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The association between residential eviction and syringe sharing among a prospective cohort of street-involved… Pilarinos, Andreas; Kennedy, Mary C; McNeil, Ryan; Dong, Huiru; Kerr, Thomas; DeBeck, Kora May 12, 2017

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RESEARCH Open AccessThe association between residentialeviction and syringe sharing among aprospective cohort of street-involved youthAndreas Pilarinos1,2, Mary Clare Kennedy1,3, Ryan McNeil1,4, Huiru Dong1, Thomas Kerr1,4 and Kora DeBeck1,5*AbstractBackground: Syringe sharing is a high-risk practice associated with the transmission of infectious diseases, such asHIV and HCV. While youth who contend with housing instability are known to be more likely to engage in high-risksubstance use, the potential relationship between being evicted from housing and syringe sharing has not beenexamined. This study assessed whether residential eviction was associated with syringe sharing among street-involvedyouth in Vancouver, Canada.Methods: Data were derived from the At-Risk Youth Study (ARYS), a prospective cohort of street-involved youth whouse drugs age 14–26 in Vancouver, Canada. The study period was June 2007 to May 2014, and the potential relationshipbetween residential eviction and syringe sharing was analyzed using multivariable generalized estimating equations (GEE)logistic regression.Results: Among 405 street-involved youth who injected drugs, 149 (36.8%) reported syringe sharing, defined asborrowing or lending a syringe, at some point during the study period. In a multivariable GEE analysis, recentresidential eviction remained independently associated with syringe sharing (adjusted odds ratio (AOR) = 1.72,95% confidence interval (CI): 1.16–2.57), after adjusting for potential confounders.Conclusions: Syringe sharing was significantly elevated among youth who had recently been evicted fromhousing. These findings indicate that policy and programmatic interventions that increase housing stability mayhelp mitigate high-risk substance use practices among vulnerable youth.Keywords: Eviction, Street-involved youth, Syringe sharing, Housing policyBackgroundInjection drug use constitutes a significant public healthconcern due to its association with the transmission ofblood-borne pathogens such as HIV and HCV as well asother severe health-related harms [1–4]. These negativehealth consequences are particularly pronounced amongpeople who inject drugs (PWID) and share syringes [5].Previous research has identified risk factors associatedwith syringe sharing that include difficulty accessing needles,binge drug use, injection cocaine use, and homelessness[6, 7]. While evidence suggests that there have beensignificant reductions in syringe sharing among adultpopulations in Vancouver, Canada, [8–10], researchamong street-involved youth indicates that rates of syringesharing have persisted at concerning levels [11, 12].Previous studies of street-involved populations havedocumented numerous health-related risks and harmsassociated with housing insecurity. To date, this workhas predominantly focused on the adverse health im-pacts of homelessness, including increased likelihood ofdrug-related risk behaviors such as intensified substanceuse [13, 14], initiation of injection drug use [15, 16],public injecting [2], and syringe sharing [17]. Morerecently, there has been increased research interest inthe health consequences of residential eviction (i.e., forceddisplacement of a tenant from a leased residence throughlegal or extra-legal mechanisms). For instance, eviction* Correspondence: uhri-kd@cfenet.ubc.ca1BC Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada5School of Public Policy, Simon Fraser University, 3277-515 Hastings W Street,Vancouver, BC V6B 5K3, CanadaFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Pilarinos et al. Harm Reduction Journal  (2017) 14:24 DOI 10.1186/s12954-017-0150-5has been associated with an increased likelihood of ex-periencing violence [18] and exhibiting a detectableHIV-1 RNA viral load among adult PWID in Vancouver,Canada [19]. In addition, studies of other marginalizedpopulations have demonstrated associations betweenhousing displacement and other mental and physicalhealth concerns including depression, anxiety, suicide,high blood pressure, and poorer self-rated health status[20]. At present, however, we know of no existing studiesthat have investigated the relationship between residentialeviction and syringe sharing. Therefore, we sought toexamine whether residential eviction was associated withsyringe sharing among a prospective cohort of street-involved youth in Vancouver, Canada.MethodsThis study is based on data from the At-Risk Youth Study(ARYS), an open prospective cohort of street-involvedyouth in Vancouver, Canada, that began in 2005. The studydesign of this prospective cohort has been previouslydescribed in detail [21]. In brief, recruitment consists ofstreet-based outreach and snowball sampling. Eligibilityis restricted to street-involved youth who are age 14–26 years at baseline, have used illicit drugs other thanor in addition to marijuana in the past 30 days, andwho provide written and informed consent. The term“street-involved” refers to youth who are currently orrecently homeless or who recently accessed services forhomeless youth. Upon enrolment, and bi-annually there-after, an interview-administered questionnaire is conductedwith participants and includes demographic information,drug use patterns, and practices, as well as engagement inhealth and social services. A stipend ($30 CAD) is providedto participants at each study visit. This study has beenapproved by the University of British Columbia and theProvidence Health Care Research Ethics Board.The study period for the present analysis was restrictedto between June 2007 and May 2014, as the measures forresidential eviction were only available during this period.To examine the potential relationship between residentialeviction and syringe sharing, all analyses were restricted tostudy observations in which participants reported injec-tion drug use in the last 6 months. The primary outcomeof interest for this analysis was syringe sharing, defined asresponding affirmatively to the question: “In the last6 months, have you fixed with a rig that had already beenused by someone else?” or “In the last 6 months have youlent your used rig to someone else?” (yes vs. no). The pri-mary explanatory variable of interest was recent residen-tial eviction, defined as responding affirmatively to thequestion: “Have you been evicted in the last 6 months”(yes vs. no).To determine whether there was a significant relation-ship between our outcome of interest and our primaryexplanatory variable, we a priori selected other secondaryexplanatory factors we hypothesized might be associatedwith both residential eviction and syringe sharing. Secondaryexplanatory factors included: age (per year older),gender (female vs. male), ethnicity (Aboriginal Ancestryvs. other), binge drug use (yes vs. no), daily heroin use (yesvs. no), daily cocaine use (yes vs. no), daily crystal meth-amphetamine use (yes vs. no), difficulty accessing syringes(yes vs. no), public injecting (yes vs. no), incarceration (yesvs. no), and accessing drug treatment (e.g., pharmacother-apy, residential treatment, and counseling) (yes vs. no). Allvariables, excluding age, gender, and Aboriginal Ancestry,refer to circumstances and behaviors over the previous6 months and were treated as time-updated covariates onthe basis of semiannual follow-up data.Initially, we examined the descriptive characteristics,stratified by reports of syringe sharing at the first studyvisit. Comparisons were made using the Pearson’s χ2 testfor binary variables (Fisher’s exact test when cell countswere less than or equal to 5) and the Wilcoxon rank-sumtest for continuous variables.Next, we used generalized estimating equation (GEE)analyses with logit link function to assess the independentassociation between residential eviction and syringe sharing.These methods provide standard errors adjusted bymultiple observations per person using an exchangeableworking correlation structure [22, 23]. Therefore, datafrom every participant follow-up visit was considered.To examine the associations between syringe sharingand each explanatory variable, we first conducted bivariateGEE analyses. To fit the multivariable model, we employeda conservative variable selection approach [24]. Specifically,we initially included the primary explanatory variable andall secondary variables where p < 0.10 in bivariate analysesin a multivariable model. We then used a stepwise ap-proach to fit a series of reduced models. After comparingthe value of the coefficient associated with the main in-dependent variable of interest (residential eviction) inthe full model to the value of the coefficient in each ofthe reduced models, we dropped the secondary variableassociated with the smallest relative change. We contin-ued this iterative process until the minimum changeexceeded 5%. Remaining variables were considered con-founders in the final multivariable model. P values areall two-sided. Statistical analyses were conducted usingSAS software version 9.4 (SAS, Cary, NC).ResultsAmong 938 street-involved, 405 (43.2%) reported injectiondrug use over the study period. Of these, 142 (35.1%) werefemale and 91 (22.5%) reported being of Aboriginal Ances-try. The median age of the sample was 22.7 years (inter-quartile range (IQR) = 20.9–24.4]. This sample contributed1131 observations, and the median number of study visitsPilarinos et al. Harm Reduction Journal  (2017) 14:24 Page 2 of 6per participant during the study period that included a re-port of active injection drug use was 2 (IQR = 1–3). Themedian follow-up time per participant was 19.2 months(IQR = 6.6–48.3).In total, 149 (36.8%) youth reported syringe sharing atsome point during the study period and a total of 208(18.4%) observations included a report of syringe sharing.Additionally, 114 (28.1%) unique participants in our sam-ple reported being evicted at least once over the studyperiod. Of these, 86 (75.4%) reported one eviction event,19 (16.7%) reported two evictions, 7 (6.1%) reported threeevictions, and 2 (1.8%) reported four evictions duringfollow-up. Among the 533 (56.8%) participants excludedfrom the study, the proportion who experienced residen-tial eviction was not significantly different from those whowere included in the study (12.2 vs. 13.5%, P = 0.304).The baseline characteristics, stratified by syringe sharingin the last 6 months, are presented in Table 1. The resultsof the bivariate and multivariable GEE analyses are pre-sented in Table 2. In bivariate analyses, recent residentialeviction (odds ratio (OR) = 1.78; 95% confidence interval(CI): 1.20–2.65) was positively associated with syringe shar-ing. In the multivariable analyses, recent residential eviction(adjusted odds ratio (AOR) = 1.72, 95% confidence interval(CI): 1.16–2.57) remained significantly and positively asso-ciated with syringe sharing after adjusting for AboriginalAncestry, which was the only identified confounder.DiscussionAmong this community-recruited cohort of 405 drug-usingstreet-involved youth in Vancouver, Canada, syringe sharingwas common with over one-third of study participantsreporting borrowing or lending used syringes during thestudy period. In multivariable analyses, residential evictionwas independently associated with syringe sharing.Whereas existing literature has demonstrated that evic-tion may have harmful health-related consequences fordrug-using populations [18–20] and that homeless and un-stably housed street-involved youth experience higher ratesof risky substance use [13, 25], the current study expandson this area of research by demonstrating that experiencingresidential eviction is linked with an increased likelihood ofsyringe sharing. One potential explanation for this findingis that evicted street-involved youth may be displaced toother neighborhoods [26], reducing spatial access toservices that provide sterile injecting equipment. Addition-ally, youth who are displaced due to residential evictionmay subsequently experience homelessness, which hasbeen positively associated with syringe sharing [7]. Forexample, homeless individuals may be more likely tocome into contact with police or experience violence,which may result in the loss of sterile injecting equipmentand an increased likelihood of sharing syringes [27–29].Another possible explanation is that evicted street-involved youth may subsequently become homeless orunstably housed [30–32] and, as a result, may be morelikely to use drugs in public settings, which has previouslybeen associated with syringe sharing [33]. However, giventhat the analyses employed herein limit interpretation oftemporal relationships, it could also be that street-involvedyouth who share syringes are more heavily involved in thestreet-based drug scene or are more likely to experiencefinancial instability, which might increase their vulnerabilityto residential eviction [32]. Further research is needed toTable 1 Baseline characteristics of street-involved youth in Vancouver, Canada, stratified by syringe sharing (n = 405)Characteristic Total (%)(n = 405)Syringe sharinga Odds Ratio(95% CI)Yes (%) (n = 95) No (%) (n = 310) p valueAge (median, IQR) 22.7 (20.9–24.4) 22.2 (20.4–23.7) 22.9 (21.1–24.5) – 0.055aFemale gender 142 (35.1) 37 (38.9) 105 (33. 9) 1.25 (0.77, 2.00) 0.364Aboriginal Ancestry 91 (22.5) 12 (12.6) 79 (25.5) 0.43 (0.22, 0.83) 0.010Binge drug useb 224 (55.3) 63 (66.3) 161 (51.9) 1.81 (1.12, 2.93) 0.015Daily heroin useb 91 (22.5) 27 (28.4) 64 (20.6) 1.52 (0.90, 2.57) 0.116Daily cocaine useb 9 (2.2) 2 (2.1) 7 (2.3) 0.93 (0.19, 4.54) 1.000†Daily crytsal methamphetamine useb 79 (19.5) 19 (20.0) 60 (19.4) 1.04 (0.59, 1.85) 0.890Residential evictionb 67 (16.5) 21 (22.1) 46 (14.8) 1.62 (0.91, 2.90) 0.099Difficulty accessing syringesb 101 (24.9) 28 (29.5) 73 (23.5) 1.37 (0.82, 2.30) 0.225Public injectingb 274 (67.7) 77 (81.1) 197 (63.6) 2.55 (1.44, 4.53) 0.001Incarcerationb 93 (23.0) 20 (21.1) 73 (23.6) 0.87 (0.50, 1.51) 0.613Accessing drug treatmentb, c 171 (42.2) 50 (52.6) 121 (39.0) 1.75 (1.10, 2.78) 0.018†p value is generated from Fisher’s Exact Test because of small cell countaRefers to continuous variable, p value is generated from Wilcoxon rank-sum testbRefers to activities in the last 6 monthscExcludes detoxification servicesPilarinos et al. Harm Reduction Journal  (2017) 14:24 Page 3 of 6better understand the mechanisms underlying the observedassociation between residential eviction and syringe sharing.While accessing housing remains imperative to redu-cing risky substance use practices among youth, thefindings of the present study suggest that maintaininghousing stability may also play an important role in re-ducing such practices. Previous research among street-involved youth in this setting indicate that financialinstability is among the most commonly reported rea-sons for eviction [32]. A recent study also found that52% of street-involved youth in Vancouver reportedbeing unable to access housing and housing referralservices [34]. The current study findings extend thiswork and underscore the importance of ensuring thatyouth receive necessary social and financial supportsto access and maintain housing in order to preventeviction and reduce risky substance use behaviors.Given that over one-third of study participants re-ported syringe sharing at some point during the studyperiod, it is evident that interventions that reduce syringesharing among street-involved youth are needed, particu-larly among those experiencing residential eviction. Amongadult populations with concurrent disorders, existing litera-ture has pointed to the effectiveness of providing housingsupports. Examples of housing supports include access tocase management supports, home support services, crisisintervention services, and health care services [35, 36]. Theprovision of housing supports have been associated withsignificant reductions in substance use and risky practices[34, 37–39], as well as improved housing stability amongstreet-involved populations [40–42].While providing housing supports has realized signifi-cant successes among adult populations and has been in-tegrated into youth homelessness strategies in the USA,Australia, and the UK, Canada has been slow to imple-ment such a model for street-involved youth [43]. There-fore, expanding housing options and supports for youthmay have the potential to reduce experiences of evic-tion and related risky substance use practices amongthis population. Particular emphasis should be placedon ensuring that housing options espouse a continuumof care that ranges from low-threshold to abstinence-based housing in order to meet diverse range of hous-ing needs facing marginalized populations of youth,particularly those who inject drugs.This study has a number of limitations. First, becauseself-reported responses were solicited for this survey, re-sults are subject to response biases. Existing literature,however, suggests that self-reported responses amongstreet-involved populations are generally reflective ofactual behaviors [44]. Nonetheless, we suspect that sociallydesirable responses would likely lead to an underreportingof high-risk practices thereby potentially leading toconservative estimates of syringe sharing. Second, theARYS cohort is a non-randomized, community-recruitedsample of street-involved youth in Vancouver and thereforemay not be generalizable to other populations. Third, giventhe observational nature of the study, there may be un-measured confounding. In addition, the methods employedherein did not allow us to determine the temporality ofthe association between residential eviction and syringesharing.Table 2 Bivariate and multivariable generalized estimating equation (GEE) analyses of factors associated with syringe sharing amongstreet-involved youth in Vancouver, Canada, (n = 405)Unadjusted AdjustedCharacteristic Odds ratio (95% CI) p value Odds ratio (95% CI) p valueResidential evictiona,b 1.78 (1.20, 2.65) 0.004 1.72 (1.16, 2.57) 0.007Age (per year older) 0.90 (0.84, 0.96) 0.001Female genderb 1.09 (0.75, 1.58) 0.656Aboriginal Ancestryb 0.51 (0.33, 0.80) 0.003 0.50 (0.32, 0.80) 0.003Binge drug usea,b 1.58 (1.21, 2.07) <0.001Daily heroin usea,b 0.93 (0.68, 1.25) 0.619Daily cocaine usea,b 0.89 (0.38, 2.10) 0.793Daily crystal methamphetamine usea,b 0.86 (0.57, 1.30) 0.471Difficulty accessing syringesa,b 2.11 (1.51, 2.94) <0.001Public injectinga,b 2.88 (1.95, 4.25) <0.001Incarcerationa,b 1.26 (0.88, 1.80) 0.214Accessing drug treatmenta,b,c 1.09 (0.80, 1.48) 0.589aRefers to activities in the last 6 monthsbComparison is yes vs. nocExcludes detoxification servicesPilarinos et al. Harm Reduction Journal  (2017) 14:24 Page 4 of 6ConclusionsIn sum, this study found that youth who recently experi-enced residential eviction had a significantly higher like-lihood of sharing syringes. These findings suggest thatpolicy approaches aiming to provide youth with accessto a continuum of housing supports may have significantpotential to mitigate residential eviction and high-risksubstance use among street-involved youth.AbbreviationsARYS: At-Risk Youth Study; PWID: People who inject drugsAcknowledgementsThe authors thank the study participants for their participation in this study,as well as both current and past study staff and researchers. We extend ourappreciation to Cody Callon, Ana Prado, Deborah Graham, Peter Vann, SteveKain, and Tricia Collingham for their administrative and research assistance.FundingThe authors thank the study participants for their contribution to theresearch, as well as current and past researchers and staff. The study wassupported by the US National Institutes of Health (U01DA038886). Dr. KoraDeBeck is supported by a MSFHR/St. Paul’s Hospital Foundation—ProvidenceHealth Care Career Scholar Award and a Canadian Institutes of HealthResearch New Investigator Award. Mary Clare Kennedy is supported by aMitacs Accelerate Award from Mitacs Canada.Availability of data and materialsThe datasets used and analyzed during the current study are available fromthe corresponding author on reasonable request.Authors’ contributionsAP, KD, and TK conceptualized the study design. HD performed the statisticalanalyses, and AP and KD interpreted the results. AP drafted the initialmanuscript. KD, TK, RM, and MCK provided substantial revisions of themanuscript and guidance throughout the writing. All authors have read andapproved the final manuscript.Competing interestsAll authors declare that they have no competing interests.Consent for publicationNot applicable.Ethics approval and consent to participateThe At-Risk Youth Study has been approved by the Providence Health Care/University of British Columbia’s Ethics Board. All participants provided informedconsent prior to participating in this study.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1BC Centre on Substance Use, British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.2Interdisciplinary Studies Graduate Program, University of British Columbia,270-2357 Main Mall, Vancouver, BC V6T 1Z4, Canada. 3School of Populationand Public Health, University of British Columbia, 2206 East Mall, Vancouver,BC V6T 1Z3, Canada. 4Division of AIDS, Department of Medicine, University ofBritish Columbia, 667-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.5School of Public Policy, Simon Fraser University, 3277-515 Hastings W Street,Vancouver, BC V6B 5K3, Canada.Received: 16 February 2017 Accepted: 1 May 2017References1. 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Brener ND, Billy JO, Grady WR. Assessment of factors affecting the validity ofself-reported health-risk behavior among adolescents: evidence from thescientific literature. J Adolesc Health. 2003;33:436–57.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Pilarinos et al. Harm Reduction Journal  (2017) 14:24 Page 6 of 6

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