

42 street youth participated in in-depth interviews. A typology of experiences was built founded on youth's street life and drug use trajectories. The transition to drug injection was examined through these experiences.

RESULTS

We identified five types of mutually exclusive experiences. The "downtowner's" experience is characterised by early street life and drug consumption trajectories, and a strong identification with the downtown milieu. These youth progress from one drug to another and, in a milieu where drug injection is omnipresent, this escalation culminates in transition to injection. The "tripper" street life and substance use trajectories begin later and are less intense. Most "tripper" youth are already chronic hallucinogens users when they arrive in downtown Montréal. Although they judge "junkies" severely, they show some ambivalence towards injection. The "on the go" experience is characterised by trajectories of drug use and street life that are intermingled, leading to a loss of control. These youth, who often have serious delinquent behaviours, come to downtown Montréal to party and consume drugs, mostly stimulants. Their drug use pattern and network make them at high risk of starting cocaine injection. The "hard-luck's" experience is characterised by a lack of identification with the downtown milieu. These youth who use drugs recreationally, end up in the streets accidentally, often because of unemployment. The "alcoholic' experience is related to alcohol misuse. These youth usually end up in the streets due to this dependence. Their street involvement is mostly an experience of solitude. The risk of transitioning to injection for both these types is low.

CONCLUSIONS

Some combinations of street life and drug use trajectories seem to contribute to injection among street youth. Some important factors interact and increase the risk of street youth transitioning to injection: poor personal assets; early rupture with primary social institutions; social integration into subcultures where both street life and "drug trips" are fashionable, drug preferences and the local drug market.

Incidence and reinfection rates of genital chlamydial infection among women aged 16-24 years attending general practice, family planning and genitourinary medicine clinics in England: a prospective cohort study by the Chlamydia Recall Study Advisory Group

BACKGROUND

In England, screening for genital chlamydial infection has begun; however, screening frequency for women is not yet determined.

AIM

To measure chlamydia incidence and reinfection rates among young women to suggest screening intervals.

METHODS

An 18-month prospective cohort study of women aged 16-24 years recruited from general practices, family planning clinics and genitourinary medicine (GUM) clinics: baseline-negative women followed for incidence and baseline-positive women for reinfection; urine tested every 6 months via nucleic acid amplification; and behavioural data collected. Extra test and questionnaire completed 3 months after initial positive test. Factors associated with infection and reinfection investigated using Cox regression stratified by healthcare setting of recruitment.

RESULTS

Chlamydia incidence was mean (95% CI) 4.9 (2.7 to 8.8) per 100 person-years (py) among women recruited from general practices, 6.4 (4.2 to 9.8) from family planning clinics and 10.6 (7.4 to 15.2) from GUM clinics. Incidence was associated with young age, history of chlamydial infection and acquisition of new sexual partners. If recently acquiring new partners, condom use at last sexual intercourse was independently associated with lower incidence. Chlamydia reinfection was mean (95% CI) 29.9 (19.7 to 45.4) per 100/person-year from general practices, 22.3 (15.6 to 31.8) from family planning clinics and 21.1 (14.3 to 30.9) from GUM clinics. Factors independently associated with higher reinfection rates were acquisition of new partners and failure to treat all partners.

CONCLUSIONS

Sexual behaviours determined incidence and reinfection, regardless of healthcare setting. Our results suggest annual screening of women aged 16-24 years who are chlamydia negative, or sooner if partner change occurs. Rescreening chlamydia-positive women within 6 months of baseline infection may be sensible, especially if partner change occurs or all partners are not treated.

Sexual and drug use risk behaviors among children and youth in street circumstances in Porto Alegre, Brazil

We conducted a cross-sectional study to assess sexual and drug use risk in 161 children and youth in street circumstances in Porto Alegre, Brazil. Median age was 14 and 79% were male. Overall, 59% reported ever having had sex; a significantly higher proportion of males (66%) compared to females (30%). Overall, 39% reported illicit drug use in the last year, and only 1.2% reported injection drug use. In multivariate analyses, correlates of unsafe sex included younger age of sexual debut, and having a steady sex partner. Independent correlates of illicit drug use included lack of family contact, increased hours in the street daily, having had an HIV test, and older age. A high proportion of children and youth in street circumstances reported high risk sex and drug exposures, confirming their vulnerability to HIV/STD. Services Centers, such as where this research was carried out, offer an opportunity for interventions.

Evaluating methamphetamine use and risks of injection initiation among street youth: the ARYS study

Many Canadian cities are experiencing ongoing infectious disease and overdose epidemics among injection drug users (IDU). These health concerns have recently been exacerbated by the increasing availability and use of methamphetamine. The challenges of reducing health-related harms among IDU have led to an increased recognition that strategies to prevent initiation into injection drug use must receive renewed focus. In an effort to better explore the factors that may protect against or facilitate entry into injection drug use, the At Risk Youth Study (ARYS) has recently been initiated in Vancouver, Canada. The local setting is unique due to the significant infrastructure that has been put in place to reduce HIV transmission among active IDU. The ARYS study will seek to examine the impact of these programs, if any, on non-injection drug users. In addition, Vancouver has been the site of widespread use of methamphetamine in general and has seen a substantial increase in the use of crystal methamphetamine among street youth. Hence, the ARYS cohort is well positioned to examine the harms associated with methamphetamine use, including its potential role in facilitating initiation into injection drug use. This paper provides some background on the epidemiology of illicit drug use among street youth in North America and outlines the methodology of ARYS, a prospective cohort study of street youth in Vancouver, Canada.

The health of street youth: a Canadian perspective

OBJECTIVE

To review epidemiologic studies of the health of street youth in industrialized countries, with a special focus on Canadian youth.

METHODS

We identified 52 peer-reviewed studies from searches of the MEDLINE database and bibliographies of published papers, for data on blood-borne and sexually transmitted infections, mental health problems, pregnancy, violence and mortality.

RESULTS

Rates of hepatitis B, hepatitis C, and HIV infection are much higher among street youth than among their non-street peers. Likewise, the prevalence of all mental health problems assessed in street youth is greater than that in non-street youth. Pregnancy is more frequent among street than household youth. Street youth also experience high levels of violence: a large proportion report physical abuse or assault. Finally, mortality is about 11 times the expected rate based on age and sex and is mainly caused by suicide and drug overdose.

CONCLUSION

Current research results are useful to orient public health interventions for street youth, but further epidemiologic research is needed. The need for Canadian data is particularly acute in specific areas including mental health, violence, pregnancy, and sexually transmitted infections such as, for example, herpes infection and syphilis.

Cessation of injecting drug use among street-based youth

Young injecting drug users (IDUs) are at high risk for a number of negative health outcomes such as hepatitis B, hepatitis C, and human immunodeficiency virus (HIV) infection. However, very little is known about injecting drug-use patterns among this population, particularly with respect to cessation of injection. We sought to identify the factors associated with cessation of injection in a population of young street-based IDUs. A prospective cohort study design was used to assess long-term (> or = 1 year) cessation of drug injection. Data was collected between January 1995 and September 2000 in Montreal, Québec, Canada. Subjects were originally recruited from various street-based outreach programs in Montreal and, for this study, had to have reported injecting drugs within the prior 6 months at baseline or during follow-up and had to have completed at least two semiannual follow-up questionnaires. Cessation incidence rates stratified by duration of injection and adjusted hazard ratios (AdjHRs) were calculated. A Cox proportional hazards regression model was used to identify risk factors independently associated with cessation of drug injection. Of 502 young IDUs, 305 subjects met the inclusion criteria. Cessation of injection for approximately 1 year or more occurred in 119 (39%) of the young IDUs. The incidence of cessation was 32.6/100 person-years but consistently declined as duration of time spent injecting increased. Independent predictors of cessation of injection were currently injecting on a less than monthly or less than weekly basis (HR = 6.4; 95% confidence interval (CI): 3.0-13.6 and HR = 2.4; 95% CI = 1.1-5.3, respectively); currently injecting two or fewer different types of drug (HR = 2.1; 95% CI = 1.1-4.0); currently employed (HR = 1.7; 95% CI = 1.1-2.7); and having at least one parent born outside of Canada (HR = 1.4; 95% CI = 1.1-1.7). Independent predictors of not ceasing injection were currently attending a needle-exchange program (HR = 0.5; 95% CI = 0.3-0.8); and current homelessness (HR = 0.6; 95% CI = 0.4-1.0). The early sharp decline in cessation of drug injection followed by a consistent decrease in this rate suggest difficulties in breaking the habit later on in the drug injecting career. Intensity of drug use and factors which may help to stabilize the social environment of the young IDU may also influence the ability to stop injecting.

Homelessness and drug abuse among young men who have sex with men in New York city: a preliminary epidemiological trajectory

The objective of this paper is to profile the role of homelessness in drug and sexual risk in a population of young men who have sex with men (YMSM). Data are from a cross-sectional survey collected between 2000 and 2001 in New York City (N = 569). With the goal of examining the import of homelessness in increased risk for the onset of drug and sexual risk, we compare and contrast three subgroups: (1) YMSM with no history of homelessness, (2) YMSM with a past history of homelessness but who were not homeless at the time of the interview, and (3) YMSM who were currently homeless. For each group, we describe the prevalence of a broad range of stressful life events (including foster care and runaway episodes, involvement in the criminal justice system, etc.), as well as selected mental health problems (including past suicide attempts, current depression, and selected help-seeking variables). Additionally, we examine the prevalence of selected drug and sexual risk, including exposure to a broad range of illegal substances, current use of illegal drugs, and prevalence of lifetime exposure to sex work. Finally, we use an event history analysis approach (time-event displays and paired t-test analysis) to examine the timing of negative life experiences and homelessness relative to the onset of drug and sexual risk. High levels of background negative life experiences and manifest mental health distress are seen in all three groups. Both a prior experience of homelessness and currently being homeless are both strongly associated with both higher levels of lifetime exposure to drug and sexual risk as well as higher levels of current drug and sexual risk. Onset of these risks occur earlier in both groups that have had an experience of housing instability (e.g., runaway, foster care, etc.) but are delayed or not present among YMSM with no history of housing instability. Few YMSM had used drug prior to becoming homeless. While causal inferences are subject to the limitations of a cross-sectional design, the findings pose an empirical challenge to the prevailing assumption that prior drug use is a dominant causal factor in YMSM becoming homeless. More broadly, the data illustrate the complexity of factors that must be accounted for, both in advancing our epidemiological understanding of the complexity of homelessness and its relationship to the onset of drug and sexual risk among high risk youth populations.

The use of the Internet by gay and bisexual male escorts: sex workers as sex educators

While prior studies have targeted street-based male sex workers as potential vectors of disease transmission, the number of men who work independently through Internet chat-rooms and other online endeavors has steadily increased. It is likely that these men differ substantially from their street-based counterparts in terms of sexual risk behaviors with their clients. The purpose of this study was to explore the ways in which the Internet has impacted the work of male escorts and their sexual practices with clients. Semi-structured qualitative interviews and quantitative surveys were administered to 46 such men. Less than half the men reported unprotected anal sex with clients. The qualitative data lend support to this finding, in that the majority talked about refusing any unsafe sex with clients, and many reported taking the extra step of educating their clients about the dangers of risky sex. Some of the escorts described the methods used to incorporate safer sex practices into sessions with their clients. Internet-based male escorts can play an important role as potential sex educators on the front lines of the fight against HIV and other sexually transmitted infections.