The Cedar project: prevalence and correlates of HIV infection among young Aboriginal people who use drugs in two Canadian cities

The Cedar Project: Racism and its impacts on health and wellbeing among young Indigenous people who use drugs in Prince George and Vancouver, BC

Racism continues to drive health disparities between Indigenous and non-Indigenous peoples in Canada. This study focuses on racism experienced by young Indigenous people who have used drugs in British Columbia (BC), and predictors of interpersonal racism. Cedar Project is a community-governed cohort study involving young Indigenous people who use drugs in Vancouver and Prince George, BC. This cross-sectional study included data collected between August 2015-October 2016. The Measure of Indigenous Racism Experiences (MIRE) scale was used to assess experiences of interpersonal racism across 9 unique settings on a 5-point Likert scale, collapsing responses into three categories (none/low/high). Multinomial logistic regression models were used to examine associations between key variables and interpersonal racism. Among 321 participants, 79% (n = 255) experienced racism in at least one setting. Thirty two percent (n = 102) experienced high interpersonal racism from police, governmental agencies (child 'welfare', health personnel), and in public settings. Ever having a child apprehended (AOR:2.76, 95%CI:1.14-6.65), probable post-traumatic stress (AOR:2.64; 95%CI:1.08-6.46), trying to quit substances (AOR:3.69; 95%CI:1.04-13.06), leaving emergency room without receiving treatment (AOR:3.05; 95%CI:1.22-7.64), and having a traditional language spoken at home while growing up (AOR:2.86; 95%CI:1.90-6.90) were associated with high interpersonal racism. Among women, experiencing high interpersonal racism was more likely if they lived in Prince George (AOR:3.94; 95%CI:1.07-14.50), ever had a child apprehended (AOR:5.09; 95%CI:1.50-17.30), and had probable post-traumatic stress (AOR:5.21; 95%CI:1.43-18.95). Addressing racism experienced by Indigenous peoples requires immediate structural systemic, and interpersonal anti-racist reforms.

Experiences of HIV among global Indigenous populations through the lens of the UN Declaration on the Rights of Indigenous Peoples

Since its introduction in 2007, the UN Declaration on the Rights of Indigenous Peoples (UNDRIP) has been adopted by 144 countries worldwide. In a ten-point statement released in 2017, Indigenous leaders in the HIV and AIDS community established a list of truths and actions to be used for advocacy to end AIDS among Indigenous Peoples through self-determination, justice, and human rights. 15 years after the UNDRIP and 5 years after the 10-point statement, this Review asks where we are in terms of upholding the UNDRIP and the International Indigenous HIV and AIDS Community statement in relation to HIV and AIDS, and what is needed to better uphold and respond to these directives. HIV in Indigenous populations continues to intersect with multiple forms of oppression, racism, and discrimination, which are yet to be eliminated from laws, policies, and practices. Eradicating white supremacy and Indigenous-specific racism across all health systems is a bare minimum requirement to uphold Indigenous rights within health care, and must be accompanied by support for Indigenous, self-determined, culturally tailored, and community-specific health and wellness services.

Overcoming the soul wound: Reflecting on experiences and resilience of intergenerational residential school survivors

BACKGROUND

Between 1883 and 1996, thousands of Indigenous children were apprehended into Canada's Residential School System. Survivors and their descendants have testified to genocidal harms caused across generations. Yet, Indigenous Peoples continue to exist and resist through inherent resilience described by intergenerational survivors in this paper.

OBJECTIVE

This article focuses on stories demonstrating the strength, power, and resilience of intergenerational residential school survivors.

PARTICIPANTS & SETTING

Cedar Project is an Indigenous-led cohort study that began as a HIV/AIDS response and contributes to healing among young Indigenous people who use drugs in British Columbia, Canada. It is governed by the Cedar Project Partnership, an Indigenous body of Elders, leaders, and health/social services experts.

METHODS

We present qualitative research involving in-depth interviews carried out with Cedar participants who have experienced significant and complex adversities including childhood maltreatment and illicit drug use. Woven throughout, Indigenous scholars who are themselves intergenerational (children and grandchildren) of residential school survivors provide first-person reflections on the findings.

RESULTS

Analysis focused on narratives of resilience and resistance to stresses of intergenerational traumas across three broad themes: working to break cycles of intergenerational trauma; foundations of resilience and making positive changes and; hopes and dreams.

CONCLUSIONS

Findings establish deeper understanding of processes that enable young people to cope with stresses of intergenerational traumas while facing institutional and structural barriers to wellness. Reflections provide context about how intergenerational experiences intersect with challenges that young intergenerational survivors continue to face. We highlight pathways to healing and sources of strength that inform recommendations for wellness.

Community trial evaluating the integration of Indigenous healing practices and a harm reduction approach with principles of seeking safety in an Indigenous residential treatment program in northern Ontario

Objective

Our primary objective was to evaluate how the Indigenous Healing and Seeking Safety (IHSS) model impacted residential addiction treatment program completion rates. Our secondary objective was to evaluate health service use 6 months before and 6 months after residential treatment for clients who attended the program before and after implementing IHSS.

Methods

We observed clients of the Benbowopka Residential Treatment before IHSS implementation (from April 2013 to March 31, 2016) and after IHSS implementation (from January 1, 2018 – March 31, 2020). The program data were linked to health administration data, including the Ontario Health Insurance Plan (OHIP) physician billing, the Registered Persons Database (RPDB), the National Ambulatory Care Reporting System (NACRS), and the Discharge Abstract Database (DAD). Chi-square tests were used to compare patient characteristics in the no-IHSS and IHSS groups. We used logistic regression to estimate the association between IHSS and treatment completion. We used generalized estimating equation (GEE) regression model to evaluate health service use (including primary care visits, ED visits overall and for substance use, hospitalizations and mental health visits), Results: There were 266 patients in the no-IHSS group and 136 in the IHSS group. After adjusting for individual characteristics, we observed that IHSS was associated with increased program completion rates (odds ratio = 1.95, 95% CI 1.02-3.70). There was no significant association between IHSS patients’ health service use at time one or time two. Primary care visits time 1: aOR 0.55, 95%CI 0.72-1.13, time 2: aOR 1.13, 95%CI 0.79-1.23; ED visits overall time 1: aOR 0.91, 95%CI 0.67-1.23, time 2: aOR 1.06, 95%CI 0.75-1.50; ED visits for substance use time 1: aOR 0.81, 95%CI 0.47-1.39, time 2: aOR 0.79, 95%CI 0.37-1.54; Hospitalizations time 1: aOR 0.78, 95%CI 0.41-1.47, time 2: aOR 0.76, 95%CI 0.32-1.80; Mental health visits time 1: aOR 0.66, 95%CI 0.46-0.96, time 2: aOR 0.92 95%CI 0.7-1.40.

Conclusions

Our results indicate that IHSS positively influenced program completion but had no significant effect on health service use.

Trial registration

This study was registered with clinicaltrials.gov (identifier number NCT04604574). First registration 10/27/2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08406-3.

Young People Who Use Drugs Views Toward the Power and Authority of Police Officers

Many young people who use drugs are structurally vulnerable to policing powers given the ongoing criminalization of drug possession. Police authority limits and the expression of that authority may play a significant role in police encounters among young people who use drugs. This qualitative study explores the views of young people who use drugs toward police power and authority in their recent encounters with police officers. Interviews were conducted with 38 young people who recently used illegal drugs in British Columbia, Canada. We found five interrelated themes related to perceptions of police authority: (1) skepticism and distrust toward authority; (2) paternalism and authority over drug use; (3) officer use of force; (4) police as power-hungry; and (5) officers above the law. Participants described police authority as limitless, unpredictable, untethered, easily abused, and lacking accountability. Participants feared holding police officers accountable to power abuses in a criminal justice system that they saw as stacked against them. Moving forward, institutional reforms may consider and account for the expression, limits, and use of police authority among young people who use drugs and other structurally vulnerable communities.

Dealing with low access to harm reduction: a qualitative study of the strategies and risk environments of people who use drugs in a small Swedish city

Background

The development of harm reduction has been limited in many areas of Sweden. This study aims to understand the implications that this has for the life circumstances and risk management of people who use drugs in areas of low access.

Methods

Eleven qualitative, semi-structured interviews were undertaken with people who use drugs in a small urban centre with no needle and syringe exchange program (NSP) or Housing First policy.

Results

Participants reported many solutions to lack of NSP, including travel to an external NSP, creating bridging distribution networks, stealing, borrowing, reusing, ordering online, and smuggling injection equipment. They were at risk of having their equipment confiscated by police. Participants were mostly homeless, and to address exclusion from housing services, were forced to frequently find new temporary solutions, sheltering themselves in public places, with friends, in cars, among others. Participants felt the lack of services reflected stigmatized notions of drug use and heightened their exclusion from general society. For example, they avoided accessing other health care services for fear of discrimination. These issues caused high levels of stress and anxiety, in addition to serious risk for many somatic and psychological health conditions, including HIV and HCV transmission.

Conclusion

Lack of harm reduction services placed a great burden on study participants to develop strategies due to gaps in official programming. It also contributes to a vicious cycle of exclusion from services. The implementation of such evidence-based programs will reduce this burden, as well as provide the indirect, symbolic effect of inclusion.

The Cedar Project: exploring the role of colonial harms and childhood maltreatment on HIV and hepatitis C infection in a cohort study involving young Indigenous people who use drugs in two Canadian cities

OBJECTIVES

This study examined associations between childhood maltreatment, colonial harms and sex/drug-related risks for HIV and hepatitis C virus (HCV) infection among young Indigenous people who use drugs.

DESIGN

The Cedar Project is a cohort involving young Indigenous people who use drugs in British Columbia (BC), Canada. Indigenous collaborators, collectively known as the Cedar Project Partnership, govern the entire research process.

SETTING

Vancouver is a large city on the traditional territory of the Coast Salish peoples. Prince George is a mid-sized city, on the traditional territory of Lheidli T'enneh First Nation.

PARTICIPANTS

420 participants completed the Childhood Trauma Questionnaire and returned for follow-up from 2003 to 2016.

PRIMARY/SECONDARY OUTCOME MEASURES

Primary outcomes were HIV and HCV infection over the study period. Secondary outcomes included sex and substance use-related risks.

RESULTS

Prevalence of childhood maltreatment was 92.6% experienced any maltreatment; 73.4% experienced emotional abuse; 62.6% experienced physical abuse; 60.3% experienced sexual abuse; 69.5% experienced emotional neglect and 79.1% experienced physical neglect. We observed significant associations between childhood maltreatment and apprehensions into residential schools and foster care. All maltreatment types were associated with higher odds of sex/substance use-related risks; sexual abuse was associated with higher odds of HCV infection (adjusted OR: 1.67; 95% CI 1.05 to 2.66; p=0.031).

CONCLUSIONS

Findings reflect high prevalence of childhood maltreatment and their associations with HIV/HCV risk and HCV infection. Public health prevention and treatment initiatives must be trauma informed and culturally safe to support healing, health, and well-being.

The Cedar Project: Relationship between child apprehension and attempted suicide among young Indigenous mothers impacted by substance use in two Canadian cities

Indigenous leaders are gravely concerned over disproportionate representation of Indigenous children in Canada's child welfare systems. Forced separation from children is deeply traumatizing for mothers and detrimental to the wellbeing of Indigenous families, communities and Nations. This study examined relationships between child apprehension and suicide attempt within a cohort of young Indigenous women impacted by substance use. We utilized data collected every 6 months (2008-2016) by the Cedar Project, an Indigenous-governed cohort study involving young Indigenous people who use drugs in British Columbia, Canada. Recent child apprehension was defined as having a child apprehended by the Ministry of Child and Family Development since last visit. Recurrent event Cox proportional hazards models estimated the independent effect of child apprehension on maternal suicide attempt. Among 293 participants, 78 (27%) reported 136 child apprehensions; incidence of first apprehension was 6.64 (95%CI: 5.25-8.29) per 100 person-years. Forty-seven (16%) participants reported 75 suicide attempts with an incidence of 4.00 (95%CI: 2.94-5.33) per 100 person-years. Participants who reported recent child apprehension (HR: 1.88, 95%CI: 1.00-3.55), had a parent attend residential school (HR: 4.12, 95%CI: 1.63-10.46), experienced recent sexual assault (HR: 4.04, 95%CI: 2.04-7.99), violence (HR: 2.54, 95%CI: 1.52-4.27) or overdose (HR: 4.97, 95%CI: 2.96-8.35) were more likely to attempt suicide. Participants who had a traditional language spoken in the home growing up were half as likely to attempt suicide (HR: 0.49, 95%CI: 0.23-1.01). Results suggest that child welfare systems in Canada perpetuate historical and intergenerational trauma among young Indigenous mothers. Indigenous self-determination over child welfare and culturally safe services are urgently needed to end cycles of child apprehension and support the wellbeing of families, communities and Nations.

The Cedar Project: Historical, structural and interpersonal determinants of involvement in survival sex work over time among Indigenous women who have used drugs in two Canadian cities

BACKGROUND

Indigenous women involved in survival sex work face multiple layers of discrimination, criminalization and alarming levels of intergenerational and lifetime trauma. This longitudinal study examined historical, structural and interpersonal factors associated with survival sex work involvement among Indigenous women who have used drugs in British Columbia (BC), Canada.

METHODS

The Cedar Project is an ongoing cohort study involving young Indigenous people who have used illicit drugs in Vancouver and Prince George, BC. Data was collected every 6 months from 2007 to 2016 . Generalized linear mixed-effects modeling was used to model survival sex work involvement, defined as exchanging sex for money, drugs, food or shelter in the previous six months.

RESULTS

Among 292 participants, 34% reported their family always/often lived by traditional culture and 37% reported their family always/often spoke their traditional language. In contrast, 48% had a parent in residential school and 72% were removed from their biological parents. In total, 55% of women were involved in survival sex work at baseline. In adjusted analyses, those who were single (ARR: 1.91; 95% CI: 1.50-2.35), identified as two-spirit (ARR: 2.16; 95% CI: 1.36-2.91), experienced sexual assault (ARR: 1.90; 95% CI: 1.22-2.58), were denied access to shelter (ARR: 1.71; 95% CI: 1.18-2.28), used crack daily (ARR: 2.85; 95% CI: 2.36-3.31), used injection drugs (ARR: 2.52; 95% CI: 1.98-3.07), and were unable to access substance use treatment (ARR: 1.58; 95% CI: 1.15-2.05) were more likely to be involved in sex work.

CONCLUSION

Indigenous-governed, wellness-based harm-reduction interventions, and structural reforms addressing housing insecurity and normalization of a culture of violence against Indigenous women, especially those involved in survival sex work, are urgently needed in Canada.

The Cedar Project - Mobile Phone Use and Acceptability of Mobile Health Among Young Indigenous People Who Have Used Drugs in British Columbia, Canada: Mixed Methods Exploratory Study

Background

Indigenous leaders continue to be concerned about high rates of HIV and barriers to HIV treatment among young Indigenous people involved in substance use. Growing evidence suggests that using mobile phones for health (mHealth) may be a powerful way to support connection with health services, including HIV prevention and treatment.

Objective

This study examined the patterns of mobile phone ownership and use among young Indigenous people who have used drugs living with or vulnerable to HIV and explored the acceptability of mHealth to support access to health care in this population.

Methods

The Cedar Project is a cohort study involving young Indigenous people who have used drugs in Vancouver and Prince George, British Columbia. This mixed methods exploratory study involved 131 Cedar Project participants enrolled in our WelTel mHealth program. At enrollment, participants completed a questionnaire related to mobile phone use and interest in mHealth. Data were linked to Cedar Project questionnaires and serodata. We present comparative statistics (quantitative) and results of a rapid thematic analysis (qualitative) related to mobile phone patterns and interest in receiving mHealth.

Results

Less than half of the participants (59/130; 45.4%) reported owning a phone. Among those with a phone, the majority owned a smartphone (46/59; 78%). Most participants with a phone reported having an unlimited texting plan (39/55; 71%), using the internet on their phone (44/59; 75%), and texting daily (44/55; 80%). A majority reported that using a mobile phone for health would be invaluable (120/130; 92.3%). There were no differences in mHealth acceptance between participants who owned a phone and those who did not (P>.99). All but one participant living with HIV felt using a mobile phone would be helpful for their health, while a small proportion of HIV-negative participants remained unsure (1.9% vs 11.7%; P=.047). In response to open-ended questions asking why using a mobile phone may be helpful for health, participants identified a diverse set of anticipated benefits: (1) connection for emotional, mental, and spiritual support, (2) connection to family, (3) staying in touch and/or being reachable, (4) overcoming current barriers to phone use, (5) convenience, privacy, and safety, and (6) access to health care and emergency services.

Conclusions

We observed high acceptance and interest in using mobile phone technology for health despite low rates of personal mobile phone connectivity among young Indigenous people who have used drugs living with and vulnerable to HIV in British Columbia, Canada. Mobile phones were viewed as a way to support connections and relationships that are seen as critical to health and well-being among young Indigenous people in this study. Findings may be useful for health care providers preparing to scale up mHealth programs to support HIV prevention and treatment in this population.

History of parenting instability and lifetime suicidal behavior in people who inject drugs

Despite high rates of suicide in people who inject drugs, little is known about the risk factors for suicide related to childhood and family history in this population. We aimed to explore the relationship between the history of out-of-home care (OHC) and lifetime suicide attempts among people who inject opioids. Participants (N = 202) were current injection opioid users with at least one previous episode of opioid maintenance treatment. They were recruited into a double-blind randomized controlled trial for opioid substitution treatment. Secondary analysis of baseline data was conducted from the European Addiction Severity Index and basic demographics questionnaires. A total of 81 (40%) participants reported a history of living in OHC and 27% reported attempting suicide. Participants who reported living in OHC were more likely to report lifetime suicide attempts compared to those who did not live in OHC. History of OHC and suicidal ideation were significant risk factors for suicide attempts adjusting for depression and anxiety. Highest rates of lifetime attempts were among participants who lived in a group home, foster care, and/or psychiatric facility. Living in OHC during childhood was significantly associated with higher rates of suicide attempts in our sample. Greater efforts should be made to provide children from vulnerable families with environments where stable one-to-one relationships can be cultivated.

Engagement in Maximally-Assisted Therapy and Adherence to Antiretroviral Therapy Among a Cohort of Indigenous People Who Use Illicit Drugs

Throughout the world, Indigenous populations experience a disproportionate burden of HIV infection. Maximally-assisted therapy (MAT) is an interdisciplinary care intervention that includes ART dispensation to support individuals with a history of addiction and homelessness. This study sought to longitudinally evaluate the relationship between engagement in MAT and achieving optimal adherence using data from an ongoing cohort of HIV-positive individuals who use drugs in Vancouver, Canada, where HIV/AIDS treatment is offered at no cost. Between December 2005 and November 2016, 354 HIV-positive Indigenous participants were enrolled and data were analyzed using generalized mixed-effects (GLMM) and marginal structural modeling. In both multivariable analyses, engagement in MAT was independently associated with optimal adherence to ART (GLMM: AOR = 4.92, 95% CI 3.18-7.62; marginal structural model: AOR = 5.76, 95% CI 3.34-9.96). MAT-based programmes could be a part of a renewed evidence-base to elevated levels of preventable HIV/AIDS-associated morbidity, mortality and viral transmission among Indigenous peoples in Canada.

Applying core theory and spatial analysis to identify hepatitis C virus infection "core areas" in British Columbia, Canada

"Core areas" of transmission for bacterial sexually transmitted infections have been identified. However, it is unclear whether core areas apply to viral infections, such as hepatitis C virus (HCV). We used geographic mapping and spatial analysis to identify distinct core areas of HCV infection in British Columbia (BC) using the BC Hepatitis Testers Cohort (BC-HTC), 1990-2013. The BC-HTC includes all BC residents tested for HCV (~1.5 million; 1990-2013). Core HCV infection areas were identified spatially and temporally for five time periods (1990-1993, 1994-1998, 1999-2003, 2004-2008 and 2009-2013) through thematic mapping, Kernel Density Estimation, Hotspot analysis and cluster analysis at the Census dissemination area level in ArcGIS and SatScan. HCV infection core areas were consistently identified. HCV core areas expanded from the downtown of major cities in different regions of BC (Metro Vancouver, Vancouver Island, and Northern BC; 1990-1998), to smaller cities in Metro Vancouver and Interior BC (2000 onwards). Statistically significant clusters, or hotspots, were also observed for downtown Vancouver, Northern BC (Prince George) and Vancouver Island from 1990 to 2008 with expansion to other urban areas in Metro Vancouver from 1990-2013. Statistically significant clusters persisted after adjustment for injection drug use, number of HCV tests, age, sex, material and social deprivation. Persistence of areas with high HCV diagnoses rates in Vancouver and Prince George supports the theory of core areas of HCV transmission. Identification of core areas can inform prevention, care and treatment programme interventions and evaluate their impact over time.

The Cedar Project: exploring determinants of psychological distress among young Indigenous people who use drugs in three Canadian cities

BACKGROUND

Mental health and wellbeing, including addressing impacts of historical trauma and substance use among young people, has been identified as a key priority by Indigenous communities and leaders across Canada and globally. Yet, research to understand mental health among young Indigenous people who have used drugs is limited.

AIMS

To examine longitudinal risk and strengths-based factors associated with psychological distress among young Indigenous people who use drugs.

METHOD

The Cedar Project is an ongoing cohort study involving young Indigenous people who use drugs in Vancouver, Prince George, and Chase, British Columbia, Canada. This study included participants who completed the Symptom Checklist-90-Revised, returned for follow-up between 2010 and 2012, and completed the Childhood Trauma Questionnaire. Adjusted linear mixed-effects models estimated effects of study variables on changes in area T-scores of psychological distress.

RESULTS

Of 202 eligible participants, 53% were women and the mean age was 28 years. Among men, childhood maltreatment (emotional abuse, physical abuse, sexual abuse, physical neglect), any drug use, blackouts from drinking, and sex work were associated with increased distress. Among women, childhood maltreatment (emotional abuse, physical abuse, physical neglect), blackouts from drinking, and sexual assault were associated with increased distress, while having attempted to quit using drugs was associated with reduced distress. Marginal associations were observed between speaking their traditional language and living by traditional culture with lower distress among men.

CONCLUSION

Culturally safe mental wellness interventions are urgently needed to address childhood trauma and harmful coping strategies that exacerbate distress among young Indigenous people who use drugs.

Abuse of power in relationships and sexual health

STI rates are high for First Nations in Canada and the United States. Our objective was to understand the context, issues, and beliefs around high STI rates from a nêhiyaw (Cree) perspective. Twenty-two in-depth interviews were conducted with 25 community participants between March 1, 2011 and May 15, 2011. Interviews were conducted by community researchers and grounded in the Cree values of relationship, sharing, personal agency and relational accountability. A diverse purposive snowball sample of community members were asked why they thought STI rates were high for the community. The remainder of the interview was unstructured, and supported by the interviewer through probes and sharing in a conversational style. Modified grounded theory was used to analyze the narratives and develop a theory. The main finding from the interviews was that abuse of power in relationships causes physical, mental, emotional and spiritual wounds that disrupt the medicine wheel. Wounded individuals seek medicine to stop suffering and find healing. Many numb suffering by accessing temporary medicines (sex, drugs and alcohol) or permanent medicines (suicide). These medicines increase the risk of STIs. Some seek healing by participating in ceremony and restoring relationships with self, others, Spirit/religion, traditional knowledge and traditional teachings. These medicines decrease the risk of STIs. Younger female participants explained how casual relationships are safer than committed monogamous relationships. Resolving abuse of power in relationships should lead to improvements in STI rates and sexual health.

The Cedar Project WelTel mHealth intervention for HIV prevention in young Indigenous people who use illicit drugs: study protocol for a randomized controlled trial

BACKGROUND

Despite successes in preventing and treating HIV, Indigenous people in Canada continue to face disproportionately high rates of HIV infection. Programs that support healing from lifetime trauma, support connection to culture, and reduce drug-related harms are critical to preventing HIV among young Indigenous people who use drugs. The Cedar Project WelTel mHealth intervention proposed here is a structured mobile-phone initiative to connect young Indigenous people who use drugs with Cedar Case Managers in a community-based setting. The intervention consists of a package of supports, including a mobile phone and cellular plan, weekly two-way text messaging, and support from Cedar Case Managers.

METHODS

The Cedar Project WelTel mHealth study is a multi-site Zelen pre-randomized trial to measure the effect of a two-way supportive text-message intervention to reduce HIV vulnerability among young Indigenous people who use illicit drugs in two Canadian cities. The trial is nested within the Cedar Project, an ongoing cohort study addressing HIV and hepatitis C vulnerability among young Indigenous people who use drugs in Vancouver and Prince George, British Columbia. The Cedar Project Partnership, an independent body of Indigenous Elders, leaders, and health/social service experts, governs all aspects of the study. Two hundred participants will be followed over a 16-month period, with HIV propensity score at 6 months as the primary outcome. Secondary outcomes include HIV propensity at 1 year, HIV risk, resilience, psychological distress, access to drug-related services, and connection to culture measured at 6 months and 1 year. Primary analysis is by intention to treat.

DISCUSSION

Culturally safe interventions that address barriers to HIV prevention while supporting the strength of young Indigenous people who use drugs are urgently needed. Despite presenting a tremendous opportunity to connect young, highly transient Indigenous people who use drugs to prevention services, supportive two-way mHealth programs have yet to be tested for HIV prevention in a community-based setting with this population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02437123 https://clinicaltrials.gov/show/NCT02437123 (registered 4 May 2015). Protocol version: 24 July 2015.

The Cedar Project: resilience in the face of HIV vulnerability within a cohort study involving young Indigenous people who use drugs in three Canadian cities

BACKGROUND

Indigenous scholars have long argued that it is critical for researchers to identify factors related to cultural connectedness that may protect against HIV and hepatitis C infection and buffer the effects of historical and lifetime trauma among young Indigenous peoples. To our knowledge, no previous epidemiological studies have explored the effect of historical and lifetime traumas, cultural connectedness, and risk factors on resilience among young, urban Indigenous people who use drugs.

METHODS

This study explored risk and protective factors associated with resilience among participants of the Cedar Project, a cohort study involving young Indigenous peoples who use illicit drugs in three cities in British Columbia, Canada. We utilized the Connor-Davidson Resilience Scale to measure resilience, the Childhood Trauma Questionnaire to measure childhood maltreatment, and the Symptom-Checklist 90-Revised to measure psychological distress among study participants. Multivariate linear mixed effects models (LME) estimated the effect of study variables on mean change in resilience scores between 2011-2012.

RESULTS

Among 191 participants, 92 % had experienced any form of childhood maltreatment, 48 % had a parent who attended residential school, and 71 % had been in foster care. The overall mean resilience score was 62.04, with no differences between the young men and women (p = 0.871). Adjusted factors associated with higher mean resilience scores included having grown up in a family that often/always lived by traditional culture (B = 7.70, p = 0.004) and had often/always spoken their traditional language at home (B = 10.52, p < 0.001). Currently knowing how to speak a traditional language (B = 13.06, p = 0.001), currently often or always living by traditional culture (B = 6.50, p = 0.025), and having recently sought drug/alcohol treatment (B = 4.84, p = 0.036) were also significantly associated with higher mean resilience scores. Adjusted factors associated with diminished mean resilience scores included severe childhood emotional neglect (B = -13.34, p = 0.001), smoking crack daily (B = -5.42, p = 0.044), having been sexual assaulted (B =  14.42, p = 0.041), and blackout drinking (B = -6.19, p = 0.027).

CONCLUSIONS

Young people in this study have faced multiple complex challenges to their strength. However, cultural foundations continue to function as buffers that protect young Indigenous people from severe health outcomes, including vulnerability to HIV and HCV infection.

HIV Among Indigenous peoples: A Review of the Literature on HIV-Related Behaviour Since the Beginning of the Epidemic

From the early days of the HIV epidemic, Indigenous peoples were identified as a population group that experiences social and economic determinants-including colonialism and racism-that increase exposure to HIV. There are now substantial disparities in HIV rates between Indigenous and non-Indigenous peoples in some countries. We conducted a comprehensive literature review to assess the evidence on HIV-related behaviors and determinants in four countries-Australia, Canada, New Zealand and the United States-in which Indigenous peoples share important features of colonization and marginalization. We identified 107 articles over more than 20 years. The review highlights the determinants of HIV-related behaviors including domestic violence, stigma and discrimination, and injecting drug use. Many of the factors associated with HIV risk also contribute to mistrust of health services, which in turn contributes to poor HIV and health outcomes among Indigenous peoples.

Blending Aboriginal and Western healing methods to treat intergenerational trauma with substance use disorder in Aboriginal peoples who live in northeastern Ontario, Canada

As with many Indigenous groups around the world, Aboriginal communities in Canada face significant challenges with trauma and substance use. The complexity of symptoms that accompany intergenerational trauma and substance use disorders represents major challenges in the treatment of both disorders. There appears to be an underutilization of substance use and mental health services, substantial client dropout rates, and an increase in HIV infections in Aboriginal communities in Canada. The aim of this paper is to explore and evaluate current literature on how traditional Aboriginal healing methods and the Western treatment model “Seeking Safety” could be blended to help Aboriginal peoples heal from intergenerational trauma and substance use disorders. A literature search was conducted using the keywords: intergenerational trauma, historical trauma, Seeking Safety, substance use, Two-Eyed Seeing, Aboriginal spirituality, and Aboriginal traditional healing. Through a literature review of Indigenous knowledge, most Indigenous scholars proposed that the wellness of an Aboriginal community can only be adequately measured from within an Indigenous knowledge framework that is holistic, inclusive, and respectful of the balance between the spiritual, emotional, physical, and social realms of life. Their findings indicate that treatment interventions must honour the historical context and history of Indigenous peoples. Furthermore, there appears to be strong evidence that strengthening cultural identity, community integration, and political empowerment can enhance and improve mental health and substance use disorders in Aboriginal populations. In addition, Seeking Safety was highlighted as a well-studied model with most populations, resulting in healing. The provided recommendations seek to improve the treatment and healing of Aboriginal peoples presenting with intergenerational trauma and addiction. Other recommendations include the input of qualitative and quantitative research as well as studies encouraging Aboriginal peoples to explore treatments that could specifically enhance health in their respective communities.

The Cedar Project: Negative health outcomes associated with involvement in the child welfare system among young Indigenous people who use injection and non-injection drugs in two Canadian cities

OBJECTIVES

Indigenous leaders and child and family advocates are deeply concerned about the health impacts of the child welfare system, including HIV vulnerability. The objectives of this study were to describe the prevalence of having been apprehended into the child welfare system and associated HIV vulnerabilities among young Indigenous people who use drugs.

METHODS

The Cedar Project is a cohort of young Indigenous people ages 14-30 years who use illicit drugs in Vancouver and Prince George, British Columbia. Multivariable logistic regression modeling determined associations between a history of involvement in the child welfare system and vulnerability to HIV infection.

RESULTS

Of 605 participants, 65% had been taken from their biological parents. Median age of first apprehension was 4 years old. Having been sexually abused, having a parent who attended residential school and being HIV-positive were all independently associated with having been involved in the child welfare system. Participants who had been involved in the child welfare system were also more likely to have been homeless, paid for sex, diagnosed and hospitalized with mental illness, self-harmed, thought about suicide, and attempted suicide. Among participants who used injection drugs, those who had been involved in child welfare were more likely to have shared needles and overdosed.

CONCLUSION

This study has found compelling evidence that young Indigenous people who use drugs in two cities in BC are experiencing several distressing health outcomes associated with child welfare involvement, including HIV infection. Jurisdictional reforms and trauma-informed programs that use culture as intervention are urgently needed.

The Cedar Project: Residential transience and HIV vulnerability among young Aboriginal people who use drugs

Aboriginal homelessness is considered to be a result of historic dispossession of traditional territories and forced displacement from community structures. Using data collected from 2005-2010 from the Cedar Project, a cohort of young Aboriginal people who use drugs in two Canadian cities, we examined how residential transience shapes HIV vulnerability. At baseline, 48 of 260 participants (18.5%) reported sleeping in six or more places ('highly transient') in the past six months. Generalized linear mixed models identified associations between high transience and sex and drug related HIV vulnerabilities. Transience was independently associated with sex work (AOR:3.52, 95%CI:2.06, 6.05); sexual assault (AOR:2.48, 95%CI:1.26, 4.86); injection drug use (AOR:4.54, 95%CI:2.71, 7.61); daily cocaine injection (AOR:2.16, 95%CI:1.26, 3.72); and public injection (AOR:2.87, 95%CI:1.65, 5.00). After stratification, transience and sexual vulnerability remained significantly associated among women but not men. Ensuring that young Aboriginal people have access to safe spaces to live, work, and inject must include policies addressing residential transience as well as the absence of a roof and walls.

The Cedar Project * : historical trauma and vulnerability to sexual assault among young aboriginal women who use illicit drugs in two Canadian cities

This study explored trends of sexual assault and associated risk factors within a cohort of young Aboriginal women who used drugs in Vancouver and Prince George, Canada, between 2003 and 2010. Results demonstrated no change in the trend of sexual assault over time; however, odds of sexual assault were significantly higher for women who had at least one parent who attended residential school, had experienced childhood sexual abuse, were involved in sex work, had been offered money to not use condoms, had used injection drugs, had injected cocaine and opiates daily, had binged with injection drugs, and had difficulty accessing clean syringes. Findings highlight the urgency of interventions addressing the complexity of risk and opportunities for healing.

Housing instability among people who inject drugs: results from the Australian needle and syringe program survey

High rates of substance dependence are consistently documented among homeless people, and are associated with a broad range of negative outcomes among this population. Investigations of homelessness among drug users are less readily available. This study examined the prevalence and correlates of housing instability among clients of needle syringe programs (NSPs) via the Australian NSP Survey, annual cross-sectional seroprevalence studies among NSP attendees. Following self-completion of a brief, anonymous survey and provision of a capillary blood sample by 2,396 NSP clients, multivariate logistic regressions identified the variables independently associated with housing instability. Nineteen percent of ANSPS participants reported current unstable housing, with primary ('sleeping rough'; 5 %), secondary (staying with friends/relatives or in specialist homelessness services; 8 %), and tertiary (residential arrangements involving neither secure lease nor private facilities; 6 %) homelessness all evident. Extensive histories of housing instability were apparent among the sample: 66 % reported at least one period of sleeping rough, while 77 % had shifted between friends/relatives (73 %) and/or resided in crisis accommodation (52 %). Participants with a history of homelessness had cycled in and out of homelessness over an average of 10 years; and one third reported first being homeless before age 15. Compared to their stably housed counterparts, unstably housed participants were younger, more likely to be male, of Indigenous Australian descent, and to report previous incarceration; they also reported higher rates of key risk behaviors including public injecting and receptive sharing of injecting equipment. The high prevalence of both historical and current housing instability among this group, particularly when considered in the light of other research documenting the many adverse outcomes associated with this particular form of disadvantage, highlights the need for increased supply of secure, affordable public housing in locations removed from established drug markets and serviced by health, social, and welfare support agencies.

The Cedar Project: impacts of policing among young Aboriginal people who use injection and non-injection drugs in British Columbia, Canada

BACKGROUND

Policing has profound health implications for people who use illicit drugs. Among Aboriginal communities, distrust of police is common, due partly to legacies of colonial policing. In response to the paucity of research among Aboriginal people who use drugs, this paper aims to: (1) Describe the policing experiences of young Aboriginal people who use drugs; (2) Identify policing activities associated with unsafe injection practices; and (3) Elucidate barriers to positive police relations.

METHODS

The Cedar Project is a cohort study involving young Aboriginal people in Vancouver and Prince George, British Columbia, who use illicit drugs. This mixed-methods study (N=372) used period prevalence from 2007 to 2010 to describe policing experiences, mixed effects regression models to identify correlates of policing activities, and thematic qualitative analysis to assess attitudes to police relations.

RESULTS

Many participants were stopped by police (73%), experienced physical force by police (28%), had drug equipment confiscated (31%), and changed location of drug use because of police (43%). Participants who reported dealing drugs (40%) were significantly more likely to experience police engagement. Among participants in Prince George, 4% reported to have had non-consensual sex with members of the criminal justice system. Policing activity was significantly associated with syringe sharing, rushed injection, and reused syringe. Due to personal experience, practical concerns, and intergenerational legacies of unfair policing practices, most participants did not want a positive relationship with police (57%). Desire for a positive relationship with police was directly associated with being helped by police, and inversely associated with being stopped by police and experiencing physical force by police.

CONCLUSION

Policing activities may be impacting the well-being of Aboriginal people who use drugs. Due to focused prosecution of street-level drug dealing, some police may favor enforcement over harm reduction. Positive police engagement and less aggressive policing may enhance perceptions of police among young Aboriginal people who use drugs.

The Cedar Project: high incidence of HCV infections in a longitudinal study of young Aboriginal people who use drugs in two Canadian cities

Background

Factors associated with HCV incidence among young Aboriginal people in Canada are still not well understood. We sought to estimate time to HCV infection and the relative hazard of risk factors associated HCV infection among young Aboriginal people who use injection drugs in two Canadian cities.

Methods

The Cedar Project is a prospective cohort study involving young Aboriginal people in Vancouver and Prince George, British Columbia, who use illicit drugs. Participants’ venous blood samples were drawn and tested for HCV antibodies. Analysis was restricted to participants who use used injection drugs at enrolment or any of follow up visit. Cox proportional hazards regression was used to identify independent predictors of time to HCV seroconversion.

Results

In total, 45 out of 148 participants seroconverted over the study period. Incidence of HCV infection was 26.3 per 100 person-years (95% Confidence Interval [CI]: 16.3, 46.1) among participants who reported using injection drugs for two years or less, 14.4 per 100 person-years (95% CI: 7.7, 28.9) among participants who had been using injection drugs for between two and five years, and 5.1 per 100 person-years (95% CI: 2.6,10.9) among participants who had been using injection drugs for over five years. Independent associations with HCV seroconversion were involvement in sex work in the last six months (Adjusted Hazard Ratio (AHR): 1.59; 95% CI: 1.05, 2.42) compared to no involvement, having been using injection drugs for less than two years (AHR: 4.14; 95% CI: 1.91, 8.94) and for between two and five years (AHR: 2.12; 95%CI: 0.94, 4.77) compared to over five years, daily cocaine injection in the last six months (AHR: 2.47; 95% CI: 1.51, 4.05) compared to less than daily, and sharing intravenous needles in the last six months (AHR: 2.56; 95% CI: 1.47, 4.49) compared to not sharing.

Conclusions

This study contributes to the limited body of research addressing HCV infection among Aboriginal people in Canada. The HCV incidence rate among Cedar Project participants who were new initiates of injection drug use underscores an urgent need for HCV and injection prevention and safety strategies aimed at supporting young people surviving injection drug use and sex work in both cities. Young people must be afforded the opportunity to provide leadership and input in the development of prevention programming.

Risk of window period HIV infection in high infectious risk donors: systematic review and meta-analysis

The OPTN defines high risk donors (HRDs), colloquially known as 'CDC high risk donors', as those thought to carry an increased risk of HIV window period (WP) infection prior to serologic detectability. However, the true risk of such infection remains unknown. To quantify the risk of WP infection in each HRD behavior category, we performed a systematic review and meta-analysis of studies of HIV prevalence and incidence. Of 3476 abstracts reviewed, 27 eligible studies of HIV infection in HRD populations were identified. Pooled HIV incidence estimates were calculated for each category of HRD behavior and used to calculate the risk of WP HIV infection. Risks ranged from 0.09-12.1 per 10 000 donors based on WP for ELISA and 0.04-4.9 based on nucleic acid testing (NAT), with NAT reducing WP risk by over 50% in each category. Injection drug users had the greatest risk of WP infection (4.9 per 10 000 donors by NAT WP), followed by men who have sex with men (4.2:10 000), commercial sex workers (2.7:10 000), incarcerated donors (0.9:10 000), donors exposed to HIV through blood (0.6:10 000), donors engaging in high-risk sex (0.3:10 000) and hemophiliacs (0.035:10 000). These estimates can help inform patient and provider decision making regarding HRDs.

Risk of window period hepatitis-C infection in high infectious risk donors: systematic review and meta-analysis

The OPTN classifies high infectious risk donors (HRDs) based on criteria originally intended to identify people at risk for HIV infection. These donors are sometimes referred to as 'CDC high risk donors' in reference to the CDC-published guidelines adopted by the OPTN. However, these guidelines are also being used to identify deceased donors at increased risk of window period (WP) hepatitis C virus (HCV) infection, although not designed for this purpose. The actual risk of WP HCV infection in HRDs is unknown. We performed a systematic review of 3476 abstracts and identified 37 eligible estimates of HCV incidence in HRD populations in the United States/Canada. Pooled HCV incidence was derived and used to estimate the risk of WP infection for each HRD category. Risks ranged from 0.26 to 300.6 per 10,000 donors based on WP for ELISA and 0.027 to 32.4 based on nucleic acid testing (NAT). Injection drug users were at highest risk (32.4 per 10,000 donors by NAT WP), followed by commercial sex workers and donors exhibiting high risk sexual behavior (12.3 per 10,000), men who have sex with men (3.5 per 10,000), incarcerated donors (0.8 per 10,000), donors exposed to HIV infected blood (0.4 per 10,000) and hemophiliacs (0.027 per 10,000). NAT reduced WP risk by approximately 10-fold in each category.

Methadone use in relation to hepatitis C virus testing in British Columbia

OBJECTIVE

We examined methadone use among a large cohort of individuals undergoing serologic testing for hepatitis C virus (HCV) infection.

METHODS

In British Columbia, community pharmacy methadone dispensations are recorded in the PharmaNet database and HCV antibody (anti-HCV) test results are recorded by the Provincial Public Reference Laboratory. Provincial HCV laboratory testing records from 1992 to 2004 were linked to methadone dispensation records from 1995-2006. We describe methadone maintenance treatment (MMT) among individuals undergoing anti-HCV testing between 1992 and 2004.

RESULTS

Between 1992 and 2004, 404,941 individuals were tested for anti-HCV in BC; 32,918 (8%) were positive. Overall, methadone was dispensed to 10,314 (2.5%) of individuals tested for anti-HCV; 1% of negative testers and 21% of positive testers. Of 10,314 individuals receiving methadone, 6732 (65%) had a positive anti-HCV test during the study period. Laboratory anti-HCV serostatus was known at MMT initiation in 70%; of these, 2596 (36%) were anti-HCV negative and 4638 (64%) were anti-HCV positive at first methadone dispensation. Seroconversion from anti-HCV negative to positive following MMT initiation was confirmed in 288 persons.

CONCLUSION

Methadone used in conjunction with other harm reduction initiatives can reduce the transmission of blood-borne infections among individuals who inject opiates, however many who enter the BC Methadone Program are already anti-HCV positive and others seroconvert after MMT initiation. Our data suggest there are missed prevention opportunities for MMT and other harm reduction services. Linkage of laboratory and health service data can provide a population lens to identify and evaluate potential prevention strategies.

The Cedar Project: methadone maintenance treatment among young Aboriginal people who use opioids in two Canadian cities

INTRODUCTION AND AIMS

The Cedar Project is a community-based study aiming to identify variables associated with ever being on methadone maintenance treatment (MMT) among young Aboriginal people using drugs and to discuss possible barriers to MMT in this population.

DESIGN AND METHODS

This is a prospective cohort study with recruitment by health-care providers, outreach, and word of mouth in Vancouver and Prince George. Participants included 605 Aboriginal participants who were age 14-30 years, reported illicit drug use in the month prior to enrolment, and provided written informed consent. Variables associated with ever being on MMT were analysed through χ(2) -testing and multivariate logistic regression, limited to people reporting opioid use (n = 397).

RESULTS

Less than half of participants reporting daily injection of opioids had ever been on MMT. In adjusted multivariate logistic regression analyses, older age [odds ratio (OR) 1.17; 95% confidence interval (CI) 1.08-1.28)]; female gender (OR 3.76; 95% CI 2.00-7.07); hepatitis C antibody positivity (OR 2.76; 95% CI 1.53-4.95); and daily opioid injection (OR 2.59; 95% CI 1.46-4.61) were positively associated with ever being on MMT. Weekly or more alcohol use (OR 0.43; 95% CI 0.21-0.87) was negatively associated with ever being on MMT.

DISCUSSION AND CONCLUSION

MMT access by young Aboriginal people is low. The associations between MMT use and other variables need further study to steer efforts directed at recruitment into MMT. The removal of barriers to MMT and inclusion of young Aboriginal people in the development of treatment programs based on Indigenous values are urgently required to help Aboriginal people who use drugs.

HIV incidence and prevalence among aboriginal peoples in Canada

We examined incidence, prevalence, and correlates of HIV infection in Aboriginal peoples in Canada and found that among most risk groups both Aboriginal and non-Aboriginal participants showed similar levels of HIV prevalence. Aboriginal peoples who use illicit drugs were found to have higher HIV incidence and prevalence when compared to their non-Aboriginal drug-using peers. Aboriginal street youth and female sex workers were also found to have higher HIV prevalence. Among Aboriginal populations, correlates of HIV-positive sero-status include syringe sharing and frequently injecting drugs, as well as geographic and social factors such as living in Vancouver or having a history of non-consensual sex. This study is relevant to Canada and elsewhere, as Indigenous populations are disproportionately represented in the HIV epidemic worldwide.

Boyfriends and booty calls: sexual partnership patterns among Canadian Aboriginal young people

OBJECTIVES

Sexual partnership patterns, forced sex, and condom non-use can contribute to STI risk, but little is known about these patterns among Aboriginal young people despite elevated STI risk in this group. We describe sexual relationship and condom use patterns among Canadian Aboriginal young people, and how these patterns relate to the socio-structural context as experienced by young people.

METHODS

We use data from in-depth individual interviews conducted in 2004 with 22 young people who reported ever having sex and who self-identified as Aboriginal in British Columbia, Canada. A thematic analysis is presented.

RESULTS

Young people described a range of partnership patterns, including 'on-off' relationships which could have high rates of partner turnover but could sometimes be viewed as acceptable contexts for pregnancy, precluding condom use. Contextual elements beyond individual control appeared to contribute to these patterns. Migration between geographic locations was linked with risky partnership patterns, especially if it was linked with family instability or substance use problems.

CONCLUSION

Sexual health interventions for this group must address partnership patterns in addition to promoting condom use. Survey research into 'migration' as a risk factor for STI transmission should consider reasons for migration. Interventions that address both individual level behaviour and the contextual elements that shape behaviour should be developed and tested.

Public injecting and HIV risk behaviour among street-involved youth

BACKGROUND

Although street-involved youth who inject illicit drugs are known to be at an increased risk of HIV and other adverse health outcomes, little is known about public injecting among this population and how injecting in public environments may impact HIV risk behaviour.

METHODS

We used data derived from a study of 560 street-involved youth in Vancouver, Canada to examine the factors associated with injecting in public environments among youth who reported injecting drugs in the past 6 months.

RESULTS

At baseline, 162 (28.9%) reported injecting drugs in the past 6 months. Among injectors, the 124 (76.5%) participants who reported injecting in public were more likely to be homeless (odds ratio [OR]=6.39, p<0.001), engage in unprotected intercourse (OR=3.09, p=0.004), deal drugs (OR=2.26, p=0.032), smoke crack cocaine (OR=3.00, p=0.005), inject heroin (OR=3.48, p=0.001), drop used syringes outdoors (OR=8.44, p<0.001), share syringes (OR=4.43, p=0.004), and were less likely to clean injection sites >75% of the time (OR=0.36, p=0.008). The majority (62.1%) reported feeling rushed while injecting in public.

CONCLUSIONS

Youth who inject in public are significantly more likely to engage in sexual and injection-related risk behaviour. Given the known elevated rates of HIV infection and other harms among this population, youth-focused interventions that target both sexual and drug-related risks associated with public drug-using environments are in urgent need of evaluation.

HIV and risk environment for injecting drug users: the past, present, and future

We systematically reviewed reports about determinants of HIV infection in injecting drug users from 2000 to 2009, classifying findings by type of environmental influence. We then modelled changes in risk environments in regions with severe HIV epidemics associated with injecting drug use. Of 94 studies identified, 25 intentionally examined risk environments. Modelling of HIV epidemics showed substantial heterogeneity in the number of HIV infections that are attributed to injecting drug use and unprotected sex. We estimate that, during 2010-15, HIV prevalence could be reduced by 41% in Odessa (Ukraine), 43% in Karachi (Pakistan), and 30% in Nairobi (Kenya) through a 60% reduction of the unmet need of programmes for opioid substitution, needle exchange, and antiretroviral therapy. Mitigation of patient transition to injecting drugs from non-injecting forms could avert a 98% increase in HIV infections in Karachi; whereas elimination of laws prohibiting opioid substitution with concomitant scale-up could prevent 14% of HIV infections in Nairobi. Optimisation of effectiveness and coverage of interventions is crucial for regions with rapidly growing epidemics. Delineation of environmental risk factors provides a crucial insight into HIV prevention. Evidence-informed, rights-based, combination interventions protecting IDUs' access to HIV prevention and treatment could substantially curtail HIV epidemics.

Harmful microinjecting practices among a cohort of injection drug users in vancouver Canada

OBJECTIVES

We sought to identify factors associated with harmful microinjecting practices in a longitudinal cohort of IDU.

METHODS

Using data from the Vancouver Injection Drug Users Study (VIDUS) between January 2004 and December 2005, generalized estimating equations (GEE) logistic regression was performed to examine sociodemographic and behavioral factors associated with four harmful microinjecting practices (frequent rushed injecting, frequent syringe borrowing, frequently injecting with a used water capsule, frequently injecting alone).

RESULTS

In total, 620 participants were included in the present analysis. Our study included 251 (40.5%) women and 203 (32.7%) self-identified Aboriginal participants. The median age was 31.9 (interquartile range: 23.4-39.3). GEE analyses found that each harmful microinjecting practice was associated with a unique profile of sociodemographic and behavioral factors.

DISCUSSION

We observed high rates of harmful microinjecting practices among IDU. The present study describes the epidemiology of harmful microinjecting practices and points to the need for strategies that target higher risk individuals including the use of peer-driven programs and drug-specific approaches in an effort to promote safer injecting practices.

The Cedar Project: correlates of attempted suicide among young Aboriginal people who use injection and non-injection drugs in two Canadian cities

OBJECTIVES

Aboriginal leadership and families are deeply concerned about the rate of suicide attempt among their young people. The objectives of this study were to (a) describe the prevalence of suicide attempt and (b) to describe correlates of vulnerability to suicide attempts within a cohort of young Aboriginal people who use drugs in 2 Canadian cities. We aimed to situate the findings within the context of historical and lifetime trauma. Study design. The Cedar Project is a prospective cohort study involving 605 young Aboriginal people aged 14-30 who use drugs in Vancouver and Prince George, British Columbia, Canada.

METHODS

Multivariable logistic regression modelling identified independent predictors of suicide attempts. Estimates of adjusted odds ratios and 95% confidence intervals were calculated.

RESULT

In multivariable analysis, residing in Prince George (Adjusted Odds Ratio [AOR]: 1.80, 95% CI: 1.23, 2.64), ever having been sexually abused (AOR: 2.07, 95% CI: 1.39, 3.08), and ever having overdosed (AOR: 2.29, 95% CI: 1.53, 3.42) independently predicted lifetime attempted suicide.

CONCLUSIONS

Suicide prevention and intervention programs must address historical and lifetime trauma among Aboriginal young people who struggle with substance dependence.

Factors associated with pregnancy and STI among Aboriginal students in British Columbia

BACKGROUND

Aboriginal adolescents are more likely to become pregnant and contract an STI than other Canadian adolescents. This study provides some of the first data on factors associated with these outcomes among Aboriginal adolescents.

METHODS

A secondary analysis was conducted using 2003 data from a large cross-sectional survey of British Columbia secondary school students. 445 young women and 360 young men who identified as Aboriginal and reported ever having sex were included in analyses. Associations between self-reported pregnancy and STI and 11 exposure variables were examined using logistic regression.

RESULTS

Of young women, 10.6% reported a pregnancy; 10.5% of young men reported causing a pregnancy. An STI diagnosis was reported by 4.2% of young women and 3.9% of young men. In multivariate analyses for young men, ever having been sexually abused was the strongest consistent risk factor for causing a pregnancy (AOR = 4.30, 95% CI 1.64-11.25) and STI diagnosis (AOR = 5.58, 95% CI 1.61-19.37). For young women, abuse was associated with increased odds of pregnancy (AOR = 10.37, 95% CI 4.04-26.60) but not STI. Among young women, substance use was the strongest consistent risk factor for both pregnancy (AOR = 3.36, 95% CI 1.25-9.08) and STI (AOR = 5.27, 95% CI 1.50-18.42); for young men, substance use was associated with higher odds of STI (AOR = 4.60, 95% CI 1.11-19.14). Factors associated with decreased risk included community, school and family involvement.

CONCLUSIONS

Health care professionals, communities and policy-makers must urgently address sexual abuse and substance use. Exploring promotion of school and community involvement and family cohesion may be useful for sexual health interventions with Aboriginal students.

High prevalence of HIV infection among homeless and street-involved Aboriginal youth in a Canadian setting

Aboriginal people experience a disproportionate burden of HIV infection among the adult population in Canada; however, less is known regarding the prevalence and characteristics of HIV positivity among drug-using and street-involved Aboriginal youth. We examined HIV seroprevalence 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. Aboriginal ethnicity was a significant correlate of HIV infection (odds ratio = 2.87, 95%CI: 1.02 – 8.09). Of the HIV positive participants, 2 (28.6%) Aboriginals and 6 (75.0%) non-Aboriginals reported injection drug use; furthermore, hepatitis C co-infection was significantly less common among Aboriginal participants (p = 0.041). These findings suggest that factors other than injection drug use may promote HIV transmission among street-involved Aboriginal youth, and provide further evidence that culturally appropriate and evidence-based interventions for HIV prevention among Aboriginal young people are urgently required.

Increasing prevalence of cocaine as the primary detoxification diagnosis among admissions presenting with current intravenous drug use: a review of detoxification records from northern British Columbia, 1999-2005

OBJECTIVES

This study sought to document the trends in drug use among intravenous drug users (IDUs) in northern British Columbia, and to discuss the public health implications.

METHOD

We conducted a 7-year medical-chart review of all IDU-related admissions (n = 2072) to an inpatient alcohol and drug detoxification centre in Prince George, British Columbia. Primary detoxification diagnosis was modeled onto year of admission using generalized estimating equations (GEE).

RESULTS

Our study demonstrated an increasing prevalence of cocaine as the primary detoxification diagnosis in IDU-related admissions in northern BC, from 32% of all IDU admissions in 1999 to 64% in 2001, and then a relatively steady elevated rate of approximately 60% between 2001-2005.

CONCLUSIONS

Given that needle exchange programs and other harm reduction services for IDUs in British Columbia are not readily available in many northern and rural areas, the risks associated with intravenous cocaine use among northern IDUs represent a serious public health challenge. Tailored harm reduction strategies should take into account the prominence of intravenous cocaine use as an HIV risk factor. In areas without well-established intravenous drug use monitoring programs, such as rural and remote areas, detoxification treatment records may serve as important sentinels for changing drug use patterns among IDUs.

The Cedar Project: historical trauma, sexual abuse and HIV risk among young Aboriginal people who use injection and non-injection drugs in two Canadian cities

Recent Indigenist scholarship has situated high rates of traumatic life experiences, including sexual abuse, among Indigenous peoples of North America within the larger context of their status as colonized peoples. Sexual abuse has been linked to many negative health outcomes including mental, sexual and drug-related vulnerabilities. There is a paucity of research in Canada addressing the relationship between antecedent sexual abuse and negative health outcomes among Aboriginal people including elevated risk of HIV infection. The primary objectives of this study were to determine factors associated with sexual abuse among participants of the Cedar Project, a cohort of young Aboriginal people between the ages of 14 and 30 years who use injection and non-injection drugs in two urban centres in British Columbia, Canada; and to locate findings through a lens of historical and intergenerational trauma. We utilized post-colonial perspectives in research design, problem formulation and the interpretation of results. Multivariate modeling was used to determine the extent to which a history of sexual abuse was predictive of negative health outcomes and vulnerability to HIV infection. Of the 543 eligible participants, 48% reported ever having experienced sexual abuse; 69% of sexually abused participants were female. The median age of first sexual abuse was 6 years for both female and male participants. After adjusting for sociodemographic variables and factors of historical trauma, sexually abused participants were more likely to have ever been on the streets for more than three nights, to have ever self-harmed, to have suicide ideation, to have attempted suicide, to have a diagnosis of mental illness, to have been in the emergency department within the previous 6 months, to have had over 20 lifetime sexual partners, to have ever been paid for sex and to have ever overdosed. The prevalence and consequences of sexual abuse among Cedar Project participants are of grave concern. Sexual trauma will continue to impact individuals, families and communities until unresolved historical trauma is meaningfully addressed in client-driven, culturally safe programming.