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Injection drug use among street-involved youth in a Canadian setting Kerr, Thomas; Marshall, Brandon D; Miller, Cari; Shannon, Kate; Zhang, Ruth; Montaner, Julio S; Wood, Evan Jun 3, 2009

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ralssBioMed CentBMC Public HealthOpen AcceResearch articleInjection drug use among street-involved youth in a Canadian settingThomas Kerr*1,2, Brandon DL Marshall1, Cari Miller3, Kate Shannon1,2, Ruth Zhang1, Julio SG Montaner1,2 and Evan Wood1,2Address: 1British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, British Columbia, Canada, 2Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada and 3Faculty of Health Sciences, Simon Fraser University, Burnaby, CanadaEmail: Thomas Kerr* - uhri-tk@cfenet.ubc.ca; Brandon DL Marshall - bmarshall@cfenet.ubc.ca; Cari Miller - dr.cari.miller@gmail.com; Kate Shannon - kshannon@cfenet.ubc.ca; Ruth Zhang - rzhang@cfenet.ubc.ca; Julio SG Montaner - jmontaner@cfenet.ubc.ca; Evan Wood - uhri-ew@cfenet.ubc.ca* Corresponding author    AbstractBackground: 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 beengrowing concern regarding high-risk drug use among street-involved youth, in particular injectiondrug use. We undertook this study to examine the prevalence of injection drug use and associatedrisks among street-involved youth in Vancouver, Canada.Methods: From September 2005 to November 2007, baseline data were collected for the At-RiskYouth 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 ofinjection.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 injectiondrug 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 amongstreet-involved youth and demonstrate its association with an array of risks and harms, includingsex work involvement, overdose, and HCV infection. These findings point to the need for a broadset of policies and interventions to prevent the initiation of injection drug use and address the risksfaced by street-involved youth who are actively injecting.Background and the United States, it is estimated that between 4% andPublished: 3 June 2009BMC Public Health 2009, 9:171 doi:10.1186/1471-2458-9-171Received: 16 February 2009Accepted: 3 June 2009This article is available from: http://www.biomedcentral.com/1471-2458/9/171© 2009 Kerr et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 7(page number not for citation purposes)Street-involved youth are increasingly common in NorthAmerican cities and are a population at heightened riskfor an array of health and social problems [1]. In Canada7% of youth between the ages of 14 and 26 are absolutely,periodically, or temporarily without safe and stable shel-ter [2,3]. Since the definition of "street youth" is oftenBMC Public Health 2009, 9:171 http://www.biomedcentral.com/1471-2458/9/171extended to individuals who may be housed but who areheavily involved in the street economy [4], the proportionof youth who fall into this category may be significantlygreater.Compared to the general population, street-involvedyouth contend with a variety of health-related risks andchallenges [1], including elevated rates of mental illness[5], blood-borne infections [5-7], sexually transmittedinfections [8], and violence [9,10]. Recent evidence fromMontreal, Canada suggests that street-involved youth, incomparison to the general population, face an 8 to 11times higher risk of mortality [11].There have also been persistent concerns regarding high-risk substance use among street-involved youth in settingsthroughout the world [12-14]. In particular, in light of theassociated risks for human immunodeficiency virus (HIV)and hepatitis C infection (HCV), increasing attention hasbeen paid to the initiation of injection drug use withinthis population. This has led to calls for an updating of therisk hierarchy so that the prevention of injection drug useis given greater attention [15]. However, the prevalence ofinjecting and associated harms among street-involvedyouth has not been studied in many urban areas in NorthAmerica [13,16,17], and, outside of Montreal [18], little isknown about the epidemiology of injection drug useamong street-involved youth in Canada. Past estimatessuggest there are at any time upwards of 150,000 youngpeople in Canada who are absolutely, periodically or tem-porarily without shelter [2]. However, there remain manychallenges associated with estimating the size of this pop-ulation given the transitory nature of street youth and lackof reliable counts of street youth (e.g., Census data, etc).Vancouver, Canada has been the site of co-occurring epi-demics of injection drug use, HIV, overdose, and HCV.However, while much study has been devoted to adultinjection drug users (IDU) in this setting, little is knownabout the prevalence and associated risks of injection druguse among the city's growing street youth population[19]. Although reliable estimates are lacking, it has beensuggested that there are between 500 to 1000 street youthliving on Vancouver streets each day [20]. While anincreasing number of studies have described the predic-tors of the initiation and cessation of injection drug use[18,21-23], there have been few studies that have com-pared the characteristics of drug-using street youth whohave and have not injected. Therefore, we undertook thisstudy to assess the prevalence and related risks and harmsof injection drug use among a cohort of drug-using street-involved youth in Vancouver.described in detail previously [19]. Briefly, participantswere recruited through snowball sampling and extensivestreet-based outreach. Persons were eligible for the studyif they were between 14 and 26 years of age, had usedillicit drugs other than or in addition to marijuana in thepast 30 days, and provided informed consent. At baselineand at semi-annual follow-up visits, participants com-plete an interviewer-administered questionnaire and pro-vide blood samples for HIV and hepatitis C (HCV)serology. The questionnaire elicits demographic data andinformation regarding injection and non-injection illicitdrug use, HIV risk behaviors, income generation, encoun-ters with police, health service utilization, and sexualactivity. The questionnaire is based on a previous instru-ment developed for adult drug users, and has been foundto reliably identify factors associated with HIV infection,mortality, and other harms [24-26]. All participantsreceived a monetary stipend of $20 after each visit. Thestudy has been approved by the University of BritishColumbia/Providence Health Care Research Ethics Board.The present study was conducted to evaluate the preva-lence of injection drug use and related risks and harmsamong street-involved youth who completed baselinestudy visits between September 2005 and November2007. Although ARYS is a prospective cohort study, giventhe low incidence of initiation into injection drug use, alongitudinal study of injection drug use initiation amongARYS participants was not possible at this time. The pri-mary outcome of interest was reporting any history ofinjection drug use (i.e., lifetime prevalence of injectiondrug use). Other self-reported variables of interest wereselected based on a review of the documented harms asso-ciated with injection drug use, and included: age; gender;Aboriginal ethnicity; history of incarceration; history ofsex work involvement (defined as exchanging sex formoney, drugs, shelter, or gifts); history of drug dealing;currently having a warrant for one's arrest; and history ofnon-fatal overdose. Variable definitions were consistentwith prior studies involving the ARYS cohort [27,28].Serologic outcomes considered included HIV- and HCV-positive status.As a first step, we conducted a univariate analyses inwhich those who did and did not report a history of injec-tion drug use were compared using Pearson's Chi-squaretest and the Wilcoxon rank test. Fisher's exact test was usedwhen one or more of the cells contained values less thanor equal to five. As a second step, a multivariate modelwas then prepared using an a priori defined statisticalapproach whereby variables that were p < 0.05 in univari-ate analyses were included in a fixed logistic regressionmodel. Variables that remained significant at p < 0.05Page 2 of 7(page number not for citation purposes)MethodsThe At-Risk Youth Study (ARYS) is a prospective cohortstudy of Vancouver street-involved youth that has beenwere regarded as factors significantly associated with theoutcome of interest. All statistical analyses were per-BMC Public Health 2009, 9:171 http://www.biomedcentral.com/1471-2458/9/171formed using SAS software version 9.1 (SAS, Cary, NC),and all p-values are two sided.ResultsIn total, 560 participants were recruited and included inthe present analyses. Of these participants, 179 (32%)were female and 131 (23.4%) were of Aboriginal ancestry.The median age was 21.9 years (interquartile range =19.8–23.9). In total, 230 (41.1%) participants reportedinjection drug use. Factors associated with injection druguse in univariate analyses are presented in Table 1 andinclude: age ≥ 22 year (odds ratio [OR] = 2.67, 95% con-fidence interval [CI]: 1.89–3.79, p < 0.001); history ofincarceration (OR = 2.04, 95% CI: 1.31–3.18, p < 0.001);sex work involvement (OR = 2.86, 95% CI: 1.89–4.32, p <0.001); drug dealing (OR = 1.61, 95% CI: 1.10–2.42, p =0.023); having a warrant for one's arrest (OR = 1.56, 95%CI: 1.03–2.33, p = 0.037); non-fatal overdose (OR = 2.76,95% CI: 1.92–3.97, p < 0.001); and HCV infection (OR =29.51, 95% CI: 10.55–82.53, p < 0.001).As shown in Table 2, factors found to be independentlyassociated with injection drug use in multivariate logisticregression analyses included: age = 22 years (adjustedodds ratio [AOR] = 1.18, 95% CI: 1.10–1.28, p < 0.001);sex work involvement (AOR = 2.17, 95% CI: 1.35–3.50, p= 0.001); non-fatal overdose (AOR = 2.10, 95% CI: 1.38–3.20, p < 0.001); and HCV infection (AOR = 22.61, 95%CI: 7.78–65.70, p < 0.001).DiscussionIn the present analysis, we found that injection drug usewas common among street-involved youth in Vancouver,with approximately 40% of the cohort reporting a historyof injection drug use. In a multivariate analysis, reportinga history of injection drug use was associated with olderage, sex work involvement, non-fatal overdose, and hepa-titis C infection.The high prevalence of injection drug use among street-involved youth in Vancouver is slightly lower thanobserved in Montreal, Canada (41% versus 60%) [18],although somewhat higher than observed in some US cit-ies [17]. Injection drug use among street-involved youthin this study was associated with several markers of risk,including sex work involvement. This is consistent withprevious studies from various settings demonstrating arelationship between injection drug use and sex workamong street-involved youth [29-32], studies which havealso suggested that the co-occurrence of injection drug useand sex work places street-involved youth at elevated riskfor HIV infection and other sexually transmitted infec-tions. The association between sex work and injectionusers (IDU) frequently resort to high-risk income generat-ing activities, such as sex work [33], to support their druguse and basic survival needs [34], and that sex work isoften linked to drug scene exposure [35]. However, previ-ous studies from our setting have also suggested a strongrelationship between the initiation of sex work amongstreet-involved youth and childhood emotional and sex-ual abuse [36]. While the forces that prompt the co-occur-rence of sex-work involvement and injection drug use willrequire further elucidation, the finding of an associationbetween sex work and injection drug use among street-involved youth in this settings is of immediate concern,given evidence suggesting that sex work involvement is astrong predictor of premature mortality among youngIDU in Vancouver [25].Injection drug use was also associated with non-fatal over-dose in this study. This is consistent with other studiesindicating a high rate of prior non-fatal overdose amongIDU [37,38] and a relationship between elevated risk foroverdose and injecting as a route of drug administration[39]. Although non-fatal overdose among IDU is typicallyassociated with heroin use [39], it is notable that crystalmethamphetamine use is highly prevalent among street-involved youth in Vancouver and has been associatedwith non-fatal overdose among this population and adultIDU [27,40].The finding that injection drug use was strongly associatedwith an elevated risk for HCV infection among youth inthis study is consistent with a previous study of street-involved youth in Montreal and is not surprising, giventhe high prevalence of HCV infection among adult IDU inVancouver [41] and the fact that injection drug use is anefficient mode of HCV transmission. Indeed, previousstudies undertaken within North America suggest thatmany young IDU acquire HCV soon after initiating inject-ing, with the estimated time to HCV infection among thispopulation being 1 to 2 years [42,43].These findings reinforce previous calls for an updating ofthe risk prevention hierarchy so that the transition toinjection drug use receives greater attention [15]. Indeed,studies have shown that the risk for acquisition of blood-borne infections is high after the onset of injecting [44],and therefore interventions that prevent the initiation ofinjecting among street-involved youth are needed, includ-ing those that target individuals (e.g., addiction treat-ment), as well as those that address the broader social,structural, and environmental determinants of injectiondrug use [45]. Unfortunately, few evidence-basedapproaches of this kind have been described. Given thatolder age (> 22 years) was associated with injection drugPage 3 of 7(page number not for citation purposes)drug use observed in the present study is also consistentwith previous research demonstrating that injection druguse in this study, future efforts should include deliveringprevention interventions to high-risk street youth not yetBMC Public Health 2009, 9:171 http://www.biomedcentral.com/1471-2458/9/171Table 1: Factors associated with injection drug use among street-involved youth (n = 560).Characteristic Yes n = 230 (41.1%) No n = 330 (58.9%) Odds Ratio (95% CI) p - valueMedian age≥ 22 years 82 (35.6) 197 (59.7) 2.67 (1.89–3.79) <0.001< 22 years 148 (64.4) 133 (40.3)GenderFemale 67 (29.1) 112 (33.9) 0.80 (0.56–1.15) 0.233Male 163 (70.9) 218 (66.1)Aboriginal ethnicityYes 51 (22.2) 80 (24.2) 0.89 (0.60–1.33) 0.570No 179 (77.8) 250 (75.8)IncarcerationYes 197 (85.7) 246 (74.5) 2.04 (1.31–3.18) <0.001No 33 (14.3) 84 (25.5)Sex workYes 74 (32.2) 47 (14.2) 2.86 (1.89–4.32) <0.001No 156 (67.8) 283 (85.8)Drug dealingYes 187 (81.3) 241 (73.0) 1.61 (1.10–2.42) 0.023No 43 (18.7) 89 (27.0)Warrants*Yes 60 (26.0) 61 (18.5) 1.56 (1.03–2.33) 0.037No 170 (74.0) 269 (81.5)OverdoseYes 107 (46.5) 79 (23.9) 2.76 (1.92–3.97) <0.001No 123 (53.5) 251 (76.1)HCV-positive†Yes 62 (26.9) 4 (1.2) 29.51(10.55–82.53) <0.001No 167 (72.6) 318 (96.4)fPage 4 of 7(page number not for citation purposes)BMC Public Health 2009, 9:171 http://www.biomedcentral.com/1471-2458/9/171exposed to injecting. Further, because these findings indi-cate that street-involved youth are at heightened risk foran array of harms through both drug use (e.g., overdoseand HCV infection) and related activities (e.g., sex workinvolvement), interventions that reduce harm amongstreet-involved youth who have taken up injecting are alsoneeded. These include conventional harm reduction inter-ventions [46], such as youth-friendly needle exchangeprograms, but also social and structural interventions thataim to mediate the risk environment of youth who injectdrugs and exchange sex, including mobile service deliveryand socio-legal reforms that facilitate safe sex work set-tings [47,48].Our study has several limitations. First, like most othercohort studies involving high-risk youth, ARYS is not arandom sample, and therefore our study findings may notbe generalize well to the larger population of street youthin Vancouver. Further, given the differences across set-tings, including differences in the types of drugs used indifferent urban environments, our findings may not gen-eralize well to street youth in other settings. Second, werelied on several measures of self-report, and thereforesome response biases may have affected our results. Inparticular, we may have underestimated some sensitivebehaviors and experiences, including injection drug useand sex work involvement. Lastly, this study design isHIV-positive‡Yes 7 (3.0) 8 (2.4) 1.64 (0.58–4.61) 0.427No 221 (96.1) 319 (96.7)* Warrants refers to having a warrant for arrest† HCV refer to hepatitis C virus‡ HIV refers to human immunodeficiency virus Values do not add up to 100% due to missing tests resultsTable 1: Factors associated with injection drug use among street-involved youth (n = 560). (Continued)ffTable 2: Logistic regression analysis of factors associated with injection drug use among street-involved youth (n = 560).Variable Adjusted Odds Ratio (AOR) 95% Confidence Interval (95% CI) p - valueAge(≥ 22 vs. < 22 years) 1.18 (1.10 – 1.28) <0.001Incarceration(yes vs. no) 1.54 (0.88 – 2.70) 0.124Sex work(yes vs. no) 2.17 (1.35 – 3.50) 0.001Overdose(yes vs. no) 2.10 (1.38 – 3.20) <0.001Drug dealing(yes vs. no) 1.20 (0.73 – 1.97) 0.472Warrants*(yes vs. no) 1.18 (0.73 – 1.93) 0.498HCV-positive(yes vs. no) 22.61 (7.78 – 65.70) <0.001Page 5 of 7(page number not for citation purposes)* Warrants refers to having a warrant for arrestBMC Public Health 2009, 9:171 http://www.biomedcentral.com/1471-2458/9/171cross-sectional in nature, and therefore causal relation-ships cannot be inferred.ConclusionIn summary, we found a high prevalence of injection druguse among street-involved youth in Vancouver. Impor-tantly, injection drug use was associated with severalmarkers of elevated risk and harm, including sex workinvolvement and overdose, as well as hepatitis C infec-tion. These findings point to the need for continuedefforts to reduce the initiation into injection use, as well asefforts to minimize the risks and harms experienced bystreet-involved youth who already inject.Competing interestsThe authors declare that they have no competing interests.Authors' contributionsTK and EW designed the study. RZ and TK conducted thestatistical analyses. TK and EW drafted the manuscript andincorporated all suggestions. All authors made significantcontributions to the conception and design of the analy-ses, interpretation of the data, and drafting of the manu-script, and all authors approved the final manuscript.AcknowledgementsThe authors thank the At-Risk Youth Study (ARYS) participants, as well as current and past ARYS investigators and staff. We also acknowledge Deb-orah Graham, Tricia Collingham, Leslie Rae, Caitlin Johnston, and Steve Kain for their assistance in research and administration.This study was supported by the US National Institutes of Health (R01 DA011591) and the Canadian Institutes of Health Research (HHP-67262 and RAA-79918). Dr. Kerr is additionally supported by the Michael Smith Foundation for Health Research (MSFHR) and the Canadian Institutes of Health Research. (CIHR). Brandon Marshall is supported by a Senior Grad-uate Trainee Award from MSFHR and a Canada Graduate Scholarship from CIHR. None of the aforementioned organizations had any further role in study design, the collection, analysis or interpretation of data, in the writing of the report, or the decision to submit the work for publication.References1. Boivin JF, Roy E, Haley N, Galbaud du Fort G: The health of streetyouth: a Canadian perspective.  Can J Public Health 2005,96(6):432-437.2. 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Soc SciMed 2008, 66(4):911-921.Pre-publication historyThe pre-publication history for this paper can be accessedhere:yours — you keep the copyrightSubmit your manuscript here:http://www.biomedcentral.com/info/publishing_adv.aspBioMedcentralPage 7 of 7(page number not for citation purposes)http://www.biomedcentral.com/1471-2458/9/171/prepub


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