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High prevalence of HIV infection among homeless and street-involved Aboriginal youth in a Canadian setting Marshall, Brandon D; Kerr, Thomas; Livingstone, Chris; Li, Kathy; Montaner, Julio S; Wood, Evan Nov 19, 2008

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ralssBioMed CentHarm Reduction JournalOpen AcceBrief reportHigh prevalence of HIV infection among homeless and street-involved Aboriginal youth in a Canadian settingBrandon DL Marshall1,2, Thomas Kerr1,3, Chris Livingstone4, Kathy Li1, Julio SG Montaner1,3 and Evan Wood*1,3Address: 1British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada , 2School of Population and Public Health, University of British Columbia, 5804 Fairview Avenue, Vancouver, BC, V6T 1Z3, Canada , 3Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada and 4Western Aboriginal Harm Reduction Society, 380 East Hastings Street, Vancouver, BC, V6A 1P4, CanadaEmail: Brandon DL Marshall - bmarshall@cfenet.ubc.ca; Thomas Kerr - uhri-tk@cfenet.ubc.ca; Chris Livingstone - livingstonechris@yahoo.com; Kathy Li - kathyli@cfenet.ubc.ca; Julio SG Montaner - jmontaner@cfenet.ubc.ca; Evan Wood* - uhri-ew@cfenet.ubc.ca* Corresponding author    AbstractAboriginal people experience a disproportionate burden of HIV infection among the adultpopulation in Canada; however, less is known regarding the prevalence and characteristics of HIVpositivity among drug-using and street-involved Aboriginal youth. We examined HIVseroprevalence and risk factors among a cohort of 529 street-involved youth in Vancouver,Canada. At baseline, 15 (2.8%) were HIV positive, of whom 7 (46.7%) were Aboriginal. Aboriginalethnicity was a significant correlate of HIV infection (odds ratio = 2.87, 95%CI: 1.02 – 8.09). Of theHIV positive participants, 2 (28.6%) Aboriginals and 6 (75.0%) non-Aboriginals reported injectiondrug use; furthermore, hepatitis C co-infection was significantly less common among Aboriginalparticipants (p = 0.041). These findings suggest that factors other than injection drug use maypromote HIV transmission among street-involved Aboriginal youth, and provide further evidencethat culturally appropriate and evidence-based interventions for HIV prevention among Aboriginalyoung people are urgently required.BackgroundAboriginal populations in Canada are contending with adisproportionate burden of HIV infection [1]. Althoughonly 3.3% of Canadians identify as American Indian, FirstNations, Inuit, or Métis, Aboriginal people accounted for18.8% of HIV test reports in 1998 and 27.3% in 2006[1,2]. Within adult Aboriginal communities, injectiondrug use is considered to be one of the primary modes ofHIV transmission, accounting for approximately 60% ofnew HIV infections [1]. Among injection drug using pop-Elevated rates of HIV incidence have also been observedamong young Aboriginal injection drug users [5,6].Although the prevalence and risk factors for HIV infectionamong Aboriginal injection drug users have been rela-tively well-described, there exists little information onHIV infection among populations of street-involved Abo-riginal youth with heterogeneous (i.e., injection and non-injection) drug-using characteristics and patterns. SinceHIV infections typically occur at earlier ages among Abo-riginal people as compared to the non-Aboriginal popula-Published: 19 November 2008Harm Reduction Journal 2008, 5:35 doi:10.1186/1477-7517-5-35Received: 6 October 2008Accepted: 19 November 2008This article is available from: http://www.harmreductionjournal.com/content/5/1/35© 2008 Marshall 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 5(page number not for citation purposes)ulations, Aboriginal ethnicity has also been shown to bean independent predictor of HIV seroconversion [3,4].tion [1], research examining the risk factors for HIVinfection among this age group is of particular salience toHarm Reduction Journal 2008, 5:35 http://www.harmreductionjournal.com/content/5/1/35public health programming and policy. We undertookthis study to examine the prevalence and characteristics ofHIV positive status among a cohort of street-involvedyouth in Vancouver.MethodsThe At Risk Youth Study (ARYS) is a prospective cohort ofdrug-using and street-involved youth that has beendescribed in detail previously [7]. Snowball sampling andextensive street-based outreach was conducted to recruitparticipants into the study. Eligibility criteria included:being between the age of 14 and 26, self-reported use ofillicit drugs other than or in addition to marijuana in thepast 30 days, and the provision of informed consent. Thestudy has been approved by the University of BritishColumbia/Providence Health Care Research Ethics Board.We also sought to ensure that the research protocols werein accordance with the Canadian Institutes of HealthResearch Guidelines for Health Research Involving AboriginalPeople [8].All participants who completed a baseline survey betweenSeptember, 2005 and October, 2006 were included in thisanalysis. At study entry, each participant completed aninterviewer-administered questionnaire and providedblood samples for HIV and hepatitis C (HCV) serology.American Indian/Aboriginal ethnicity (yes vs. no) wasdefined as self-identified First Nations, Aboriginal, Inuit,or Métis origin. Other variables that were included in thisanalysis included age (<22 vs. ≥ 22), sex (female vs. male),Downtown Eastside (DTES) residency, homelessness,injection drug use, syringe sharing, history of incarcera-tion, history of sex work, history of sexual abuse, everengaging in anal intercourse, condom use (inconsistentvs. consistent), and for males, ever engaging in sex withmen. As described previously [9], individuals wererecorded as residents of the Downtown Eastside if theyresponded "DTES" to the question, "What local neigh-bourhoods or cities have you lived in during the past 6months". Individuals classified as DTES residents mayinclude those who are homeless and sleep or spend mostof their time in the neighbourhood. To be consistent withprevious studies, syringe sharing included lending or bor-rowing used syringes, and inconsistent condom use wasdefined as not always using a condom during vaginal andanal intercourse with all regular and casual partners[10,11].Pearson's chi-square test was used to determine the factorsassociated with HIV positive status at baseline (Table 1).Fisher's exact test was used when one or more of the cellcounts was less than or equal to five. Since we onlyobserved 15 positive diagnoses, multivariate analysis waseach HIV positive participant were aggregated and are pre-sented in Table 2.FindingsA total of 529 participants completed a baseline surveyand were eligible for this analysis. The median age of thesample was 22.0 (interquartile range: 19.9 – 23.9), 159(30.1%) were female, 404 (76.4%) had been homeless inthe past six months, and 221 (41.8%) reported ever inject-ing. In total, 127 (24.0%) participants self-identified asAboriginal, American Indian, First Nations, Inuit, orMétis.Of the entire sample, 15 (2.8%) tested positive for HIV, ofwhom 7 (46.7%) were of Aboriginal ethnicity. As shownin Table 1, Aboriginal ethnicity was associated with HIVinfection (odds ratio [OR] = 2.87, 95%CI: 1.02 – 8.09), aswas injection drug use (OR = 2.75, 95%CI: 0.98 – 7.73)and sex trade work (OR = 4.35, 95%CI: 1.54 – 12.26).Younger participants were less likely to be infected withHIV (OR = 0.14, 95%CI: 0.03 – 0.65).Among the HIV positive individuals (Table 2), only 2(28.6%) Aboriginal participants reported injecting drugsand none reported sharing syringes. HIV-infected Aborig-inal youth were significantly less likely to be co-infectedwith HCV (Fisher's exact test p-value = 0.041).DiscussionAmong a community-based sample of street-involvedyouth, Aboriginal participants were more than two and ahalf times more likely to be infected with HIV. The preva-lence of HIV among Aboriginal youth in this sample was5.5%, a proportion similar to that reported in a recentstudy of at-risk Aboriginal youth in two cities in BritishColumbia [12]. The prevalence of HIV among Aboriginalyouth in this setting is also substantially higher than thosethat have been observed among street youth populationsin Montréal (1.9%) and Toronto (2.2%) [13,14]. Further-more, the fact that HIV-infected Aboriginal youth wereless likely to report injection drug use and be co-infectedwith HCV suggests that unsafe sexual activity, sex work,and other unmeasured antecedent factors may be respon-sible for a significant proportion of infections. These find-ings are concerning and suggest that immediate andculturally appropriate policy and programmatic remediesare required to prevent further infections among Aborigi-nal youth and to provide increased resources to thoseindividuals who are already infected.Other factors that were associated with HIV positivity inbivariate analysis are similar to other studies of HIV infec-tion among street-involved youth in Canada. For exam-Page 2 of 5(page number not for citation purposes)not conducted; however, the individual characteristics of ple, older age, history of injection drug use, and sex workwere also all significant correlates of HIV infection amongHarm Reduction Journal 2008, 5:35 http://www.harmreductionjournal.com/content/5/1/35a cohort of street-involved youth in Montreal [14]. Of par-ticular relevance to our setting is the high prevalence ofincarceration observed among both HIV positive and neg-ative participants – in fact, all seven HIV positive Aborigi-nal individuals also reported a history of incarceration.Given that incarceration has been associated with bothHIV risk behaviours [15] and HIV incidence [16] in Van-couver, interventions to reduce street youths' exposure tocorrectional environments and the HIV-related harmsassociated with them are in urgent need of evaluation. Offurther concern is that over half of HIV-infected Aborigi-associations between sexual abuse and HIV risk behav-iours among this population [17]. These results suggestthat programs which aim to support HIV positive Aborig-inal young people should recognize and address the last-ing effects of historical trauma and cultural assimilationstemming from the Canadian residential school systemon current levels of sexual abuse, substance use, and otherHIV-related vulnerabilities.Recently, the federal government of Canada announcedthat funding to community and regional HIV programsTable 1: Factors associated with HIV seropositive status among a cohort of homeless and street-involved youth (n = 529)Characteristic HIV Positiven (%)n = 15HIV Negativen (%)n = 514Odds Ratio(95% CI)p-valueAge< 22 2 (13.3) 265 (51.6) 0.14 (0.03 – 0.65) 0.003≥ 22 13 (86.7) 249 (48.4)SexFemale 5 (33.3) 153 (29.8) 1.18 (0.40 – 3.51) 0.778Male 10 (66.7) 361 (70.2)Aboriginal EthnicityYes 7 (46.7) 120 (23.3) 2.87 (1.02 – 8.09) 0.037No 8 (53.3) 394 (76.7)DTES Residency†Yes 4 (26.7) 139 (27.0) 0.98 (0.31 – 3.13) 1.000No 11 (73.3) 375 (73.0)Homeless†Yes 11 (73.3) 393 (76.5) 0.85 (0.26 – 2.71) 0.761No 4 (26.7) 121 (23.5)Injection Drug Use†Yes 8 (53.3) 151 (29.4) 2.75 (0.98 – 7.73) 0.046No 7 (46.7) 363 (70.6)Syringe Sharing†Yes 3 (20.0) 45 (8.8) 2.59 (0.70 – 9.56) 0.148No 12 (80.0) 467 (91.2)Incarceration‡Yes 11 (73.3) 382 (74.3) 0.95 (0.30 – 3.04) 1.000No 4 (26.7) 132 (25.7)Sex Work‡Yes 8 (53.3) 107 (20.8) 4.35 (1.54 – 12.26) 0.003No 7 (46.7) 407 (79.2)Sexual Abuse‡Yes 6 (42.9) 132 (26.0) 2.13 (0.73 – 6.23) 0.271No 8 (57.1) 375 (74.0)MSM‡Yes 2 (13.3) 33 (6.4) 2.24 (0.49 – 10.36) 0.261No 13 (86.7) 481 (93.6)Anal Intercourse‡Yes 5 (33.3) 149 (29.0) 1.22 (0.41 – 3.64) 0.774No 10 (66.7) 365 (71.0)Condom Use* †Inconsistent 4 (57.1) 284 (69.6) 0.58 (0.13 – 2.65) 0.442Consistent 3 (42.9) 124 (30.4)Note: † – refers to activities in the past 6 months; ‡ – refers to lifetime history; * – among sexually active participantsPage 3 of 5(page number not for citation purposes)nal participants reported experiencing sexual abuse, afinding which supports a recent study showing strongwould be redirected towards the Canadian HIV VaccineInitiative [18,19]. Although research funding for HIV vac-Harm Reduction Journal 2008, 5:35 http://www.harmreductionjournal.com/content/5/1/35cines is undoubtedly integral to long-term HIV strategies,the observed prevalence of HIV among Aboriginal youthobserved in this and other studies supports statementsmade by the Assembly of First Nations that, relative to thesize of the epidemic, HIV programs for Aboriginal pro-grams are chronically under-funded and are in urgentneed of further investment [20]. The Canadian AboriginalAIDS Network has also argued that a serious lack of youth-specific HIV prevention programmes for Aboriginal youthexists across the country, and as such a national strategyon Aboriginal youth HIV/AIDS prevention is required[21]. Given these concerns, research and interventionsthat seek to identify effective strategies for addressing HIVinfection and related vulnerabilities among Aboriginalyoung people should be a public health priority.Our study is limited by its nonrandom sampling method-ology that precludes generalization to the larger street-involved population in British Columbia. However, thesociodemographic characteristics of our sample are simi-lar to those observed among other street youth studies inthis setting [22,23]. Secondly, stigmatized behaviourssuch as injection drug use and syringe sharing may beunderreported, particularly as the reliability and validityof self-report among samples of Aboriginal youth hasbeen questioned by some authors [24]. However, a reviewof studies assessing the reliability and validity of self-reported drug use and HIV risk behaviours among injec-tion drug users concluded that these measures are suffi-ciently valid [25]. It is also important to note that theprevalence of injection drug use and related behavioursreported in our study are similar to those from a recentlydesirable reporting were present in the data, we have noreason to believe that Aboriginal and non-Aboriginal par-ticipants would differ with respect to the likelihood of theunderreporting of certain behaviours. Furthermore, it isnoteworthy that biological evidence (i.e., hepatitis Cserostatus) supports the self-reported data suggesting ahigher proportion of sexually acquired HIV among Abo-riginal participants. Finally, although we recognize thatHIV vulnerability among Aboriginal populations is pro-duced through a complex interplay of social, structural,and historical factors such as poverty, cultural oppression,and the multigenerational effects of the residential schoolsystem [6], we were unable to measure and characterizemany of these effects.In summary, we observed an alarmingly high prevalenceof HIV infection among street-involved Aboriginal youth.Our findings demonstrate that urgent and culturallyappropriate action is required to address the pervasiveinequities that perpetuate marginalization and height-ened vulnerability to HIV among Aboriginal young peo-ple in Canada.Competing interestsBM, TK, CL, KL, and EW declare that they have no compet-ing interests. JM has received grants from, served as an adhoc adviser to, or spoken at events sponsored by Abbott,Argos Therapeutics, Bioject Inc., Boehringer Ingelheim,BMS, Gilead Sciences, GlaxoSmithKline, Hoffmann-LaRoche, Janssen-Ortho, Merck Frosst, Panacos, Pfizer,Schering, Serono Inc., TheraTechnologies, Tibotec (J&J),and Trimeris.Authors' contributionsEW had full access to all of the data and takes responsibil-ity for the integrity of the results and the accuracy of thestatistical analysis. BM conceived the study concept anddesign and was responsible for the composition of themanuscript.The statistical analysis was conducted by KL and the inter-pretation of the results was performed by BM, CL, EW, JMand TK. The manuscript was edited and revised by BM, CL,EW, JM and TK. All authors read and approved the finalmanuscript.AcknowledgementsWe would particularly like to thank the ARYS participants for their willing-ness to be included in the study, as well as current and past ARYS investi-gators and staff. We would specifically like to thank Deborah Graham, Tricia Collingham, Leslie Rae, Caitlin Johnston, Steve Kain, and Calvin Lai for their research and administrative assistance. The study was supported by the US National Institutes of Health and the Canadian Institutes of Health Research (CIHR). Brandon Marshall is supported by training awards Table 2: Characteristics of HIV positive homeless and street-involved youth (n = 15).Characteristic Aboriginaln (%)n = 7Non-Aboriginaln (%)n = 8Age < 22 1 (14.3) 1 (12.5)Female 3 (42.9) 2 (25.0)DTES Residency† 3 (42.9) 1 (12.5)Homeless† 5 (71.4) 6 (75.0)Injected Drugs† 2 (28.6) 6 (75.0)Shared Syringes† 0 (0.0) 3 (37.5)Incarceration‡ 7 (100.0) 5 (62.5)Sex Work‡ 4 (57.1) 4 (50.0)Sexual Abuse‡ 4 (57.1) 2 (25.0)MSM‡ 2 (28.6) 0 (0.0)Anal Intercourse‡ 2 (28.6) 3 (37.5)Inconsistent Condom Use† 2 (28.6) 2 (25.0)Hepatitis C Infection 1 (14.3) 6 (75.0)Note: † – refers to activities in the past 6 months; ‡ – refers to lifetime history;Page 4 of 5(page number not for citation purposes)published analysis of risk behaviours among Aboriginalyouth who use drugs in Vancouver [12]. Even if sociallyfrom the Michael Smith Foundation for Health Research (MSFHR) and CIHR. Thomas Kerr is supported by fellowships from MSFHR and CIHR.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 2008, 5:35 http://www.harmreductionjournal.com/content/5/1/35References1. Public Health Agency of Canada: HIV/AIDS Epi Updates, Novem-ber 2007.   [http://www.phac-aspc.gc.ca/aids-sida/publication/epi/pdf/epi2007_e.pdf].2. Public Health Agency of Canada: Understanding the HIV/AIDSEpidemic among Aboriginal Peoples in Canada: The Com-munity at a Glance.   [http://www.phac-aspc.gc.ca/publicat/epiu-aepi/epi-note/pdf/epi_notes_aboriginal_e.pdf].3. 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