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HIV knowledge and perceptions of risk in a young, urban, drug-using population Johnston, C. L.; Marshall, Brandon David Lewis; Qi, Jiezhi; Zonneveld, C. J.; Kerr, Thomas; Montaner, Julio; Wood, Evan Nov 1, 2011

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HIV knowledge and perceptions of risk in a young, urban, drug-using populationC.L. Johnstona, B.D.L. Marshalla,b, J. Qia, C.J. Powera, T. Kerra,c, J.S.G. Montanera,c, and E.Wooda,c,*aBritish Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, BC, CanadabDepartment of Epidemiology, Mailman School of Public Health, Columbia University, New York,NY, USAcDepartment of Medicine, University of British Columbia, St. Paul’s Hospital, Vancouver, BC,CanadaAdolescence represents a critical developmental stage when behaviours that influence healthlater in adulthood are initiated or ingrained. Therefore, the adolescent years are a crucialtime for the acquisition of knowledge and the development of decision-making skills aboutsexual health and human immunodeficiency virus (HIV) risk-taking behaviours.The Joint United Nations Program on HIV/AIDS (UNAIDS) has reported that, globally,youth between the ages of 15 and 24 years represent 45% of all new HIV infections.1 As aresult, UNAIDS has made ‘empowering young people to protect themselves from HIV’ oneof its priority areas. In British Columbia, HIV prevention education is included in the publicschool curriculum from Grade 6 onwards.2 Therefore, a youth would have to have droppedout of school before Grade 6 not to have been exposed to at least a minimal amount offormal HIV education. Nonetheless, there is limited culturally appropriate educationavailable for youth who fall outside the school system and/or who represent specific at-riskpopulations. Adolescent illicit drug users who are street-involved represent one such at-riskcommunity.In Canada, youth account for only 3.5% of all HIV-positive persons.3 Decisions aroundfunding and resources for HIV prevention education programmes have traditionally reliedon statistics such as those presented above; however, a low population prevalence of HIVinfection may hide significant risks for transmission within some subpopulations. Lowtesting rates and lack of consideration for the potential for disease propagation in sexuallyactive and drug-using youth may further limit resources allocated to new programming, andmay not be pushing educators to create novel ways of furthering their scope of preventioneducation to reach vulnerable populations.4© 2011 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.*Correspondence to: Urban Health Research Initiative, B.C. Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, 608–1081Burrard Street, Vancouver, B.C., V6Z 1Y6 Canada. Tel.: +1 604 806 9692; fax: +1 604 806 9044., uhri-ew@cfenet.ubc.ca (E. Wood).Ethical approvalUniversity of British Columbia and Providence Health Care Research Ethics Board.Competing interestsNone declaredPublisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to ourcustomers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review ofthe resulting proof before it is published in its final citable form. Please note that during the production process errors may bediscovered which could affect the content, and all legal disclaimers that apply to the journal pertain.NIH Public AccessAuthor ManuscriptPublic Health. Author manuscript; available in PMC 2012 November 1.Published in final edited form as:Public Health. 2011 November ; 125(11): 791–794. doi:10.1016/j.puhe.2011.09.008.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptThe present study was undertaken to measure HIV knowledge among a cohort of young,street-involved drug users, and to gain a better understanding of their HIV risk-takingbehaviours and perceptions of risk of HIV acquisition. It is hoped that the results from thisstudy can be used to inform novel intervention programmes intended specifically for street-involved youth.The At-Risk Youth Study (ARYS) is a prospective cohort of young, street-involved drugusers that has been described in detail elsewhere.5 Briefly, for the purposes of the ARYS,‘street-involved’ was defined as youth who spend a substantial amount of time on the street,are engaged in the street economy, and may be at risk of being homeless.6 Mixed samplingmethods, including extensive street-based outreach, were employed to recruit youth into thestudy. Persons were eligible for the study if they had used illicit drugs (other than or inaddition to marijuana) by any mode at least once in the month prior to enrolment, werebetween 14 and 25 years of age, and provided informed consent. All participants in thisstudy were HIV negative at the time of interview. At enrolment, participants saw an on-siteresearch nurse and provided a blood sample for HIV and hepatitis C virus antibody testing.Individuals who tested positive for HIV were referred to appropriate health services. Atbaseline and semi-annually, subjects completed an interviewer-administered questionnaire inone of the community-based research offices. The location of the study office was selectedspecifically because it is geographically close to where many street youth congregate. Thequestionnaire elicits demographic data as well as information about drug use and HIV riskbehaviour, including sexual practices and risks related to sex work. All participants weregiven a stipend (C$20) at each study visit. The study was approved by the ProvidenceHealth Care/University of British Columbia Research Ethics Board.Descriptive statistics used to describe the characteristics of the study population included:age (per year older), gender (female vs male), sexual orientation [lesbian, gay, bisexual,transgender (LGBT) vs heterosexual] and Aboriginal ancestry (i.e. those who self-identifiedas First Nations, Aboriginal, Inuit or Métis). Sex behaviours included: number of sexpartners (>1 vs ≤1), any unprotected intercourse during anal and/or vaginal intercourse (yesvs no), relationship status [single/casually dating vs long-term relationship (i.e. duration ofat least 3 months with the same partner)] and participation in sex trade work (yes vs no).Drug-use behaviours included: drugs used (heroin, cocaine, crystal methamphetamine, clubdrugs and crack cocaine), any injection drug use (yes vs no) and syringe sharing (yes vs no).All behavioural variables referred to the past 6 months. Perceptions of HIV risk wereexamined using responses to the question: ‘Compared with other drug users in Vancouver,how likely do you think you are to get HIV/AIDS?’ Responses were grouped into threecategories: much more or a bit more likely, about the same, and much less or a bit lesslikely.The primary outcome of interest was derived from responses to the 18-item HIV KnowledgeQuestionnaire (HIV-KQ-18), a validated instrument that has been shown to be internallyconsistent, stable and suitable for use with low-literacy populations.7 Answer options forquestions on HIV knowledge were ‘true’, ‘false’ or ‘don’t know’, and each correct answerwas given one point. The sample was dichotomized into high vs low knowledge based onthe sample median. Cronbach’s alpha was computed to determine the internal consistency ofscores derived from this sample.In order to determine the characteristics independently associated with higher HIVknowledge, a logistic regression analysis was conducted that included all variables that weresignificant in bivariate analysis at a conservative cut-off of P<0.10. All analyses wereconducted using SAS Version 9.1.Johnston et al. Page 2Public Health. Author manuscript; available in PMC 2012 November 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptBetween May 2006 and January 2010, 589 youth were recruited into the ARYS. The medianage was 22 [interquartile range (IQR) 20–24] years, 186 (31.6%) were female, 83 (14.1%)self-identified as LGBT, and 143 (24.3%) were of Aboriginal ancestry. Only one-third(n=196) had a high school education or higher. The median score on the HIV-KQ-18 was 15(IQR 12–16). Internal reliability was very good (Cronbach’s α=0.82). The level of HIV risk-taking behaviour was high. Overall, 217 (36.8%) youth reported multiple sex partners, 428(72.7%) had engaged in unprotected intercourse, 46 (7.8%) reported sex trade work, 160(27.2%) injected an illicit drug, and 40 (6.8%) reported syringe sharing in the past 6 months.The majority of respondents (80.2%) perceived themselves to be at lower risk for acquiringHIV compared with their peers, while 15.2% perceived themselves to be at about the samerisk, and 4.6% perceived themselves to be at higher risk.The logistic regression analyses demonstrated that several factors were independentlyassociated with higher HIV knowledge (see Table 1). In the final multivariate model, youthwith higher HIV knowledge were independently more likely to be older [adjusted odds ratio(AOR) 1.08 per year older, 95% confidence interval (CI) 1.01–1.15; P=0.031], have a highschool education or higher (AOR 1.42, 95% CI 0.99–2.04; P=0.054), have used club drugs(AOR 0.66, 95% CI 0.46–0.94; P=0.023) and engage in unprotected intercourse (AOR 1.73,95% CI 1.23–2.44; P=0.002), and were less likely to be of Aboriginal ancestry (AOR 0.69,95% CI 0.47–1.02; P=0.063).Given the urban Canadian setting, where HIV education is believed to be widely availableboth formally and informally, the low HIV knowledge scores among street-involved youthin Vancouver were surprising. As mentioned, HIV education is included in the BritishColumbia public school curriculum, starting in Grade 6 and repeated in subsequent grades;however, less than one-third of youth in the ARYS reported having a high school educationor higher, which may explain the relatively low level of HIV knowledge in this sample.Unfortunately, it was not possible to assess the amount of exposure to formal HIV educationamong study participants. Although a number of community organizations in Vancouveroffer HIV education to street-involved youth, participants were not asked whether they hadreceived HIV education from these programmes or whether they had obtained HIVinformation from other sources. The low HIV knowledge scores of street-involved youth inthe ARYS are of concern given that participants also report low perceptions of risk ofacquiring HIV. Further to this, lower HIV knowledge scores among Aboriginal youth in thestudy impart even greater cause for concern, given this community’s already heightenedvulnerability to HIV.5,8One could argue that the low HIV risk perception may explain the high level of HIV risk-taking behaviour. However, it is noteworthy that higher HIV knowledge was not associatedwith reduced drug use, or safer injection-related or sexual risk-taking behaviours. In fact,those with higher HIV knowledge scores were more likely to report inconsistent condom useduring sexual intercourse, and were just as likely to have had multiple sex partners asparticipants with lower HIV knowledge scores. Traditionally, educational programmestargeted at youth to prevent HIV transmission have been based on a model that increasedknowledge results in improved ability to reduce risk-taking behaviour.9 However, the resultsof this study suggest that HIV education programmes may not be reaching high-risk youthpopulations or are not having their intended effect. Further research is required to elucidatewhy high HIV knowledge does not seem to reduce engagement in HIV risk behaviour in thispopulation.Given the complex forces that drive HIV risk-taking behaviour, educational programmesthat focus on prevention should recognize the unique cultural, social and environmentalcharacteristics of street-involved, drug-using youth. Specifically, HIV risk reductionJohnston et al. Page 3Public Health. Author manuscript; available in PMC 2012 November 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscripteducation programmes should not be the sole responsibility of the public school system, andshould use evidence-based modes for educating. Although further study is required, peer-based models for education delivery may allow for greater access to drug-using youth whodo not use mainstream services, and for those who may have ‘aged out’ (22–30 years) ofyouth services. Health educators who come from within the community may have privilegedaccess, and are better able to engage the trust and confidence of members of the targetcommunity. Youth who are or have been drug users are therefore well situated to identifyand understand the unique learning needs of the community.9 Peer educators have also beenshown to understand the cultural nuances and languages of their peer group, and withtraining and educational skills development can deliver contextually accurate and culturallyappropriate health education.10The absence of a probability sample limits the ability of this study to generalize to the drug-using adolescent population in Canada. This is a common methodological problem in studiesinvolving difficult-to-access populations; however, through the application of targetedsampling and multiple modes of recruitment, the authors believe that the current studypopulation is a representative cross-section of the drug-using, street-involved youthpopulation in the Metro Vancouver area. Additionally, recall and perceived desirability ofresponses around stigmatized behaviours, such as illicit drug use and sexual risk-takingpractices, may be under-reported.The present study found low HIV knowledge among a sample of Canadian street-involvedyouth, and a positive association between knowledge and HIV risk behaviour. Given themultitude of situations and environments that promote HIV risk behaviour among drug-using youth, education programmes should be fully evaluated and must recognize the uniquecharacteristics and factors that drive risk among this population. Although further research isneeded, consideration should also be given to alternative education methods such as thoseoffered through popular education, including participatory education, multi-media and socialnetworking, which may be more successful in meeting the learning needs of this communityof youth.9,11AcknowledgmentsFundingUS National Institute for Health, Canadian Institute for Health Research, and Michael Smith Foundation for HealthResearch.References1. Joint United Nations Programme on HIV/AIDS. Report on the global HIV/AIDS epidemic 2008.Geneva: UNAIDS; 2008.2. Ministry of Education. Health and career education K to 7: integrated resource package 2006.Victoria, BC: Ministry of Education, Province of British Columbia; 2006.3. Public Health Agency of Canada. HIV/AIDS epi updates, November 2007. Ottawa, ON:Surveillance and Risk Assessment Division, Centre for Infectious Disease Control and Prevention,Public Health Agency of Canada; 2007.4. Mill JE, Jackson RC, Worthington CA, et al. HIV testing and care in Canadian Aboriginal youth: acommunity based mixed methods study. BMC Infect Dis. 2008; 8:132. [PubMed: 18840292]5. Marshall BDL, Kerr T, Livingstone C, Li K, Montaner JSG, Wood E. High prevalence of HIVinfections among homeless and street-involved Aboriginal youth in a Canadian setting. HarmReduction J. 2008; 5:35.Johnston et al. Page 4Public Health. Author manuscript; available in PMC 2012 November 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript6. Marshall BDL, Kerr T, Shoveller JA, Patterson TL, Buxton JA, Wood E. Homelessness andunstable housing associated with an increased risk of HIV and STI transmission among street-involved youth. Health Place. 2009; 15:753–60. [PubMed: 19201642]7. Carey MP, Schroder KE. Development and psychometric evaluation of the brief HIV KnowledgeQuestionnaire. AIDS Educ Prev. 2002; 14:172–82. [PubMed: 12000234]8. Duncan KC, Reading C, Borwein AM, Murray MC, Palmer A, Michelow W, Samji H, Lima VD,Montaner JS, Hogg RS. HIV incidence and prevalence among Aboriginal peoples in Canada. AIDSBehav. 2011; 15:214–27. [PubMed: 20799061]9. Wallerstein N, Bernstein E. Empowerment education: Freire’s ideas adapted to health education.Health Educ Behav. 1988; 15:379.10. Weeks MR, Li J, Dickson-Gomez J, Convey M, Martinez M, Radda K, Clair S. Outcomes of apeer HIV prevention program with injection drug and crack users: the risk avoidance partnership.Subst Use Misuse. 2009; 44:253–81. [PubMed: 19142824]11. Young SD, Rice E. Online social networking technologies, HIV knowledge, and sexual risk andtesting behaviors among homeless youth. AIDS Behav. 2011; 15:253–60. [PubMed: 20848305]Johnston et al. Page 5Public Health. Author manuscript; available in PMC 2012 November 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptJohnston et al. Page 6Table 1Factors associated with higher human immunodeficiency virus knowledge among a young, urban, drug-population (n=589).Characteristic Unadjusted OR (95% CI) P-value Adjusted OR (95% CI)Age (per year older) 1.09 (1.02–1.16) 0.007 1.08 (1.01–1.15)Sex (female vs male) 1.02 (0.72–1.44) 0.911Ancestry (Aboriginal vs other) 0.71 (0.49–1.04) 0.073 0.69 (0.47–1.02)Sexual orientation (LGBT vs other) 1.15 (0.72–1.83) 0.563High school education (yes vs no) 1.56 (1.11–2.21) 0.011 1.42 (0.99–2.04)Relationship status (single/dating vs long-term relationship) 0.81 (0.57–1.15) 0.230Number of sex partnersa (>1 vs ≤1) 1.02 (0.73–1.43) 0.900Unprotected intercoursea (yes vs no) 2.19 (1.51–3.18) <0.001 1.73 (1.23–2.44)Sex trade worka (yes vs no) 1.14 (0.62–2.10) 0.664Any heroin usea (yes vs no) 1.04 (0.73–1.47) 0.843Any cocaine usea (yes vs no) 1.14 (0.82–1.58) 0.433Any crack usea (yes vs no) 1.05 (0.76–1.46) 0.756Any crystal meth usea (yes vs no) 1.04 (0.75–1.45) 0.796Club drug usea (yes vs no) 0.70 (0.50–0.98) 0.036 0.66 (0.46–0.94)Injection drug usea (yes vs no) 0.90 (0.63–1.30) 0.574Syringe sharinga (yes vs no) 0.76 (0.40–1.46) 0.411OR, odds ratio; CI, confidence interval; LGBT, lesbian, gay, bisexual or transgender.aActivities in the past 6 months.Public Health. Author manuscript; available in PMC 2012 November 1.


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