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Factors associated with difficulty accessing crack cocaine pipes in a Canadian setting Ti, Lianping; Buxton, Jane; Wood, Evan; Shannon, Kate; Zhang, Ruth; Montaner, Julio; Kerr, Thomas Mar 30, 2012

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Factors associated with difficulty accessing crack cocaine pipesin a Canadian settingLianping Ti, BSc1,2 [Graduate Student] [Research Assistant], Jane Buxton, MD3,4[Associate Professor] [Harm Reduction Lead], Evan Wood, MD, PhD2,5 [Director] [UrbanHealth Research Initiative] [Associate Professor], Kate Shannon, PhD2,3,5 [Director][Gender & Sexual Health Initiative] [Associate Faculty] [Assistant Professor], Ruth Zhang,MSc6 [Statistician], Julio Montaner, MD2,5 [Director] [Head of Division of AIDS], andThomas Kerr, PhD2,5 [Director] [Urban Health Research Initiative] [Associate Professor]1Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC,Canada V5A 1S62British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608-1081 BurrardStreet, Vancouver, BC, Canada V6Z 1Y63School of Population and Public Health, University of British Columbia, 5804 Fairview Avenue,Vancouver, BC, Canada V6T 1Z34Epidemiological Services, British Columbia Centre for Disease Control, 655 West 12th Avenue,Vancouver, BC, Canada V5Z 4R45Department of Medicine, University of British Columbia, St. Paul’s Hospital, 1081 Burrard Street,Vancouver, BC, Canada V6Z 1Y66Provincial Health Services Authority, 700-1380 Burrard Street, Vancouver, BC, Canada V6Z 2H3AbstractBackground—Crack cocaine pipe sharing is associated with various health-related harms,including hepatitis C transmission. Although difficulty accessing crack pipes has been found topredict pipe sharing, little is known about the factors that limit pipe access in settings where pipesare provided at no cost, albeit in limited capacity. Therefore, we investigated crack pipe accessamong people who use drugs in Vancouver, Canada.Methods—Data was collected through two Canadian prospective cohort studies. Generalizedestimating equations (GEE) with logit link for binary outcomes was used to identify factorsassociated with difficulty accessing crack pipes.Results—Among 914 participants who reported using crack cocaine, 33% reported difficultyaccessing crack pipes. In multivariate analyses, factors independently associated with difficultyaccessing crack pipes included: sex work involvement (adjusted odds ratio [AOR] = 1.57; 95%confidence interval [CI]: 1.03 – 2.39), having shared a crack pipe (AOR = 1.69; 95%CI: 1.32 –2.16), police presence where one buys/uses drugs (AOR = 1.47; 95%CI: 1.10 – 1.95), difficultyaccessing services (AOR = 1.74; 95%CI: 1.31 – 2.32), and health problems associated with crackuse (AOR = 1.37; 95%CI: 1.04 – 1.79). Reasons given for difficulty accessing pipes includedsources being closed (48.2%) and no one around selling pipes (18.1%).Send correspondence to: Thomas Kerr, PhD, Director, Urban Health Research Initiative, BC Centre for Excellence in HIV/AIDS,608 - 1081 Burrard Street, Vancouver BC V6Z 1Y6, Canada, Tel: 604-806-9116, Fax: 604-806-9044, uhri-tk@cfenet.ubc.ca.NIH Public AccessAuthor ManuscriptDrug Alcohol Rev. Author manuscript; available in PMC 2013 November 01.Published in final edited form as:Drug Alcohol Rev. 2012 November ; 31(7): 890–896. doi:10.1111/j.1465-3362.2012.00446.x.$watermark-text$watermark-text$watermark-textDiscussion—A substantial proportion of people who smoke crack cocaine report difficultyaccessing crack pipes in a setting where pipes are available at no cost but in limited quantity.These findings indicate the need for enhanced efforts to distribute crack pipes and address barriersto pipe access.Keywordsharm reduction; crack smoking; crack pipe access; VancouverINTRODUCTIONIllicit drug use continues to be associated with severe health-related harms, including thetransmission of HIV and other blood-borne diseases [1,2]. In response, many cities haveimplemented harm reduction programs that include the provision of sterile drug injectingequipment [3,4]. While this practice has been found to be effective in reducing the healthrisks associated with injection drug use, less attention has been paid to addressing theadverse health sequelae of crack cocaine use, including infectious disease transmission,burns, and injuries to the oral cavity [5,6]. This persists despite the fact that crack cocaineuse has become increasingly popular among people who use illicit drugs [7,8] and despiterecent evidence demonstrating the benefits of crack pipe distribution programs in reducingcrack pipe sharing [9].Controversy surrounding the distribution of crack cocaine smoking paraphernalia continues[10,11], and in Canada crack pipe distribution programs have recently been closed due topolitical or public pressure [12,13]. In Vancouver, the BC Centre for Disease Control(BCCDC) and Vancouver Coastal Health Authority (VCHA) are responsible for distributingcrack cocaine smoking paraphernalia free of charge, including plastic crack pipemouthpieces, wooden push sticks, and brass screens. Currently, crack kits, which includecrack pipes, are being distributed for free through five distribution sites selected as part ofVCHA’s eight-month pilot project [14,15]. Although crack pipes are provided for free andsold through a few non-governmental organizations or local shops, it is important to notethat pipes are not as widely available as needles and syringes, and because of this,individuals have often been restricted to obtaining one pipe per day at many distributionsites [14].Despite the growing problem of crack cocaine use and the increasing controversysurrounding crack pipe distribution, little is known about the impact of crack pipeavailability on individual health, and little is known about the factors that constrain access tocrack pipes. Therefore, we conducted a longitudinal study to identify the prevalence andfactors associated with difficulty accessing crack pipes among two community-recruitedcohorts of drug users in Vancouver.METHODSThe Vancouver Injection Drug Users Study (VIDUS) and the AIDS Care Cohort to evaluateExposure to Survival Services (ACCESS) are two prospective cohort studies of people whouse drugs who have been recruited through self-referral and street outreach since May 1996.These cohorts have been described in detail previously [16,17]. Briefly, persons wereeligible to enter the VIDUS study if they had injected illicit drugs at least once in theprevious month and resided in the greater Vancouver region at enrolment. ACCESSeligibility criteria included being HIV-infected and have used illicit drugs other thancannabinoids in the previous month. All eligible participants provided written informedconsent. At baseline and semi-annually, study participants complete an interviewer-Ti et al. Page 2Drug Alcohol Rev. Author manuscript; available in PMC 2013 November 01.$watermark-text$watermark-text$watermark-textadministered questionnaire which elicits information about drug use and other behaviouralpatterns, income-generation practices, engagement with medical and addiction treatmentservices, encounters with law enforcement, and other related experiences with the criminaljustice system. In addition, participants also provided blood samples for HIV and hepatitis C(HCV) testing, and HIV disease monitoring. At the conclusion of each visit, studyparticipants receive $20 CDN for their time. The study has received ethical approval fromProvidence Health Care/University of British Columbia’s Research Ethics Board. Thepresent study is restricted to those participants who reported smoking crack cocaine in theprevious six months, and were seen for study follow-up during the period of December 2009to May 2011. We restricted our study to this period given that the measures for importantexplanatory variables were only available for this period.The primary outcome of interest for this analysis was having reported difficulty accessingcrack pipes. Our measure for this variable was based on responses to the question: “Do youfind it hard to get new pipes when you need them?”. Participants who responded “yes” or“sometimes” were coded as having difficulty accessing crack pipes. Independent variablesbelieved to be potentially associated with crack pipe access included socio-demographicinformation: age (per year older), gender (female vs. male), HIV status (yes vs. no), andDowntown Eastside (DTES) residence (yes vs. no). Other factors considered included:frequency of crack use in the last six months (≥ once per day vs. < once per day), sex workinvolvement (yes vs. no), crack pipe sharing in the last six months (yes vs. no), noticingpolice presence where drugs are bought or used in the previous month (yes vs. no), difficultyaccessing services in the last six months (yes vs. no), and any health problems from smokingcrack cocaine in the last six months (any vs. none). The variable “difficulty accessingservices” includes services such as health services, counselling services, housing services,harm reduction services, and/or police services. Participants were defined as havingdifficulty accessing services if they responded “yes” to the following question: “In the lastsix months, was there ever any time you were in need of a service but could not obtain it(e.g., housing, counseling, police)?” Additionally, the “any health problems” variable wasdefined as ever experiencing at least one of the following health-related harms associatedwith crack use in the last six months: burns (lips), mouth sores, cut fingers/sores, raw throat,or coughing blood.As a first step, we examined univariate associations between socio-demographiccharacteristics and difficulty accessing crack pipes at baseline using Pearson’s Chi-squaretest and the Wilcoxon rank sum test. Since analyses of factors potentially associated withdifficulty accessing crack pipes during follow-up included serial measures for each subject,we used generalized estimating equations (GEE) for binary outcomes with logit link for theanalysis of correlated data to determine which factors were independently associated withthe outcome throughout the 18-month follow-up period. These methods provided standarderrors adjusted by multiple observations per person using an exchangeable correlationstructure. Therefore, data from every participant follow-up visit were considered in thisanalysis. Variables potentially associated with difficulty accessing crack pipes wereexamined in univariate GEE analyses. In order to adjust for potential confounding, allvariables that were associated with the dependent variable at p < 0.10 in GEE univariateanalyses were entered into a multivariate logistic GEE model. As a subanalysis, amongthose participants who reported “yes” or “sometimes” to difficulty accessing crack pipes, weasked them to indicate reasons why they found it difficult to get new pipes and reported thecorresponding prevalence. All statistical analyses were performed using SAS softwareversion 9.1. All p-values are two-sided.Ti et al. Page 3Drug Alcohol Rev. Author manuscript; available in PMC 2013 November 01.$watermark-text$watermark-text$watermark-textRESULTSDuring the study period, a total of 914 participants completed follow-up visits, including341 (37.3%) females. The median age of participants at baseline was 43 years (interquartilerange [IQR]: 36 – 48). These participants contributed to a total of 1,645 observations duringthe follow-up period. Among the 914 individuals recruited during the study period, 224(24.5%) individuals reported difficulty accessing crack pipes at baseline. Additionally, 78(8.5%) reported difficulty accessing crack pipes during follow-up.Baseline characteristics of the participants stratified by baseline reports of difficultyaccessing crack pipes are shown in Table 1. As shown here, individuals who reporteddifficulty accessing crack pipes were more likely to be female (odds ratio [OR] = 1.36; 95%confidence interval [CI]: 1.00 – 1.85) and more likely to report sex work involvement in thelast six months (OR = 2.53; 95%CI: 1.62 – 3.95).The univariate and multivariate GEE analyses are presented in Table 2. In univariate GEEanalyses, factors positively associated with difficulty accessing crack pipes included: femalegender (OR = 1.36; 95%CI: 1.04 – 1.76), sex work involvement (OR = 1.91; 95%CI: 1.30 –2.80), crack pipe sharing (OR = 1.91; 95%CI: 1.51 – 2.41), noticing police presence wheredrugs are bought or used (OR = 1.57; 95%CI: 1.19 – 2.06), difficulty accessing services (OR= 1.98; 95%CI: 1.50 – 2.61), and experiencing health problems associated with crack use(OR = 1.61; 95%CI: 1.25 – 2.09).In multivariate GEE analyses, factors that remained positively associated with difficultyaccessing crack pipes included: sex work involvement (adjusted odds ratio [AOR] = 1.57;95%CI: 1.03 – 2.39), crack pipe sharing (AOR = 1.69; 95%CI: 1.32 – 2.16), noticing policepresence where drugs are bought or used (AOR = 1.47; 95%CI: 1.10 – 1.95), difficultyaccessing services (AOR = 1.74; 95%CI: 1.31 – 2.32), and experiencing health problemsassociated with crack use (AOR = 1.37; 95%CI: 1.04 – 1.79). Of the 302 participants whoreported difficulty accessing crack pipes at some point during the study period, the threeprimary reasons given for difficulty accessing pipes included: sources being closed (48.2%),no one around selling pipes (18.1%), and being out of the area with no crack pipedistribution services around (17.4%).DISCUSSIONIn the present study, 33% of all participants reported difficulty accessing crack pipes in asetting where crack pipes are provided free or at low cost. Longitudinal analyses establishedsignificant and independent associations between difficulty accessing crack pipes and anumber of characteristics, including crack pipe sharing, experiencing health problemsrelated to crack smoking, difficulty accessing services, noticing police presence where drugsare bought or used, and sex work involvement. Among those who reported difficultyaccessing crack pipes, the main reason given for problems with pipe access was that sourcesdistributing or selling pipes (e.g. stores, harm reduction distribution sites) were closed or notavailable.In our study crack pipe sharing was associated with difficulty accessing pipes. This result isconsistent with findings from previous literature examining the availability of injecting andsmoking paraphernalia, which indicate that difficulty accessing drug paraphernalia is astrong predictor of paraphernalia sharing [18,19]. Although lesser attention has been givento programs that target crack smokers, a Canadian study reported a reduction in crack pipesharing following the introduction of a crack pipe distribution program [9]. Crack pipe reuseand sharing can lead to multiple health problems, including cuts, sores, and burns on themouth [5,9,20]. This can be due to the degradation of crack pipes over time or the use ofTi et al. Page 4Drug Alcohol Rev. Author manuscript; available in PMC 2013 November 01.$watermark-text$watermark-text$watermark-texthazardous makeshift devices, such as tin cans [18]. Our findings indicate that difficulty withaccessing pipes was positively associated with health problems common among crack users,and suggest that increasing access to crack pipes may alleviate some of these problems (e.g.,burns, cuts on lips). However, this association may be due to a selection bias in the study.Heavy users of crack cocaine may report a higher difficulty in accessing pipes due to theirfrequent use of crack cocaine. Further, heavy users cannot completely avoid the harmfulhealth effects of using crack cocaine frequently, and will consequently have a higher risk ofhealth harms, such as coughing blood, compared to infrequent users, as many health impactsof crack smoking occur independently of crack pipe access.We further observed a strong positive association between access to services and difficultyaccessing crack pipes. This may suggest that crack users are experiencing barriers toservices in general and not just barriers to crack pipe distribution services specifically.Consistent with previous studies demonstrating significant barriers to health service accessamong IDU in several settings [21,22], this study revealed that crack cocaine users facebarriers to various services, including those that provide housing and food. Although furtherresearch is needed to identify the reasons why crack users face these barriers, previousresearch has pointed to the problem of stigmatizing attitudes of service providers towardpeople who use drugs as one common cause [21,23]. In many settings, peer-basedinterventions have been found to be successful in countering stigma, and in extending thereach and effectiveness of conventional public health programs [24,25]. More specifically, astudy conducted in Vancouver evaluating the adequacy and use of crack kits demonstratedthe effectiveness of peer-delivered outreach in providing education on safer crack use [26].Given the ongoing problems with stigmatization, and the effectiveness of various peer-basedmethods for illicit drug users, enhanced efforts to utilize peer-based services may havepotential to address service barriers among crack users.Our finding that crack users who noticed police presence in the areas where they buy anduse drugs were more likely to report difficulty accessing crack pipes suggests that lawenforcement efforts may also be presenting barriers to crack pipe acquisition. Although lessresearch has concentrated on crack pipe distribution programs specifically, prior studieshave shown that police presence can deter IDU from accessing needle syringe programs(NSP) [27–29]. Reports of confiscation and destruction of drug paraphernalia by police havealso been identified as practices that undermine disease prevention efforts [27,30]. In aneffort to avoid confrontations with police, IDU have been known to revert to unsafe andrisky practices, including borrowing and lending injection equipment [27]. Given the knownhealth-related harms associated with equipment sharing [6,18], efforts to reduce theoverreliance on law enforcement and to increase harm reduction services should be exploredfurther. Furthermore, police should avoid visible patrolling around health servicesfrequented by drug users to ensure access to sterile syringe and crack pipes.Of concern, crack users who engage in sex work were significantly more likely to reportdifficulty accessing crack pipes. This finding is likely reflective of the fact that most sexworkers work during late night hours and in outlying areas, away from the fixed sitedistribution sites (e.g. community organizations, clinics). A study involving women instreet-level sex work revealed a geographical relationship between access to health and NSPservices and avoidance of violence and policing [31]. The displacement of sex workers dueto police pressure and fear of arrest has been shown to significantly reduce access to healthand harm reduction services, and likely acts as a key barrier to current crack pipedistribution [31,32]. Given that close to 100% of street-based sex workers in Vancouverhave been shown to smoke crack, and the majority report daily, intensive crack use [33], theincreased barriers to accessing pipes among sex workers is of major concern. Our resultssuggest that distribution efforts need to significantly scale-up availability of crack pipesTi et al. Page 5Drug Alcohol Rev. Author manuscript; available in PMC 2013 November 01.$watermark-text$watermark-text$watermark-textthrough outreach and mobile resources to reach sex workers during late night hours and inmore isolated spaces across Vancouver. Further, efforts to address and reduce the impacts ofpolicing on the displacement of sex workers should also be undertaken.In many settings, including Vancouver, funding and political constraints have restricted thehours of operation of harm reduction distribution sites [34,35]. Consistent with priorresearch reporting difficulty accessing sterile syringes at night [35,36], it is not surprisingthat almost half of the participants in this study attributed difficulty accessing pipes tooperating hours of stores and harm reduction distribution sites. In light of this finding,enhanced efforts are needed to extend the hours of harm reduction services in order toincrease access to crack pipes among this subpopulation. As well, additional programs suchas mobile distribution sites that extend beyond the DTES may prove to be beneficial in thissetting.There are a number of limitations to this study. Firstly, the cohorts used for this study werenot derived from random samples and were cohorts of IDU and HIV-positive drug users;therefore it is not known whether these findings will be reflective of the population of crackcocaine users in the local community or in other settings. Secondly, the study relies on self-report, which may introduce reporting biases, especially when reporting stigmatizedbehaviours such as crack pipe sharing [37]. Another limitation of our study is that thestatistical methods used only examine characteristics that co-occur with difficulty accessingcrack pipes. The nature of our study cannot untangle the precise causal relationshipsbetween these associations and therefore, further examination of these temporal dynamicswould be required to understand the causal pathways between difficulty accessing pipes,health outcomes, and social and structural factors considered.In sum, the present study found a high proportion of participants reported difficultyaccessing crack pipes in a setting where crack pipes are provided for free but in limitedquantity. Almost half reported limited operating hours as the main reason for low crack pipeacquisition. Significant barriers to crack pipe acquisition were associated with policepresence and sex work involvement. In addition, crack pipe sharing, health problems, andbarriers to accessing services were also positively associated with difficulty accessing crackpipes. These findings highlight the need to enhance crack pipe distribution efforts andreduce crack-related harms through extended operating hours and use of mobile outreach-based approaches. An indirect benefit of increasing crack pipe distribution may be to createa point of engagement for crack users to connect them to other health services. As well,strategies to increase safer crack use behaviours when new crack pipes are unavailable maybe beneficial for this subpopulation.AcknowledgmentsThe authors thank the study participants for their contribution to the research as well as current and past researchersand staff. We would specifically like to thank Deborah Graham, Tricia Collingham, Carmen Rock, Peter Vann,Caitlin Johnston, Steve Kain, and Calvin Lai for their research and administrative assistance, and Dr. Robert Hoggfor facilitating access to the British Columbia Centre for Excellence HIV/AIDS Drug Treatment Program data.Funding for this study was provided by the US National Institutes of Health (R01DA021525) and the CanadianInstitutes of Health Research (MOP-79297, RAA-79918). Thomas Kerr is supported by the Michael SmithFoundation. Julio Montaner is supported by the Ministry of Health Services and the Ministry of Healthy Living andSport, from the Province of British Columbia; through a Knowledge Translation Award from CIHR; and through anAvant-Garde Award (No 1DP1DA026182-01) from the National Institute on Drug Abuse, at the US NationalInstitutes of Health.Ti et al. Page 6Drug Alcohol Rev. Author manuscript; available in PMC 2013 November 01.$watermark-text$watermark-text$watermark-textREFERENCES1. Mahanta J, Borkakoty B, Das HK, Chelleng OK. The risk of HIV and HCV infections amonginjection drug users in northeast India. AIDS Care. 2009; 21:1420–1424. [PubMed: 20024719]2. Tyndall MW, Currie S, Spittal P, Li K, Wood E, O’Shaughnessy MV, Schechter MT. Intensiveinjection cocaine use as the primary risk factor in the Vancouver HIV-1 epidemic. Aids. 2003;17:887–893. [PubMed: 12660536]3. Witteveen E, Schippers G. Needle and Syringe Exchange Programs in Amsterdam. Subst UseMisuse. 2006; 41:835–836. [PubMed: 16809172]4. Wodak A, Cooney A. Effectiveness of sterile needle and syringes programmes. Int J Drug Policy.2005; 16S:S31–S44.5. Faruque S, Edlin B, McCoy C, Word C, Larsen S, Schmid D, Von Bargen J, Serrano Y. Crackcocaine smoking and oral sores in three innercity neighborhoods. J Acquir Immune Defic Syndr.1996; 13:87–92.6. Tortu S, McMahon J, Pouget E, Hamid R. Sharing of Noninjection Drug-Use Implements as a RiskFactor for Hepatitis C. Subst Use Misuse. 2004; 39:211–224. [PubMed: 15061559]7. Fischer B, Rehm J, Patra J, Cruz MF. Changes in illicit opioid use across Canada. Cmaj. 2006;175:1385–1387. [PubMed: 17116905]8. Werb D, Debeck K, Kerr T, Li K, Montaner J, Wood E. Modelling crack cocaine use trends over 10years in a Canadian setting. Drug Alcohol Rev. 2010; 29:271–277. [PubMed: 20565519]9. Leonard L, DeBuneis E, Pelude L, Medd E, Birkett N, Seto J. “I inject less as I have easier access topipes”: Injecting, and sharing of crack-smoking materials, decline as safer crack-smoking resourcesare distributed. Int J Drug Policy. 2008; 19:255–264. [PubMed: 18502378]10. Bailey I. Rethinking crack kits for addicts. The Globe and Mail. 201011. Hunter J. A measure of prevention in a little bag of goodies. Globe and Mail. 200812. Dormer D. Province shuts down free crack pipe program. Calgary Sun. 201113. Weismiller B. Free crack pipe service discontinued in Calgary. Calgary Herald. 201114. Olivier C. Vancouver health body begins free crack pipe program for addicts. National Post. 201115. Hager M. Free pipes distributed to curb disease. The Vancouver Sun. 201116. Kerr T, Wood E, Small D, Palepu A, Tyndall M. Potential use of safer injecting facilities amonginjection drug users in Vancouver’s downtown eastside. Cmaj. 2003; 169:759–763. [PubMed:14557313]17. Wood E, Tyndall M, Spittal P, Li K, Hogg R, Montaner J, O’Shaughnessy M, Schechter M.Factors associated with persistent high-risk syringe sharing in the presence of an establishedneedle exchange programme. Aids. 2002; 16:941–943. [PubMed: 11919503]18. Ivsins A, Roth E, Nakamura N, Krajden M, Fischer B. Uptake, benefits of and barriers to safercrack use kit (SCUK) distribution programmes in Victoria, Canada—A qualitative exploration. IntJ Drug Policy. 2011; 22:292–300. [PubMed: 21700443]19. Kerr T, Fairbairn N, Hayashi K, Suwannawong P, Kaplan K, Zhang R, Wood E. Difficultyaccessing syringes and syringe borrowing among injection drug users in Bangkok, Thailand. DrugAlcohol Rev. 2009; 29:157–161. [PubMed: 20447223]20. Porter J, Bonilla L, Drucker E. Methods of smoking crack as a potential risk factor for HIVinfection: Crack smokers’ perceptions and behavior. Contemp Drug Probl. 1997; 24:319–347.21. Brener L, Von Hippel W, Kippax S, Preacher K. The Role of Physician and Nurse Attitudes in theHealth Care of Injecting Drug Users. Subst Use Misuse. 2010; 45:1007–1018. [PubMed:20441447]22. Spicer N, Bogdan D, Brugha R, Harmer A, Murzalieva G, Semigina T. ’It’s risky to walk in thecity with syringes’: understanding access to HIV/AIDS services for injecting drug users in theformer Soviet Union countries of Ukraine and Kyrgyzstan. Globalization and Health. 2011; 723. Chan K, Stoove M, Sringernyuang L, Reidpath D. Stigmatization of AIDS Patients: DisentanglingThai Nursing Students’ Attitudes Towards HIV/AIDS, Drug Use, and Commercial Sex. AIDSBehav. 2008; 12:146–157. [PubMed: 17364148]Ti et al. Page 7Drug Alcohol Rev. Author manuscript; available in PMC 2013 November 01.$watermark-text$watermark-text$watermark-text24. Broadhead R, Heckathorn D, Anthony D, Madray H, Mills R, Hughes J. Harnessing peer networksas an instrument for AIDS prevention: Results from a peer-driven intervention. Public Health Rep.1998; 113:42–57. [PubMed: 9722809]25. Hayashi K, Wood E, Wiebe L, Qi J, Kerr T. An external evaluation of a peer-run outreach-basedsyringe exchange in Vancouver, Canada. Int J Drug Policy. 2010; 21:418–421. [PubMed:20359877]26. Boyd S, Johnson J, Moffat B. Opportunities to learn and barriers to change: crack cocaine use inthe Downtown Eastside of Vancouver. Harm Reduct J. 2008; 527. Small W, Kerr T, Charette J, Schechter M, Spittal P. Impacts of intensified police activity oninjection drug users: Evidence from an ethnographic investigation. Int J Drug Policy. 2006; 17:85–95.28. Wood E, Kerr T, Small W, Jones J, Schechter M, Tyndall M. The Impact of a Police Presence onAccess to Needle Exchange Programs. J Acquir Immune Defic Syndr. 2003; 34:116–117.[PubMed: 14501805]29. Aitken C, Moore D, Higgs P, Kelsall J, Kerger M. The impact of a police crackdown on a streetdrug scene: evidence from the street. Int J Drug Policy. 2002; 13:193–202.30. Werb D, Wood E, Small W, Strathdee S, Li K, Montaner J, Kerr T. Effects of police confiscationof illicit drugs and syringes among injection drug users in Vancouver. International Journal ofDrug Policy. 2008; 19:332–338. [PubMed: 17900888]31. Shannon K, Rusch M, Shoveller J, Alexson D, Gibson K, Tyndall M. Mapping violence andpolicing as an environmental–structural barrier to health service and syringe availability amongsubstance-using women in street-level sex work. Int J Drug Policy. 2008; 19:140–147. [PubMed:18207725]32. Sex Work, HIV/AIDS, and Human Rights Central and Eastern European Harm Reduction Networkin Central and Eastern Europe and Central Asia. Lithuania: Central and Eastern European HarmReduction Network; 2005.33. Shannon K, Bright V, Gibson K, Tyndall M. Sexual and Drug-related Vulnerabilities for HIVInfection Among Women Engaged in Survival Sex Work in Vancouver, Canada. Can J PublicHealth. 2007; 98:465–469. [PubMed: 19039884]34. Treloar C, Cao W. Barriers to use of Needle and Syringe Programmes in a high drug use area ofSydney, New South Wale. Int J Drug Policy. 2005; 16:308–315.35. Wood E, Tyndall M, Spittal P, Li K, Hogg R, O’Shaughnessy M, Schechter M. Needle exchangeand difficulty with needle access during an ongoing HIV epidemic. Int J Drug Policy. 2002;13:95–102.36. Wood E, Kerr T, Spittal P, Small W, Tyndall M, O’Shaughnessy M, Schechter M. An externalevaluation of a peer-run “Unsanctioned” syringe exchange program. J Urban Health. 2003;80:455–464. [PubMed: 12930883]37. Des Jarlais D, Paone D, Milliken J, Turner C, Miller H, Gribble J, Shi Q, Hagan H, Friedman S.Audio-computer interviewing to measure risk behaviour for HIV among injecting drug users: aquasi-randomised trial. Lancet. 1999; 353:1657–1661. [PubMed: 10335785]Ti et al. Page 8Drug Alcohol Rev. Author manuscript; available in PMC 2013 November 01.$watermark-text$watermark-text$watermark-text$watermark-text$watermark-text$watermark-textTi et al. Page 9Table 1Socio-demographic factors associated with difficulty accessing crack pipes at baseline (n = 914)Difficulty accessing crackpipesCharacteristic Yesn (%)(n = 224)Non (%)(n = 690)Odds Ratio(95% CI)p - valueAge1     ≥ 43 years old 97 (43.5) 334 (48.5) 0.82 (0.60 – 1.11) 0.20     < 43 years old 126 (56.5) 355 (51.5)Gender     Female 96 (42.9) 245 (35.5) 1.36 (1.00 – 1.85) 0.05     Male 128 (57.1) 445 (64.5)HIV positivity     Yes 104 (46.4) 312 (45.2) 1.05 (0.78 – 1.42) 0.75     No 120 (53.6) 378 (54.8)Sex trade involvement*     Yes 39 (17.4) 53 (7.7) 2.53 (1.62 – 3.95) <0.01     No 185 (82.6) 637 (92.3)Living in DTES†     Yes 135 (60.3) 433 (62.8) 0.90 (0.66 – 1.23) 0.51     No 89 (39.7) 257 (37.2)CI: confidence intervalDTES: downtown eastside of Vancouver*Activities or situations referring to the previous 6 months†Current activities1Note that counts for age do not add up to n = 914 due to 2 missing responses (n = 912).Drug Alcohol Rev. Author manuscript; available in PMC 2013 November 01.$watermark-text$watermark-text$watermark-textTi et al. Page 10Table 2Bivariate and multivariate GEE analysis of factors associated with difficulty accessing crack pipes duringfollow-up 2009–2011Unadjusted AdjustedCharacteristic Odds Ratio(95% CI)p - value Odds Ratio(95% CI)p - valueAge  (per year older) 0.85 (0.66 – 1.10) 0.22 - -Gender  (female vs. male) 1.36 (1.04 – 1.76) 0.02 1.24 (0.92 – 1.66) 0.15HIV positivity  (yes vs. no) 1.09 (0.84 – 1.41) 0.51 - -Sex trade involvement*  (yes vs. no) 1.91 (1.30 – 2.80) <0.01 1.57 (1.03 – 2.39) 0.03Living in DTES†  (yes vs. no) 0.91 (0.70 – 1.18) 0.48 - -Crack use frequency*  ≥ once per day vs.   < once per day1.25 (0.98 – 1.58) 0.07 1.03 (0.80 – 1.33) 0.82Shared crack pipe*  (yes vs. no) 1.91 (1.51 – 2.41) <0.01 1.69 (1.32 – 2.16) <0.01Police presence‡  (yes vs. no) 1.57 (1.19 – 2.06) <0.01 1.47 (1.10 – 1.95) <0.01Difficulty accessing services*  (yes vs. no) 1.98 (1.50 – 2.61) <0.01 1.74 (1.31 – 2.32) <0.01Health problems*  (any vs. none) 1.61 (1.25 – 2.09) <0.01 1.37 (1.04 – 1.79) 0.02GEE: generalized estimating equationCI: confidence intervalDTES: downtown eastside of Vancouver*Activities or situations referring to the previous 6 months†Current activities‡Activities or situations referring to the previous monthDrug Alcohol Rev. Author manuscript; available in PMC 2013 November 01.


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