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Elevated rates of HIV infection among young Aboriginal injection drug users in a Canadian setting Miller, Cari L; Strathdee, Steffanie A; Spittal, Patricia M; Kerr, Thomas; Li, Kathy; Schechter, Martin T; Wood, Evan Mar 8, 2006

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ralssBioMed CentHarm Reduction JournalOpen AcceResearchElevated rates of HIV infection among young Aboriginal injection drug users in a Canadian settingCari L Miller*1, Steffanie A Strathdee2, Patricia M Spittal1,3, Thomas Kerr1,4, Kathy Li1, Martin T Schechter1,2 and Evan Wood1,4Address: 1British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada, 2University of California School of Medicine, Department of Family and Preventive Medicine, Division of International Health & Cross-Cultural Medicine, San Diego, USA, 3University of British Columbia, Department of Health Care and Epidemiology, Vancouver, Canada and 4University of British Columbia, Faculty of Medicine, Vancouver, CanadaEmail: Cari L Miller* - cmiller@cfenet.ubc.ca; Steffanie A Strathdee - sstrathdee@ucsd.edu; Patricia M Spittal - pspittal@cfenet.ubc.ca; Thomas Kerr - tkerr@cfenet.ubc.ca; Kathy Li - kathyli@cfenet.ubc.ca; Martin T Schechter - martin.schechter@ubc.ca; Evan Wood - ewood@cfenet.ubc.ca* Corresponding author    AbstractObjectives: Recent reports have suggested that Aboriginal and American Indian people are atelevated risk of HIV infection. We undertook the present study to compare socio-demographicand risk variables between Aboriginal and non-Aboriginal young (aged 13 – 24 years) injection drugusers (IDUs) and characterize the burden of HIV infection among young Aboriginal IDUs.Methods: We compared socio-demographic and risk variables between Aboriginal and non-Aboriginal young IDUs. Data were collected through the Vancouver Injection Drug Users Study(VIDUS). Semi-annually, participants have completed an interviewer-administered questionnaireand have undergone serologic testing for HIV and Hepatitis C (HCV).Results: To date over 1500 Vancouver IDU have been enrolled and followed, among whom 291were aged 24 years and younger. Of the 291 young injectors, 80 (27%) were Aboriginal. Incomparison to non-Aboriginal youth, Aboriginal youth were more likely to test seropositive foreither HIV (20% vs 7%, p=< 0.001) or Hepatitis C virus (HCV) (66% vs 38%, p =< 0.001), beinvolved in sex work and live in the city's IDU epi-centre at baseline. After 48 months of follow-up,Aboriginal youth experienced significantly higher HIV seroconversion rates than non-Aboriginalyouth, 27.8 per ppy (95% CI: 13.4–42.2) vs. 7.0 per ppy (95% CI: 2.3–11.8) respectively (log-rank p= 0.005) and the incidence density over the entire follow-up period was 12.6 per 100 pyrs (CI:6.49–21.96) and 3.9 per 100 pyrs (CI: 1.8–7.3) respectively.Interpretation: These findings demonstrate that culturally relevant, evidence based preventionprograms are urgently required to prevent HIV infection among Aboriginal youth.Introduction sons of Aboriginal and American Indian descent may bePublished: 08 March 2006Harm Reduction Journal2006, 3:9 doi:10.1186/1477-7517-3-9Received: 16 September 2005Accepted: 08 March 2006This article is available from: http://www.harmreductionjournal.com/content/3/1/9© 2006Miller 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 6(page number not for citation purposes)In Canada and the United States, the respective Centresfor Disease Control have been alerted to the fact that per-at elevated risk for HIV/AIDS [1-3], though little data ispresently available to inform prevention efforts. In theHarm Reduction Journal 2006, 3:9 http://www.harmreductionjournal.com/content/3/1/9province of British Columbia, HIV surveillance data indi-cated that Aboriginal people accounted for approximately4% of the total population but comprised 18% of newHIV infections between 1996 and 2000 [4,5]. It is esti-mated that nearly half of the urban Aboriginal populationin Canada is under the age of 25 years compared to 30%of the non-Aboriginal population[6]. To date there hasbeen little focus on the impact of the HIV/AIDS epidemicon young Aboriginal peoples and few data are availableregarding risk factors for HIV transmission among Aborig-inal youth.Aboriginal people in Canada are overrepresented amongmarginalized groups at risk for HIV/AIDS such as injec-tion drug users (IDU) and street youth, particularly in thewestern provinces where a relatively higher proportion ofAboriginal people reside [2,6]. For example, in the Van-couver Injection Drug Users Study (VIDUS), Aboriginalpeople account for approximately 25% of the 1500 IDUenrolled[7]. Aboriginal service providers have suggestedthat injection drug use may be one of the ways in whichAboriginal people cope with the complex effects of dis-crimination, poverty and cultural dislocation, includingthe multigenerational effects of the residential school sys-tem [8].National Canadian epidemiologic surveillance data sug-gest that Aboriginal youth may be at particularly high riskof HIV/AIDS, whereby 33% of newly diagnosed Aborigi-nal people were under the age of 30 as compared with20% of non-Aboriginal people[2]. In addition, between1998 and 2000, 60% of new HIV infections among Abo-riginal people were attributed to injection drug use[1].While there has been much literature documenting theexplosive HIV outbreak that occurred among injectiondrug users in Vancouver[9], only recently has attentionbeen paid to the elevated rates of HIV infection amongAboriginal IDUs[8,10]. However, no studies have specifi-cally considered HIV prevalence and incidence ratesamong Aboriginal youth in this setting. We undertookthis study to compare young Aboriginal IDU and non-Aboriginal IDU in a city where an explosive and ongoingHIV epidemic has occurred and where approximately onequarter of the IDU population are Aboriginal.MethodsThe Vancouver Injection Drug User Study (VIDUS) is aprospective cohort study of injection drug users who havebeen recruited through self-referral and street outreachfrom Vancouver's Downtown Eastside since May 1996.The Downtown Eastside is Vancouver's poorest neighbor-hood and IDU epi-centre, where an estimated 4,700 IDUsand 1,000 street youth reside in an area of approximatelyare common. The cohort has been described in detail pre-viously[9,11,12]. Briefly, persons were eligible for theVIDUS if they had injected illicit drugs at least once in theprevious month, and resided in the greater Vancouverregion. At baseline and semi-annually, subjects have pro-vided venous blood samples and completed an inter-viewer-administered questionnaire. All participantsprovided informed consent, and were given a stipend($20 CDN) at each study visit.InstrumentThe questionnaire elicits demographic data as well asinformation about drug use, HIV risk behavior, and theuse of drug treatment. Behavioral variables were elicited ateach semi-annual follow-up visit and are in reference tothe six-month period prior to the interview. Risk factorvariables considered in the present analyses include: sexwork, use of methadone maintenance therapy (MMT), fre-quency of cocaine and heroin injection, and sexual riskvariables. Sex-work involvement was defined as exchang-ing sex for money, goods, drugs, shelter, or anything elseduring the previous 6 months. Sexual behaviours withcasual and regular sex partners were assessed separately,and sexual risk was defined as one or more instances ofunprotected vaginal or anal intercourse. Regular partnerswere defined as "someone you have had a sexual relation-ship with for more than three months (not including cli-ents/tricks)" and casual partners were defined as"someone you have had a sexual relationship with for lessthan three months (not including tricks/clients)". As hasbeen done previously[13], unstable housing was definedas living in a single room occupancy hotel, transitionalliving arrangements, or homelessness. As previously[11],frequent cocaine or heroin injection refers to at least dailyuse, and frequent crack use refers to at least daily crackcocaine smoking and we also evaluated alcohol use andreporting requiring help with injections [14] in the sixmonths previous to the time of interview. Sexually trans-mitted infections (STIs) were based on self-report. Alltime-updated behavioral variables are elicited in referenceto the six months preceding the interview whereas socio-demographic covariates (ie gender, ethnicity) were treatedas fixed baseline covariates.Statistical analysisThe present analyses were restricted to VIDUS participantsaged 24 years and younger who were recruited betweenMay 1996 and May 2003. As has been done previ-ously[15], youth were defined as those participants in thecohort who were ≤24 years at enrolment based on the agecriterion for youth and/or adolescents used in reports onHIV/AIDS generated by the United Nations, the WorldHealth Organization, the Centres for Disease Control andPage 2 of 6(page number not for citation purposes)ten city blocks, and where inexpensive housing in theform of hotels and single room occupancy hotels (SROs)Health Canada. Aboriginal ethnicity was based on self-report to the question: "are you of First Nation, Aborigi-Harm Reduction Journal 2006, 3:9 http://www.harmreductionjournal.com/content/3/1/9nal, Inuit, or Métis origin and/or do you have a statusIndian card issued by the federal government?" For thepurpose of these analyses, all Aboriginal groups werecombined and defined as "Aboriginal" due to the largenumber of different Nations comprising Aboriginalgroups in Canada and British Columbia thus presentingstatistical challenges due to power related issues. How-ever, it is noted that we present data combining individu-als representing many nations that differcharacteristically, and these differences are not consideredin these analyses.For the analysis of baseline characteristics and baselineHIV prevalence, we used contingency table analysis tocompare socio-demographic, HIV serology, and risk factorvariables for Aboriginal and non-Aboriginal youth. Chi-square and Fischer's exact tests were used to comparesocio-demographic and risk factors among the Aboriginaland non-Aboriginal youth. We identified characteristicsthat were independently associated with Aboriginal youthby fitting a logistic regression model considering all varia-bles that were statistically associated with Aboriginal eth-nicity at the p < 0.05 level in univariate analyses.Baseline HIV-negative youth with at least one follow-upvisit were eligible for an analysis of the time to HIV infec-tion. In these analyses, time zero was defined as the dateof enrolment into the study. Participants who did notbecome HIV-infected during the follow-up period werecensored as of May 2003 or at the time of their most recentfollow-up prior to this date. Cumulative HIV incidenceCox proportional hazards regression was used to assessthe independent effect of both fixed and time-dependentcovariates on time to HIV seroconversion. In the first mul-tivariate model, we considered all variables that were sta-tistically associated with HIV seroconversion at the p <0.05 level in univariate analyses in a fixed model thatincluded all of these covariates. Because we were con-scious that the number of HIV seroconversions was smalland statistical power was limited, we also prepared a par-simonious model that only included those behavioral var-iables that remained statistically associated (p < 0.05)with HIV seroconversion after adjustment. All statisticalanalyses were performed using SAS software version 8.0(SAS, Cary, NC). All reported p values were 2-sided.ResultsBetween May 1996 and May 2003, 1548 participants wererecruited into the VIDUS study among whom there were291 (19%) participants aged ≤24 years. Overall, 80 (27%)of the youth were Aboriginal and 211 (73%) were non-Aboriginal.As shown in Table 1, there was no statistical differencebetween Aboriginal and non-Aboriginal youth withrespect to age [median 16 (IQR: 14–18) vs. 17 (IQR: 15–19) respectively (p = 0.114)]; however, Aboriginal youthhad, on average, been injecting longer [median number ofyears since first injection was 5 (IQR: 2–8) vs. 3 (IQR: 1–5)] than non-Aboriginal youth (p =< 0.001). Aboriginalyouth were more likely to be female (OR: 2.22 [CI: 1.31–3.79]), report a history of sexual abuse (OR: 1.78 [CI:Table 1: Comparison of baseline sociodemographic characteristics, drug and sexual risk variables between Aboriginal youth (N = 80) and Non-Aboriginal youth (N = 211) aged 24 and under in the VIDUS project.Aboriginal Youth (N = 80, 27%)Non-Aboriginal Youth (N = 211, 73%)Odds Ratios [95% CI] *p-valueYears Fixing 5 (IQR: 2–8) 3 (IQR: 1–5) ------- <0.001HIV-positive 16 (20) 20 (7) 4.15 [1.86–9.22] <0.001HCV-positive 53 (66) 80 (38) 3.21 [1.87–5.52] <0.001Female 52 (65) 96 (46) 2.22 [1.31–3.79] 0.003Unstable House 52 (65) 124 (59) 1.30 [0.76–2.22] 0.332Sex Trade 50 (63) 77 (36) 2.90 [1.70–4.94] <0.001Sexual Abuse 40 (50) 76 (36) 1.78 [1.06–2.99] 0.029Condoms w/Regular 17 (21) 34 (16) 1.40 [0.73–2.69] 0.304Condoms w/Casual 15 (19) 64 (30) 0.53 [0.28–1.00] 0.047STI 37 (46) 70 (33) 1.73 [1.03–2.93] 0.039Alcohol Use 34 (43) 88 (42) 1.03 [0.61–1.74] 0.903≥ 1 Daily Heroin 38 (48) 119 (56) 0.70 [0.42–1.17] 0.174≥ 1 Daily Cocaine 35 (44) 59 (28) 2.00 [1.17–3.42] 0.010≥ 1 Daily Crack 16 (20) 26 (12) 1.78 [0.90–3.53] 0.096Help Injecting 36 (45) 115 (55) 0.68 [0.41–1.15] 0.145On MMT 0 (0) 7 (3) ----------- 0.099*All reported p-values are two-sided. STI = sexually transmitted infection, MMT = methadone maintenance therapy.Page 3 of 6(page number not for citation purposes)rates were calculated using the Kaplan-Meier methods andHIV-infection rates were compared by the log-rank test.1.06–2.99]), work in the sex trade (OR: 2.90 [CI: 1.70–4.94]), report a recent STI (OR: 1.73 [CI: 1.03–2.93]) andHarm Reduction Journal 2006, 3:9 http://www.harmreductionjournal.com/content/3/1/9inject cocaine (OR: 2.00 [CI: 1.17–3.42]) and speedballs(OR: 2.07 [CI: 1.06–4.02]) on a frequent basis.There were no differences between Aboriginal and non-Aborginal groups with respect to alcohol use (OR: 1.03[CI: 0.61–1.74]), condom use with regular sexual partners(OR: 1.40 [CI: 0.73–2.69]), crack cocaine use (OR: 1.78[CI: 0.90–3.53]) or ever accessing methadone mainte-nance therapy (OR: 0.0 [CI: 0.0–0.0]). Aboriginal youthwere less likely to use condoms with casual sexual part-ners (OR: 0.53 [CI: 0.28, 1.00]). Of note, at study enroll-ment, Aboriginal youth were more like to have tested HIV-positive (OR: 4.15 [95% CI: 1.86–9.22]) and HCV-posi-tive (OR: 3.21 [CI: 1.87–5.52]).In the multi-variable analysis that adjusted for all varia-bles significant in the univariate analysis, independentassociations with Aboriginal ethnicity were HIV positivity(OR: 2.54 [CI: 1.25–5.16]), HCV positivity (OR: 1.91 [CI:1.00–3.65]), and sex trade involvement (OR: 2.08 [CI:1.15–3.77]). Conversely, daily heroin injection wasinversely associated with Aboriginal ethnicity (OR: 0.50[CI: 0.28–0.91]). The multivariate model was furtheradjusted for residing in the Downtown Eastside of Van-couver (OR; 2.17 [CI: 1.21–3.88]) since this neighbor-hood is where injection drug use activity is concentratedand due to the disproportionate number of Aboriginalpeoples residing in this area of Vancouver.We then examined the time to HIV-infection among Abo-riginal and non-Aboriginal youth. There were 196 youthwho were HIV negative at enrolment and completed atleast one follow-up visit during the observation period. Ofhad occurred in 21 (11%) of the 196 youth, among whom12 (22%) were among Aboriginal and 9 (6%) wereamong non-Aboriginal youth. As shown in the Kaplan-Meier analysis (Figure 1) the cumulative HIV incidencerate after 48 months was 27.8% (95% CI: 13.4–42.2) forAboriginal youth vs. 7.0% (CI: 2.3–11.8) for non-Aborig-inal youth (log-rank p = 0.005) and HIV incidence densityover the entire follow-up period was 12.6% per 100 pyrs(CI: 6.49–21.96) and 3.9 per 100 pyrs (CI: 1.8–7.3)respectively.In univariate Cox regression analyses, factors associatedwith HIV seroconversion among the youth were; Aborigi-nal ethnicity (Relative Hazard [RH]: 3.38 [95%CI: 1.43–8.03]), unstable housing (RH: 2.59 [CI: 1.00–6.71]), sextrade (RH: 2.96 [CI: 1.24–7.07]), ≥1 daily heroin injection(RH: 2.65 [CI: 1.05–6.73]), ≥1 daily cocaine injection(RH: 5.85 [CI: 2.40–14.30]), and requiring help injecting(RH: 3.47 [CI: 1.46–8.29]).In the multi-variable analysis (Table 2), after removingnon-significant (p > 0.05) behavioral variables, factorsindependently associated with HIV seroconversionamong the youth were Aboriginal ethnicity (Adjusted Rel-ative Hazard [ARH]: 2.46, [CI: 1.00–6.03]) and ≥1 dailycocaine injection (ARH: 3.88, [CI: 1.54–9.78]).DiscussionThe main finding of this study was that Aboriginal youthwho inject drugs were more than four times as likely to beHIV-infected at enrolment and were more than twice aslikely to become HIV-infected during follow-up than non-Aboriginal youth who inject drugs. These data are con-cerning and corroborate the concerns voiced by manypeople in the Aboriginal community as well as Aboriginalservice providers[8]. The exceedingly high HIV incidencerate of 27.8 per person years among the young Aboriginalparticipants indicates that culturally appropriate preven-tion programs and services that address the health needsof HIV-positive Aboriginal people are urgently needed.Aboriginal youth were more likely to inject cocaine on adaily basis than non-Aboriginal youth. Injection cocaineuse has consistently been found to be a strong independ-ent risk factor for HIV and HCV infection amongIDUs[16], particularly in this setting[8,11,17]. Aboriginalyouth were more likely to use crack on a daily basis, abehaviour that has been shown to increase vulnerabilityto sexually transmitted infections [18-20].None of the young Aboriginal injectors had ever accessedmethadone maintenance therapy even though almost halfreported using heroin daily at baseline. Methadone main-Kaplan-Meier product limit cumulative HIV incidence strati-fied by Aboriginal ethnicityFigure 1Kaplan-Meier product limit cumulative HIV incidence strati-fied by Aboriginal ethnicity.02468101214161820222426280 6 12 18 24 30 36 42 48Time (months)Aboriginalnon-Aboriginalp = 0.005Log-rankPage 4 of 6(page number not for citation purposes)the 196 youth, 55 (28%) were Aboriginal and 141 (72%)non-Aboriginal. As of May 31, 2003, HIV seroconversiontenance therapy has been shown to aid in risk reductionamong injection drug users[21,22]. Overall, uptake ofHarm Reduction Journal 2006, 3:9 http://www.harmreductionjournal.com/content/3/1/9methadone among the young participants is very low sug-gesting there may be a need to explore reduced access tomethadone treatment services among at risk youth. In theUnited States some studies have suggested that African-American IDU are less likely to be enrolled in methadonemaintenance programs [23-25] which may be due in partto African American peoples distrust of methadone as asubstance abuse treatment[26]. This finding may also sug-gest an apprehension among Aboriginal youth to accesstreatment services not specifically designed for and in col-laboration with this population.Among the Aboriginal youth in this study, 65% werefemale, which is disproportionate to other IDU cohortstudies where females tend to comprise approximatelyone third of the sample[13,16,27]. The link betweenyoung Aboriginal females and injection drug use in thepresent setting requires further investigation; at the veryleast, this finding underscores a need for targeted inter-ventions designed specifically for and in collaborationwith young Aboriginal females. In this study, Aboriginalyouth were more likely to be engaged in sex trade workand to report a history of sexual abuse, which may beexplained by the higher proportions of females in thisgroup. However, there remains an urgent need for a cul-turally appropriate public health response to sexual abusesurvivors and sex work prevention programs for childrenas well as programs offering safety to young womeninvolved in sex work.Compared to other youth, Aboriginal youth were morelikely to report lower prevalence of condom use with cas-ual sexual partners and to self-report recently diagnosedSTI's. These findings demonstrate a potential need forincreased awareness regarding the risks of HIV acquisitionfrom unsafe sex in this population. HIV interventionsual relationships as well as the effects of discrimination,the residential school system and cultural dislocation [28-30].Several limitations of this study should be acknowledged.First, as has been previously described, the study popula-tion was not a random sample of all IDUs and the analy-ses was primarily based on self-reported behaviours.However, previous studies in our setting have suggestedthe sample is representative of IDUs in the commu-nity[31]. Nevertheless, due to the small sample size in ouranalyses, further studies will be required to confirm therisk factors associated with HIV seroconversion amongAboriginal youth. In addition, qualitative studies willlikely be valuable in providing a better understanding ofthe HIV-related vulnerabilities that may be unique toyoung Aboriginal people.In summary, we identified exceedingly high baseline HIVprevalence and subsequent elevated HIV incidence amongyoung Aboriginal injection drug users. Our study alsohighlights the disproportionate number of young femaleAboriginal people using injection drugs and an increasedvulnerability to sex work. Our findings demonstrate theurgent need for policy-makers, in collaboration with theaffected community, to implement an evidence-basedand culturally appropriate HIV prevention and addictiontreatment strategy to respond to the dual epidemics ofinjection drug use and HIV among young Aboriginal drugusers. Ultimately, all service delivery programs includingdrug treatment and methadone maintenance therapy,requires Aboriginal involvement to validate and provideculturally appropriate assessments of the services offered.References1. Health Canada: HIV/AIDS Among Aboriginal Persons in Can-ada: A Continuing Concern.  Ottawa, Centre for Infectious Dis-Table 2: Cox regression of the prognostic factors associated with time to HIV infection among the youth (aged ≤24) in the VIDUS cohort (N = 196).Characteristic Relative Hazard [95% CI] Adjusted Relative Hazard [95% CI]Aboriginal 3.38 [1.43–8.03] 2.46 [1.00–6.03]Female 1.95 [0.79–4.84]Unstable House 2.59 [1.00–6.71] 2.20 [0.84–5.76]Sex Trade 2.96 [1.24–7.07]Condoms w/Reg 0.20 [0.03–1.52]Condoms w/Casual 0.83 [0.30–2.28]≥ 1 Daily Heroin 2.65 [1.05–6.73]≥ 1 Daily Cocaine 5.85 [2.40–14.30] 3.88 [1.54–9.78]Help Injecting 3.47 [1.46–8.29] 2.18 [0.89–5.76]On MMT 1.66 [0.64–4.30]Page 5 of 6(page number not for citation purposes)among this population will likely need to consider differ-ential power dynamics between females and males in sex-ease Prevention and Control; 2002. 2. Health Canada: HIV and AIDS among Aboriginal people in .Ottawa, Bureau of HIV/AIDS, STD and TB; 2000. Publish with BioMed Central   and  every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central Harm Reduction Journal 2006, 3:9 http://www.harmreductionjournal.com/content/3/1/93. CDC: HIV/AIDS among US women: Minority and youngwomen at continuing risk.  Atlanta, Centres for Disease Control;2001. 4. Statistics Canada: 1996 Census: Aboriginal Data.  In The DailyOttawa, Statistics Canada; 1998. 5. BCCDC: HIV/AIDS Update Year End 2000.  , British ColumbiaCentre for Disease Control Society STD/AIDS Control; 2000:1-43. 6. Statistics Canada: 2001 Aboriginal Peoples Survey.  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