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Homelessness among a cohort of women in street-based sex work: the need for safer environment interventions Duff, Putu; Deering, Kathleen; Gibson, Kate; Tyndall, Mark; Shannon, Kate Aug 12, 2011

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RESEARCH ARTICLE Open AccessHomelessness among a cohort of women instreet-based sex work: the need for saferenvironment interventionsPutu Duff1,2, Kathleen Deering1,2, Kate Gibson3, Mark Tyndall1 and Kate Shannon1,2,4*AbstractBackground: Drawing on data from a community-based prospective cohort study in Vancouver, Canada, weexamined the prevalence and individual, interpersonal and work environment correlates of homelessness among252 women in street-based sex work.Methods: Bivariate and multivariate logistic regression using generalized estimating equations (GEE) was used toexamine the individual, interpersonal and work environment factors that were associated with homelessnessamong street-based sex workers.Results: Among 252 women, 43.3% reported homelessness over an 18-month follow-up period. In themultivariable GEE logistic regression analysis, younger age (adjusted odds ratio [aOR] = 0.93; 95%confidenceinterval [95%CI] 0.93-0.98), sexual violence by non-commercial partners (aOR = 2.14; 95%CI 1.06-4.34), servicing ahigher number of clients (10+ per week vs < 10) (aOR = 1.68; 95%CI 1.05-2.69), intensive, daily crack use (aOR =1.65; 95%CI 1.11-2.45), and servicing clients in public spaces (aOR = 1.52; CI 1.00-2.31) were independentlyassociated with sleeping on the street.Conclusions: These findings indicate a critical need for safer environment interventions that mitigate the socialand physical risks faced by homeless FSWs and increase access to safe, secure housing for women.BackgroundEmerging research suggests substantial health inequitiesexist among individuals without adequate, safe, andaffordable shelter. Homelessness represents a uniquesocial and physical environment that has been shown tosubstantially influence distribution of health inequities,risk taking and adverse health outcomes among margina-lized populations [1,2]. “Absolute homelessness” isdefined as “individuals living in the streets with no physi-cal shelter of their own, including those who spend theirnights in emergency shelters”[3]. Homelessness is agrowing concern worldwide: according to a 2005 count,one billion people lack adequate housing, and approxi-mately 100 million do not have housing at all [4]. InNorth America, homelessness is on the rise in manyurban centres [5]. A 2005 homelessness count in the USestimated that 744,313 people experienced homelessnessnationwide, with homelessness heavily concentrated inthe country’s major cities [5,6]. In the greater region ofVancouver, Canada, the total number of homeless indivi-duals is increasing; a 2008 homelessness count identified2,660 homeless people, over double the 2002 estimate[6]. The high rates of homelessness in the greater Van-couver region suggests that current poverty-alleviationand housing interventions are inadequate in curbinghomelessness in the city [6].Of particular importance, despite a large body ofresearch examining the individual, social and physicalcontexts of homelessness among injection drug users(IDU) to date [1,7], there remains limited research docu-menting the prevelance and correlates of homelessnessamong street-based sex work populations, or how pat-terns of risk compare with their housed counterparts.Furthermore, the few studies to date among female sexworkers (FSWs) have been cross-sectional. For example,in Miami, Florida, a recent cross-sectional study among* Correspondence: gshi@cfenet.ubc.ca1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, CANADAFull list of author information is available at the end of the articleDuff et al. BMC Public Health 2011, 11:643http://www.biomedcentral.com/1471-2458/11/643© 2011 Duff et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.street-based FSWs documented a higher number of vagi-nal and oral sexual transactions with clients, increasedodds of engaging in unprotected vaginal intercourse andmore frequent accounts of exchanging sex while high ondrugs among homeless sex workers [8]. Clients of home-less FSWs were also more likely to refuse to use condomscompared to clients of more stably housed FSWs. Thisstudy provides important cross-sectional data on the sex-ual risks among homeless FSWs. Given that work envir-onment factors have been increasingly shown to play acritical role in shaping health risks among FSWs, includ-ing negotiation of sexual risks, and violence [1,8,9], thecontext of absolute homelessness warrants furtherinvestigation.An array of health problems have been associated withbeing homeless, including mental illness, physical violence,and substance abuse [2,7,9]. The convergence of these fac-tors may elevate an individual’s risk for homelessness,leading to the concept of “hard to house” individuals.Higher rates of drug use and sharing of needles have beenobserved among homeless compared to non-homelessindividuals [1,10,11]. Having a greater number of sexualpartners, engagement in unprotected sex and involvementin sex work have also been linked to homelessness and/orhousing instability [12,13]. Many homeless persons areconfronted with environmental conditions that mayfurther exacerbate drug and sexual practices, placing themat higher risk for HIV infection. For example, homeless-ness and unstable housing have been associated with shar-ing injection drug paraphernalia (rigs, needles)[11] and theuse of shooting galleries [14]. Persons who are homelessor unstably housed have been found to have HIV ratesthat are up to nine-fold higher than those who are stablyhoused [15]. In addition, evidence suggests that homelesspersons experience numerous barriers to accessing healthcare and harm reduction services [16].In order to address the dearth of longitudinal researchon the individual, interpersonal and work environmentfactors associated with homelessness among female sexworkers (FSWs), our study aimed to evaluate the preva-lence and correlates of absolute homelessness (sleepingon the street) among a prospective cohort of street-based FSWs in Vancouver, Canada.MethodsData were drawn from a community-based prospectivecohort that has been described in detail previously [17].Briefly, 252 street-based FSWs (response rate of 94%)were recruited and consented to participate in the studybetween 2006 and 2008. Based on the mapping of solici-tation spaces (’sex work strolls’), a time-space samplingstrategy was employed to recruit hard-to-reach popula-tions by sampling at times and places where they oftencongregate. Unlike other sampling strategies, physicalspaces instead of persons are the primary sampling unit[18]. The outreach team of current/former FSWsrecruited participants at staggered working hours andlocations at sex work strolls, using vehicles for late-nightoutreach for safety and increased coverage [17]. Thestudy’s eligibility criteria included being female or trans-gender aged 14 years or older, actively engaging in street-level sex work and using illicit drugs within the pastmonth (excluding marijuana). This analysis was restrictedto three visits over an 18 month period; participantscompleted baseline and at least one of two semi-annualfollow up visits which consisted of an interview-adminis-tered questionnaire by a peer researcher (current/formerstreet-based FSW), a nurse-administered pre-test coun-seling questionnaire, and HIV screening. Respondentsreceived $25 honoraria compensation at each 6-monthlyvisit for their time and expertise. This research receivedethical approved by UBC/Providence Health ethicsreview board.Dependent variableOur dependent variable was ‘absolute homelessness’ in theprevious 6 months based on a ‘yes’ response to the surveyitem “Have you slept on the street for one night or longerover the previous 6-month period?” Interviewers weretrained to ensure that only true cases of homelessnesswere coded as positive responses.Explanatory variablesIndividual, interpersonal and contextual/work environ-ment factors were considered a priori based on our earlierqualitative research, and the homelessness literature. Aspreviously [19], age was considered a continuous variable(years) and ethnicity was defined as Caucasian vs. non-Caucasian. Individual drug use patterns included dailycocaine and heroin injection, crystal methamphetamineuse (injection/non-injection). As in our previous work[20], given the high rates of crack cocaine among street-based FSWs, we have stratified intensity of daily crack useat the median (10 or more rocks per day). Interpersonalvariables of interest included servicing a higher number ofclients per week (10+ vs less), inconsistent condom use byclients, being pressured into sex without a condom, havingborrowed used syringes and pipes, and having experienceda ‘bad date’ (physical and/or sexual violence by a client),within the past 6 months. As homelessness has previouslyshown to be associated with sexual violence by non-com-mercial partners [20], we adjusted our model for thispotential confounding effect. Work environment factors ofinterest included primary types of outdoor solicitationspaces (main streets/commercial corridors, alleys/indus-trial areas, residential communities), as well as servicing inoutdoor public spaces (alleys, industrial settings) as com-pared to indoor spaces.Duff et al. BMC Public Health 2011, 11:643http://www.biomedcentral.com/1471-2458/11/643Page 2 of 7Statistical analysisData was analyzed longitudinally. Baseline variables ofage, ethnicity and education were considered as fixedcovariates. All other factors were treated as time-updatedcovariates that referred to experiences occurring duringthe previous six-month period. As previously [21], datafrom each participant’s baseline and follow up wereincluded and analyzed using generalized estimating equa-tions (GEE), which accounted for each individuals’repeated measurements over the 18-month observationperiod; thus, data from each participant’s follow-up visitwas included. These methods provided standard errorsadjusted by repeated observations per person using anexchangeable correlation structure. Missing data wereaddressed through the GEE estimating mechanism,which uses the all available pairs method to encompassthe missing data from dropouts or intermittent missingdata. All non-missing pairs of data are used in the esti-mators of the working correlation parameters. Given thecyclical nature of homelessness, this method allowed usto analyze factors associated with the outcome of sleep-ing on the street in each 6-month period.Descriptive statistics (e.g. prevalence, medians andinterquartile range [IQR]) of baseline individual, interper-sonal and work environment factors were presented, stra-tified by homelessness. Bivariate and multivariablelogistic regression with GEEs was used to examine therelationship between individual, interpersonal and workenvironment factors and being homeless in the previoussix months. Bivariate analyses were used to examineassociations and test for potential collinearity or effectmodification. P-values were generated using the Fisher’stest of exact probability when one or more observationswas less than or equal to five. A multivariate logisticregression model was constructed using GEE and subse-quently fitted with factors that were significantly asso-ciated with homelessness at a p < 0.10-level to adjust forpotential or known confounders. Variables were retainedas significant in multivariable analyses at p < 0.05. The p-values reported are two-sided; bivariate and adjustedodds ratios (OR and aOR respectively) with 95% confi-dent intervals (95%CIs) were reported.ResultsThis analysis was restricted to 252 sex workers who com-pleted baseline and up to two follow-up surveys between2006 and 2008. Just over half (51%) were Caucasian, and49% were non-Caucasian (Indigenous/Aboriginal (includ-ing, being of First Nations, Metis, Inuit ancestry) oranother visible minority). The median age of participantswas 35 years [IQR: 25-41]. All participants self-identifiedas women, of whom sixteen participants (6.3%) were trans-gendered (male-to-female). The lifetime prevalence ofabsolute homelessness was 88%, with a median age of firstsleeping on the street of 17 years [IQR: 14-25]. Over 18-months follow-up period, 43% of participants reportedbeing homeless (sleeping on the street) at least once, sug-gesting that many of these women cycle in and out ofhomelessness.The unadjusted and adjusted odds ratios in the multi-variate analysis are presented in Tables 1 and 2. In bivari-ate analysis, injecting heroin (OR = 1.49; 95%CI 1.03-2.15),injecting or smoking crystal methamphetamine (OR =2.21; 95%CI 1.26-3.87), injecting cocaine (OR = 1.17; 95%CI 0.80-1.69) and intensive crack use (OR = 1.65; 95%CI1.19-2.30) within the past six months, having borrowed aused syringe/pipe (OR = 0.32; 95%CI 0.02-0.66), numberof clients per week (OR = 1.69; 95%CI 1.12-2.54), sexualviolence (OR = 1.99; 95%CI 1.03-3.83) and servicing cli-ents in outdoor spaces (OR = 1.81; 95%CI 1.29-2.54) wereall found to be significant. In the multivariate GEE logisticregression analyses, sexual violence by non-commercialpartners (aOR = 2.14; 95%CI 1.06-4.35), servicing a highervolume of clients (10+ per week vs < 10) (aOR = 1.68; 95%CI 1.05-2.69), intensive, daily crack use (aOR = 1.65; 95%CI 1.11-2.45), servicing clients in public spaces (aOR =1.52; 95% CI 1.00-2.31), and younger age (aOR = 0.93;95%CI 0.93-0.98), were independently correlated withsleeping on the street.DiscussionThis study is one of few that examines the prevalence andcorrelates of homelessness among street-based FSWs. Theresults demonstrate a staggering prevalence of both life-time and recent homelessness among street-based FSWs,with a median age of first sleeping on the street duringadolescence. Of particular concern, after adjusting forindividual and interpersonal risks, homeless street-basedFSWs were more likely to be younger, to experience sex-ual violence by non-commercial partners, to service ahigher volume of weekly clients, to report intensive, dailycrack smoking, and to exchange sex in outdoor spaces (ascompared to indoor settings).These findings collectively highlight the intersectingsocial and physical contexts of place in shaping healthinequities among street-based FSWs. In our study, home-less street-based FSWs were 68% more likely to service ahigh number of clients (10+) per week compared to theirhoused counterparts, pointing to increased economicdependence on sex work for survival among impoverishedwomen. This finding persisted even after adjustment forfrequency and intensity of drug use, suggesting that lackof a basic necessity such as housing combined with theimmediacy of sleeping on the street may confer additionalneed to exchange sex for basic resource needs, such asshelter or food. Our results extend earlier studies amonghomeless and marginally housed youth and IDU thatfound higher number of sexual partnerships than theirDuff et al. BMC Public Health 2011, 11:643http://www.biomedcentral.com/1471-2458/11/643Page 3 of 7more stably housed counterparts [10,12], perhaps throughcommercial sex exchanges. Similarly, Surratt and Inciardi(2004) found significantly more frequent vaginal and oralsex acts among homeless FSWs compared to their housedcounterparts. Sexual violence by non-commercial partnersis higher among homeless street-based FSWs suggestingthat lack of access to safe, affordable spaces may reducestreet-based FSWs’ capacity to negotiate safety and elevatetheir risk for exploitation and abuse by intimate partnersand other sexual partners. Other studies in North Americahave observed heightened risk of physical and sexual vio-lence among homeless women [22]. Qualitative studieshave highlighted that women immersed in the street econ-omy occupy a subordinate role in the male-centred streetideology, and are often the victims of exploitation, physicaland symbolic violence [23]. Street-entrenched womenoften enter intimate partnerships as a strategy for protec-tion from structural, symbolic and interpersonal violenceintrinsic to life on the street, however the power imbal-ances arising from these partnerships sometimes trapwomen in abusive relationships [23].Importantly, contrary to a recent study among homelessand unstably housed male and female IDUs that foundincreased risk of unprotected sex compared to their stablyhoused counterparts [12], there were no differences incondom use among homeless and housed street-basedFSWs. Instead, in our study, homeless street-based FSWswere more likely to work in public spaces, a context pre-viously shown to be correlated with geographic ‘hotspots’for increased coercive unprotected sex by clients in thissetting [24]. These findings suggest that factors relating tounsafe sex work environments may be more important inthe context of condom use negotiation and violenceamong street-based FSWs. However, the social and physi-cal context of the lack of availability of safe places to sleepfor street-based FSWs may play a more distal role on thecausal pathway to unprotected sex by removing options toservice clients indoors, within a setting where criminaliza-tion and enforcement are already displacing much of thestreet-based sex market to outlying areas.Finally, unlike earlier investigations that have focusedexclusively on IDUs, slightly less than half of our sampleTable 1 Sample characteristics for individual, interpersonal and sex work environment factors among homeless andhoused street-based FSWsCharacteristic Absolute Homeless FSWs(last 18 months)43.32 (%) n = 107Housed FSWs(last 18 months)56.68 (%) n = 140p -valueIndividual Sociodemographic FactorsAge (years, Interquartile range) 27 [ IQR1:23-37] 38 [IQR: 32-42] < .001EthnicityCaucasian 54 (50.94) 82 (58.99)Aboriginal 52 (49.06) 57 (41.01) 0.571EducationLess than high school 75 (42.61) 101 (57.39)High School Graduate 22 (48.89) 23 (51.11) 0.967College/University 9 (36.00) 16 (64.00) 0.292Drug Use PatternsCocaine injection * 35 (44.30) 44 (55.70) 0.042Heroin injection* 59 (49.17) 61 (50.83) 0.033Crystal methamphetamine* 22 (68.75) 10 (31.25) 0.005Intensive, daily crack cocaine smoking)* 47 (48.45) 50 (51.55) 0.003Interpersonal FactorsReceptive sharing of used syringes/pipes* 75 (75.00) 60 (60.00) 0.064Number of clients per week (10+) 40 (49.38) 41 (50.62) 0.012Consistent condom use by clients* 16 (55.17) 13 (44.83) 0.957Physical/sexual violence by client* 25 (47.17) 28 (52.83) 0.596Physical violence by an intimate partner* 31 (47.69) 34 (52.31) 0.119Sexual violence by an intimate partner* 5 (45.45) 6(54.55) 0.039Physical Work Environment FactorsPrimarily solicits clients on main streets/commercial areas* 27 (81.82) 6 (18.18) 0.453Primarily services clients in outdoor public spaces (streets, alleys,parks)*43 (84.31) 8 (15.69) 0.1031 IQR = interquartile range* = last 6 months.Duff et al. BMC Public Health 2011, 11:643http://www.biomedcentral.com/1471-2458/11/643Page 4 of 7of street based FSWs were injectors while the majoritysmoked crack cocaine. In our study we found that beinghomeless was significantly associated with intensive,daily crack smoking. Our findings suggest that the pres-sures of living on the street may contribute to heigh-tened levels of crack use among homeless street-basedFSWs. Since many of the women in our sample live inVancouver’s downtown eastside, an area characterizedby homelessness, poverty and high levels of drug use,this setting may increase street-based FSWs’ exposure tohigh-risk environments such as crack houses, publicdrug markets, and shooting galleries that may elevatetheir crack consumption. Furthermore, living on thestreets may also facilitate the creation of social ties withother drug users, encouraging and/or exacerbatingintensive daily crack use among homeless street-basedFSWs. Given that drug use is often an antecedent ofhomelessness and exchanging sex for survival [25],increased drug use among homeless street-based FSWsin our study was not unexpected. However, given thegrowing concern that crack cocaine smoking hasemerged as a risk factor for HIV acquisition amongIDUs in our setting [26], replacing cocaine injection inthe earlier phases of the epidemic, our results haveimportant public health implications. Further explora-tion of the contexts of homeless FSWs who smokecrack but do not inject is needed, combined withincreased safer environment interventions targeting thispopulation.Collectively, our findings suggest that physical andsocial contexts of homelessness may contribute to orexacerbate violence, sexual- and drug- related risks andpoint towards the need for safer environment interven-tions that mitigate homelessness and associated risks.Safer environment interventions aimed at improvingaccess and availability of safe, stable low-income housingfor women in street-based sex work is particularly impor-tant in Vancouver, given the high costs of rental unitsand steady decreases in low income housing stock [27].At the macro-level, policies that support expanding thecontinuum of safe, secure housing options for women arewarranted, from low-threshold transitional shelters tosupportive housing models. These housing options needto be coupled with higher rental subsidies and rentalassistance programs that have proven effective elsewhere[28]. Furthermore, our results suggest that women- andsex work-only housing options need to be piloted andevaluated to reduce exposure to violence by intimateTable 2 Unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (95%CI’s) for the relationshipbetween individual-level, interpersonal and sex work environment factors and homelessness among street-basedFSWs in VancouverCharacteristic Unadjusted Odds Ratio (95% CI) Adjusted Odds Ratio (95% CI)Individual Sociodemographic FactorsAge 0.94 (0.92-0.97) 0.95 (0.93-0.98)Aboriginal† (vs. non-aboriginal) 1.14 (0.73-1.76)EducationLess than high school completion ReferenceHigh school graduate† 1.32 (0.55-3.15)Education, any college/university† 1.70 (0.62-4.64)Drug Use PatternsCocaine Injection*† 1.17 (0.80-1.69)Heroin Injection* 1.49 (1.03-2.15) 1.16 (0.76-1.79)Crystal methamphetamine use * 2.21 (1.26-3.87) 1.57 (0.91-2.71)Intensive, Daily Crack Cocaine Smoking* 1.65 (1.19-2.30) 1.65 (1.11-2.45)Social/Interpersonal FactorsReceptive sharing of used syringe/pipe† 0.32 (0.02-0.66)Number of clients per week (10+)* 1.69 (1.12-2.54) 1.68 (1.05-2.69)Consistent condom use by clients*† 1.01 (0.62-1.65)Physical/sexual violence by client *† 1.13 (0.72-1.79)Physical violence by intimate partner*† 1.34 (0.93-1.93)Sexual violence by intimate partner * 1.99 (1.03-3.83) 2.14 (1.06-4.35)Physical Work Environment FactorsPrimarily solicits clients on main streets/commercial areas*† 1.18 (0.77-1.80)Primarily services clients in outdoor public spaces (streets, alleys, parks)* 1.81 (1.29-2.54) 1.52 (1.00-2.31)* = last 6 months†Variable not entered into logistic model.Duff et al. BMC Public Health 2011, 11:643http://www.biomedcentral.com/1471-2458/11/643Page 5 of 7partners, strangers and mitigate sexual risks amongstreet-based FSWs. These types of interventions shouldbe supported by removal of criminal sanctions targetingsex work, given growing evidence of the links betweenenforcement of criminalized policies and displacement ofstreet-based FSWs away from health and support services[9,24]. At the micro-level, other safer environment inter-ventions that have proven effective in modifying theimmediate risk environment and should be scaled upinclude peer-led outreach strategies [21]. Mobile healthand support outreach services continue to be a critical,low-threshold model of connecting street-involvedwomen with health and support services, and should beexpanded to isolated sex work spaces.This study has a number of limitations that should benoted. The findings from this study may not be generaliz-able to off-street sex workers (e.g. exotic dance, escort) ormale sex workers. Given the observational nature of thisresearch, we cannot determine causality, though somepotential temporal bias may be reduced due to the use ofgeneralized estimating equations that account forrepeated responses by the same respondent. This studyused self-report data, and women’s responses may besubject to social desirability bias. However, a number ofstudies have found sex workers and drug users to providetruthful accounts of their sex and drug use activitieswhen questioned in a non-threatening environment [29].Due to a low prevalence of transgender women (6.3%),we were unable to tease out differences in homelessnessby sexual identity in our current analysis. Finally, due toa recall period of 6 months, our results may be suscepti-ble to recall bias. To reduce this bias, strategies such asusing an individual event six months prior were used tofacilitate recall. These results contribute to the growingbody of literature advocating the importance of addres-sing environmental conditions that increase HIV risks, asa means to stemming the epidemic.ConclusionIn summary, this longitudinal study demonstrates a highprevalence of homelessness among street-based FSWs inan urban Canadian setting, with the median age of firstsleeping on the street during adolescence. Of particularconcern, 43% of women reported absolute homelessnessover just 18-months of follow-up, suggesting women cyclein and out of housing. Homeless FSWs were younger,experienced higher exposure to violence by non-commer-cial partners, serviced a higher number of clients and weremore likely to engage in sex work in public spaces as com-pared to their housed counterparts. Taken together, thesefindings support the need for safer environment interven-tions to modify the social and physical contexts of riskfaced by homeless FSWs and increase access to safe,secure housing options for vulnerable women.AcknowledgementsThis work was supported through an operating grant from the CanadianInstitutes of Health Research (CIHR, HHP-98835). KD is supported through aCIHR and Michael Smith Foundation for Health Research (MSFHR) doctoralresearch trainee award, and MWT is supported through a MSFHR SeniorScholar Award. KS is supported through a MSFHR Scholar Award, a CIHRNew Investigator Award, and National Institutes of Health Research(R01DA028648). We would like to extend our thanks to the women whoparticipated project, including our many community partners, advisory boardmembers and in particular the peer research team: Shari, Rose, Chanel,Laurie, Debbie, and Adrian. We would like to acknowledge our research andadministrative staff, including Peter Vann, Ruth Zhang, Eric Fu, Ofer Amram,and Calvin Lai.Author details1British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, CANADA. 2School of Populationand Public Health, University of British Columbia, 5804 Fairview Avenue,Vancouver, BC, V6T 1Z3, CANADA. 3WISH Drop-In Centre Society, Vancouver,BC, V6B 1S5, CANADA. 4Department of Medicine, University of BritishColumbia, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z1Y6, CANADA.Authors’ contributionsKS had access to the data and takes full responsibility for the integrity of thedata. PD and KS developed the analyses plan, and KD conducted thestatistical analyses. PD wrote the first draft of the manuscript and integratedsuggestions from all co-authors. All authors made significant contributionsto the conception and design of the analyses, interpretation of the data,and drafting of the manuscript, and all authors approved the finalmanuscript.Competing interestsThe authors declare that they have no competing interests.Received: 6 May 2011 Accepted: 12 August 2011Published: 12 August 2011References1. Corneil TA, Kuyper LM, Shoveller J, Hogg RS, Li K, Spittal PM, Schechter MT,Wood E: Unstable housing, associated risk behaviour, and increased riskfor HIV infection among injection drug users. Health Place 2006, 12:79-85.2. Krieger J, Higgins DL: Housing and health: time again for public healthaction. American Journal of Public Health 2002, 92:758-768.3. United Nations: Towards Possible Change to the CensusRecommendations on Families and Households. Working Paper 12 UnitedNations Economic Commission for Europe (UNECE), Geneva.4. United Nations Centre for Human Settlements Press Release: 100 MillionHomeless in World. [http://www.un.org/Conferences/habitat/unchs/press/women.htm].5. U.S. Department of Housing and Urban Development Office of CommunityPlanning and Development: 2008 annual homeless assessment report.[http://www.hudhre.info/documents/4thHomelessAssessmentReport.pdf].6. Goldberg M, Eberle Planning and Research undefined Jim Woodward &Associates Inc, Deborah Kraus Consulting, Graves J, Infocus Consulting, JohnTalbot and Associates: On our streets and in our shelters. Results of the2005 Greater Vancouver Homeless Count Social Planning and ResearchCouncil of BC.7. Aidala AA, Sumartojo E: Why housing? AIDS Behav 2007, 11:1-6.8. Surratt HL, Inciardi JA: HIV risk, seropositivity and predictors of infectionamong homeless and non-homeless women sex workers in Miami,Florida, USA. AIDS Care 2004, 16:594-604.9. Eastwood EA, Birnbaum JM: Physical and sexual abuse and unstablehousing among adolescents with HIV. AIDS Behav 2007, 11:116-127.10. Coady MH, Latka MH, Thiede H, Golub ET, Ouellet L, Hudson SM, Kapadia F,Garfein RS: Housing status and associated differences in HIV riskbehaviors among young injection drug users (IDUs). AIDS Behav 2007,11:854-863.11. Des Jarlais DC, Braine N, Friedmann P: Unstable housing as a factor forincreased injection risk behavior at US syringe exchange programs. AIDSBehav 2007, 11:78-84.Duff et al. BMC Public Health 2011, 11:643http://www.biomedcentral.com/1471-2458/11/643Page 6 of 712. Marshall BDL, Kerr T, Shoveller JA, Patterson TL, Buxton JA, Wood E:Homelessness and unstable housing associated with an increased risk ofHIV and STI transmission among street-involved youth. Health & Place2009, 15:783-790.13. Surratt HL, Inciardi JA: HIV risk, seropositivity and predictors of infectionamong homeless and non-homeless women sex workers in Miami,Florida, USA. AIDS Care 2004, 16:594-604.14. Metraux S, Metzger D, Culhane D: Homelessness and HIV risk behaviorsamong injection drug users. Journal of Urban Health 2004, 81:618-629.15. Culhane DP, Gollub E, Kuhn R, Shpaner M: The co-occurrence of AIDS andhomelessness: results from the integration of administrative databasesfor AIDS surveillance and public shelter utilisation in Philadelphia.J Epidemiol Community Health 2001, 55:515-20.16. Aidala AA, Lee G, Abramson DM, Messeri P, Siegler A: Housing need,housing assistance, and connection to HIV medical care. AIDS Behav2007, 11:101-115.17. Shannon K, Bright V, Allinott S, Alexson D, Gibson K, Tyndall MW:Community-based HIV prevention research among substance-usingwomen in survival sex work: The Maka Project Partnership. Harm ReductJ 2007, 4:20.18. Stueve A, O’Donnell LN, Duran R, San Doval A, Blome J: Time-spacesampling in minority communities: results with young Latino men whohave sex with men. Am J Public Health 2001, 91(6):922-926.19. Shannon K, Bright V, Gibson K, Tyndall MW: Sexual and drug-relatedvulnerabilities for HIV infection among women engaged in survival sexwork in Vancouver, Canada. Can J Public Health 2007, 98:465-469.20. Shannon K, Kerr T, Strathdee SA, Shoveller J, Montaner JS, Tyndall MW:Prevalence and structural correlates of gender based violence among aprospective cohort of female sex workers. BMJ 2009, 339:b2939.21. Deering KN, Kerr T, Tyndall MW, Montaner JSG, Gibson K, Irons L,Shannon D: A peer-led mobile outreach program and increasedutilization of detoxification and residential drug treatment amongfemale sex workers who use drugs in a Canadian setting. Drug andAlcohol Dependence 2011, 113:46-54.22. Bourgois P, Prince B, Moss A: The Everyday Violence of Hepatitis CAmong Young Women Who Inject Drugs in San Francisco. Hum Organ2004, 63:253-264.23. Bourgois P: The moral economies of homeless heroin addicts:confronting ethnography, HIV risk, and everyday violence in SanFrancisco. Subst Use Misuse 1998, 33.24. Shannon K, Strathdee SA, Shoveller J, Rusch M, Kerr T, Tyndall MW:Structural and Environmental Barriers to Condom Use Negotiation WithClients Among Female Sex Workers: Implications for HIV-PreventionStrategies and Policy. American Journal of Public Health 2009, 99:659-665.25. Wechsberg WM, Lam WKK, Zule W, Hall G, Middlesteadt R, Edwards J:Violence, homelessness, and HIV risk among crack-using African-American women. Subst Use Misuse 2003, 38:669-700.26. DeBeck K, Kerr T, Li K, Fischer B, Buxton J, Montaner J, Wood E: Smoking ofcrack cocaine as a risk factor for HIV infection among people who useinjection drugs. CMAJ 2009, 181:585-589.27. 2009 Survey of Low-Income Housing in the Downtown Core. [http://vancouver.ca/commsvcs/housing/pdf/2009survey.pdf].28. Wolitski RJ, Kidder DP, Pals SL, Royal S, Aidala A, Stall R, Holtgrave DR,Harre D, Courtenay-Quirk C: Randomized Trial of the Effects of HousingAssistance on the Health and Risk Behaviors of Homeless and UnstablyHoused People Living with HIV. AIDS Behav 2009.29. De Irala J, Bigelow C, McCusker J, Hindin R, & Zheng L: Reliability of self-reported human immunodeficiency virus risk behaviors in a residentialdrug treatment population. Am J Epidemiol 1996, 143(7):725-732.Pre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/11/643/prepubdoi:10.1186/1471-2458-11-643Cite this article as: Duff et al.: Homelessness among a cohort of womenin street-based sex work: the need for safer environment interventions.BMC Public Health 2011 11:643.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitDuff et al. BMC Public Health 2011, 11:643http://www.biomedcentral.com/1471-2458/11/643Page 7 of 7


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