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The Cedar Project: Residential transience and HIV vulnerability among young Aboriginal people who use drugs
Health & Place 33 (2015) 125–131
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Health & Place journal homepage: www.elsevier.com/locate/healthplace
The Cedar Project: Residential transience and HIV vulnerability among young Aboriginal people who use drugs Kate Jongbloed a, Vicky Thomas b,c, Margo E. Pearce a, Kukpi Wunuxtsin Christian d, Hongbin Zhang b, Eugenia Oviedo-Joekes a, Martin T. Schechter a, Patricia M. Spittal a,n, for The Cedar Project Partnership1 a
School of Population and Public Health, University of British Columbia, Vancouver, Canada The Cedar Project, Centre for Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, Canada c Wuikinuxv Nation, The Cedar Project, Prince George, Canada d Splatsin te Secwepemc, British Columbia, Canada b
art ic l e i nf o
a b s t r a c t
Article history: Received 22 September 2014 Received in revised form 18 December 2014 Accepted 18 February 2015 Available online 2 April 2015
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. & 2015 Published by Elsevier Ltd.
Keywords: Aboriginal peoples HIV risk Housing stability Drug use Residential transience
1. Introduction “The narrative of Indigenous homelessness has to start at the beginning, that is, with the historical truth of the original and ongoing dispossession of Indigenous people and of its consequences for the first peoples” (Murray, 2010). Scholars of Aboriginal health have argued that Aboriginal homelessness and housing instability is a result of historic dispossession of traditional territories and forced displacement from community structures (Reading and Wien, 2009; United Native Nations Society, 2001; Menzies, 2009; Leach, 2010; Ruttan et al., 2010; Dodson, 2010; Adelson, 2005). Under the Indian Act (Indian
n
Corresponding author. Tel.: þ 1 604 806 8779; fax: þ 1 604 806 9044. E-mail address: [email protected] (P.M. Spittal). 1 Elders Violet Bozoki (Lheidli T'enneh) and Earl Henderson (Cree, Metis), Prince George Native Friendship Centre, Carrier Sekani Family Services, Positive Living North, Red Road Aboriginal HIV/AIDS Network, Central Interior Native Health, Vancouver Native Health Society, Canadian Aboriginal AIDS Network, All Nations Hope, Splatsin Secwepemc Nation, Neskonlith Indian Band, and Adams Lake Indian Band. http://dx.doi.org/10.1016/j.healthplace.2015.02.008 1353-8292/& 2015 Published by Elsevier Ltd.
Act, RSC, 1985), Canada's reserve system carved up traditional lands and closely controlled where Aboriginal people were allowed to live and travel (Adelson, 2005). Beginning in 1920, Aboriginal parents were required by law to send their children away to residential schools as part of a church-state partnership to culturally assimilate Aboriginal children. Residential schools were sites of ritualized abuse, designed to “take the Indian out of the child” (Chansonneuve, 2005). Generations of children were taught to feel ashamed of their heritage, language, customs and spiritual traditions (Christian and Spittal, 2008). In total, more than 100,000 children were forcibly removed from their homes and families between 1867 and 1986 (Royal Commission on Aboriginal Peoples, 1996). In 1951, responsibility for child welfare was delegated to Canadian provinces. At this time, only 1% of youth in care in Canada were Aboriginal (Turpel-Lafond, 2013). During the “Sixties Scoop”, thousands of Aboriginal children were apprehended and placed in foster or adoptive homes across Canada (Trocmé et al., 2004). Removal from biological parents was often permanent and children often moved several times while in care. Today, more than half of children in care in Canada's western-most province of British Columbia (B.C.) are Aboriginal, although Aboriginal people
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account for just 5% of the population (Turpel-Lafond, 2013; Statistics Canada, 2011). These government actions have systematically and deliberately dismantled Aboriginal homes, families, and communities. Severing of family and community ties has left an indelible mark on individuals and communities across generations, creating “a homeless state” (Menzies, 2009; Christian and Spittal, 2008). Today, the systemic nature of housing instability among Aboriginal people is captured in virtually every housing measure in B.C., including housing quality, affordability, residential transience, and homelessness (Canada Mortgage and Housing Corporation, 2006; Kraus et al., 2010; Kutzner and Ameyaw, 2010; Distasio et al., 2005). Aboriginal people in Canada are also significantly over-represented in Canada's HIV epidemic (Public Health Agency of Canada, 2010). Aboriginal people comprise just 3.8% of the total Canadian population, but account for 8% of people in Canada living with HIV (Public Health Agency of Canada, 2010). The rate of new infections among Aboriginal people is 3.6 times higher than non-Aboriginal people (Public Health Agency of Canada, 2010). In B.C., nearly 15% of HIV diagnoses in 2011 were among Aboriginal people (B.C. Centre for Disease Control, 2011). Aboriginal women and young people in particular have been severely impacted by the HIV epidemic (Public Health Agency of Canada, 2010; B.C. Ministry of Healthy Living and Sport, 2007; Marshall et al., 2008; Miller et al., 2006; Spittal et al., 2007). Critical to understanding the relationship between housing status and HIV infection are the ways in which housing shapes drug use practices, structures intimate relationships, and impacts individual self-worth (Rhodes et al., 2005; Aidala and Sumartojo, 2007; Dickson-Gomez et al., 2009). Lack of housing limits the physical space in which to manage the logistics of safe sex and safe injection, such as storing clean needles or negotiating condom use. Difficulties finding and maintaining housing may force young people into living arrangements with sexual partners where they feel unsafe or powerless. Further, living in public or semi-public spaces precludes the physical and emotional safety and security often found at home (Jacobson et al., 2009; Robertson, 2007). Powerful social meaning attached to having “a home of one's own” means that those living in sub-standard housing may struggle to maintain self-worth and dignity (Aidala and Sumartojo, 2007). In these ways, both the physical and place-based aspects of housing play an important intermediate role in increasing HIV vulnerability. This study examines how residential transience shapes vulnerability to HIV infection among young Aboriginal people who use illicit drugs in B.C.
2. Methods 2.1. Study sample The Cedar Project is a prospective cohort study of young Aboriginal people who use injection and non-injection drugs in Vancouver and Prince George, B.C. The methods used in the Cedar Project have been previously published in detail (Spittal et al., 2007). This study involved young people who self-identify as Aboriginal, including Métis, First Nations, Inuit and status and non-status Indians. Between 2003 and 2005, participants living primarily in the downtown areas of both cities were recruited through health care providers, street outreach, and word of mouth. Eligibility criteria included being aged 14–30 and having used illicit drugs, other than marijuana, in the month before enrollment. Drug use was confirmed using saliva screens (Oral-screen, Avitar Onsite Diagnostics). All participants met with an Aboriginal study coordinator who explained procedures, confirmed eligibility and sought informed consent. Participants completed a detailed questionnaire on socio-demographic characteristics, patterns of drug use, sexual vulnerability and use of services
administered by an interviewer at each six-month visit. Blood samples were taken and tested for antibodies to HIV and Hepatitis C at each visit. Participants were offered pre- and post-test counseling with trained nurses. They were requested, but not required, to return for test results. Each participant was given a $20 stipend at each visit to compensate for their time. All analyses presented here were restricted to participants who attended more than one interview during the study period. Of 605 participants in the Cedar Project cohort, 352 participants responded to the questions related to residential transience introduced during the fourth cycle of interviews. This follow-up, for which 260 participants returned, serves as the baseline for this study. 2.2. Study setting Cedar Project offices are located in Vancouver and Prince George, two urban centers in British Columbia. Vancouver is B.C.'s largest city, located on the province's south-west coast. Just over 40,000 Aboriginal people lived in Metro Vancouver in 2006, accounting for two percent of the population (Milligan, 2006a). Located in B.C.'s northern interior, Prince George is a forestry and mining town home to just under 9000 Aboriginal people, accounting for 11% of the population (Milligan, 2006b). Vancouver's Downtown Eastside neighborhood has been the setting of the province's largest open-air illicit drug market, and the centre of an explosive HIV epidemic (Corneil et al., 2006; Maas et al., 2007). The neighborhood is home to approximately 5000 people who use injection drugs and is characterized by extreme poverty, high crime rates, and housing instability (Maas et al., 2007). It is estimated that 40% of its residents are Aboriginal people. A high concentration of services related to substance abuse, sex work, and poverty are available in the neighborhood. However, while the service landscape of Vancouver's Downtown East Side has been well studied and documented, comparatively little is understood about Prince George's downtown core as a setting for high intensity drug use and homelessness. 2.3. Measures Participants were considered “highly transient” if they reported having slept in six or more different places in the past six months. The reference group included participants who were less transient (slept in one to five different places in the past six months). Sexual vulnerability was defined as occurring any time in the six months preceding the follow-up interview, including: condom use with regular and casual partners (always versus not always); sex work (yes versus no); and sexual assault (yes versus no). A sub-sample of participants who reported injecting in the prior six months was asked about: injection drug use (yes versus no); high frequency opiate injection (daily versus less than daily); high frequency cocaine injection (daily versus less than daily); high frequency methamphetamine injection (daily versus less than daily); needing help injecting (yes versus no); needle sharing (yes versus no); and public injection (ever versus never). Each multivariate model included variables hypothesized to confound the relationship between being highly transient and sex- and drug-related HIV vulnerability over time. These included age (in years), city of residence (Vancouver versus Prince George), and biological sex (male versus female). 2.4. Analysis Participant characteristics and housing patterns at baseline were compared between those who were highly transient and those who were not. Categorical variables were compared using Pearson's chisquared and Fisher's exact test where appropriate. Continuous variables were compared using a Student t-test. All p values presented are
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two sided. Bivariable and multivariable longitudinal models examined the relationship between being highly transient and sex- and drugrelated HIV vulnerabilities. These analyses relied on up to seven cycles of interviews between November 2005 and January 2010. To account for the correlations between repeated measures within subjects, generalized linear mixed models (GLMM) were fitted with a Gaussian–Hermite approximation. Finally, multivariable models were stratified by gender. Odds ratios and 95% confidence intervals were estimated to describe associations between housing status and sexand drug-related HIV vulnerabilities over time. Variables significant at a level of po0.05 were included in multivariable models. All statistical models were completed using R version 2.15.0 (R Development Core Team, 2012) with lme4 package. 2.5. Ethical considerations This study follows the guidelines in the Tri-Council Policy Statement on Ethical Conduct for Research Involving Humans— Chapter 9 Research involving the First Nations Inuit and Métis Peoples of Canada (CIHR et al., 2010). In addition, the study adheres to the principles of Ownership, Control, Access and Possession in relation to research with Aboriginal people (Schnarch, 2004). Aboriginal collaborators were involved in the conception, design and interpretation of this study. The University of British Columbia Providence Health Care Research Ethics Board approved the study. All participants provided informed consent.
3. Results Among 260 participants for whom baseline housing data was available, age at enrollment ranged from 15 to 33 and the median age was 24.5 years. In total, 131 (50.4%) participants reported residing in Vancouver at baseline, compared to Prince George, and 140 (53.8%) participants were female. Participants in both Prince George and Vancouver were highly mobile at baseline, with 18.5% reporting being highly transient in the six months prior to enrollment (Table 1). Prince George participants were more likely to be highly transient compared to those in Vancouver. Overall, 90% of Prince George participants reported living in two or more places in the six months prior to enrollment, compared to 74% in Vancouver. Prince George participants also reported higher rates of visiting a reserve in the prior six months. Bivariate comparisons of participant characteristics between participants who reported being highly transient and those who reported medium (2–5 places) or low (1 place) transience at baseline are summarized in Table 2. Results from longitudinal analyses (Table 3) included 1631 observations contributed by 352 participants, all of whom attended more than one follow-up interview between 2005 and 2010. Participants attended between two and seven visits; the median number of follow-up visits was six. The reference category in all models was participants who reported low or medium levels of transience in the prior six months.
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Sex work, sexual assault, and injecting drugs in the past six months were significantly associated with being highly transient in bivariate analysis. Among participants who inject drugs, high transience was associated with daily cocaine injection and injecting in public. Needed help injecting and sharing needles were marginally associated with high levels of housing transience (0.05 op o0.1). Being highly transient was independently associated with significantly elevated odds of participating in sex work and experiencing sexual assault in the previous six months. After adjusting for city, sex and age, high transience was associated with 4.54 increased odds of injecting drugs, and 2.16 increased odds of injecting cocaine daily. Injecting in public also remained significantly associated with high levels of housing transience in adjusted analysis. The highly gendered nature of sexual assault and sex work prompted a stratified analysis. Participation in sex work (AOR: 4.54, 95%CI: 2.56, 8.05) and sexual assault (AOR: 3.03, 95%CI: 1.46, 6.26) remained significant among young women but not among young men.
4. Discussion High levels of housing instability observed among young Aboriginal people who use drugs in this study are cause for alarm, as vulnerability to drug and sex-related harm appears to be greater among those who are highly transient. Although we are unable to infer causal relationships between housing status and HIV vulnerability from this study, the associations observed here suggest that finding and maintaining home is a critical component in keeping young Aboriginal people who use drugs safe and healthy. 4.1. Supporting young Aboriginal people in moments of transition Participants in both study locations reported disturbingly high levels of transience, with many moving six or more times in the previous six months. These findings are consistent with the “hyper-mobility” of Aboriginal young people reported in previous studies (Distasio et al., 2005, 2004). Others have observed that frequent moves are associated with severe mental illness, being younger, living in a low income area, and substance abuse (Lix et al., 2007, 2006). Though this study did not seek to determine the causes of transience among young Aboriginal people who use illicit drugs, it likely reflects the volatility and daily challenge of finding safety that accompanies high intensity drug use. Frequent moves may be a direct result of living in inherently temporary situations, such as shelters, couch-surfing or jail, as well as movement between cities and reserves. More than a quarter of participants in this study had visited a reserve and another quarter of participants had been incarcerated in the past six months at baseline. Crisis moments, such as evictions, breakdown of relationships, and arrest may also account for the residential transience observed in this study.
Table 1 Housing patterns of Cedar Project participants by city at baseline (2005).
Transience: number of different places slept in the past 6 months Low: 1 place Medium: 2–5 places High: 6þ places Been to a reserve in the past 6 months In detention, prison or jail in the past 6 months
Prince George (n¼129) no. (%)
Vancouver (n¼ 131) no. (%)
Total (n ¼260) no. (%)
p value
13 90 26 49 35
34 75 22 16 32
47 165 48 65 67
0.004
(10.1) (69.8) (20.2) (38.0) (27.3)
(26.0) (57.3) (16.8) (12.4) (24.6)
(18.1) (63.5) (18.5) (25.5) (26.0)
o 0.001 0.617
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Table 2 Baseline characteristics of Cedar Project participants by level of transience (2005). Highly transient (n¼ 48) no. (%)
Low or medium (n¼ 212) no. (%)
Total (n¼ 260) no. (%)
p value
Demographic characteristics Age at baseline (median, range¼ 15–33) Female gender Lived in Vancouver Identifying as gay, lesbian, bisexual or two-spirited In a relationship
25.5 30 (62.5) 22 (45.8) 8 (16.7) 43 (89.6)
24.5 110 (51.9) 109 (51.4) 25 (11.8) 186 (88.6)
24.5 140 (53.8) 131 (50.4) 33 (12.7) 229 (88.8)
0.150 0.183 0.485 0.360 0.841
Traumatic life experiences At least one parent attended residential school Ever taken from biological parents Experienced sexual abuse prior to age 13
34 (70.8) 31 (64.6) 29 (60.4)
162 (77.5) 149 (70.3) 100 (48.1)
196 (76.3) 180 (69.3) 129 (50.4)
0.327 0.440 0.123
Sexual vulnerabilities Consistent condom use (p6m)a Participated in sex work (p6m) Experienced sexual assault (p6m)
16 (48.5) 19 (43.2) 4 (8.7)
65 (41.5) 44 (20.9) 5 (2.4)
81 (42.4) 63 (24.7) 9 (3.5)
0.437 0.002 0.059
Drug-related vulnerabilities Injected drugs (p6m)b Daily or more opiate injection (p6m)c Daily or more methamphetamine injection (p6m)c Daily or more cocaine injection (p6m)c Need help injecting (p6m)c Needle sharing (p6m)c Injected in public (p6m)c Injected with a stranger (p6m)c
33 15 2 11 12 8 23 9
75 24 12 19 21 9 36 16
Health outcomes Presence of antibodies to Hepatitis C virus (HCV) Presence of antibodies to HIV
22 (52.4) 6 (13.0)
(89.2) (46.9) (6.2) (34.4) (36.4) (24.2) (71.9) (27.3 )
(75.8) (32.9) (16.4) (26.0) (28.0) (12.0) (48.0) (21.3)
108 39 14 30 33 17 59 25
63 (32.5) 26 (13.0)
(79.4) (37.1) (13.3) (28.6) (30.6) (15.7) (55.1) (23.1)
0.085 0.172 0.218 0.383 0.385 0.108 0.023 0.500
85 (36.0) 32 (13.0)
0.015 0.994
Note: p6m ¼ in the past 6 months. a b c
among those reporting having a casual or regular sexual partner (n¼ 215). among those reporting ever having injected drugs (n¼137). among those reporting injecting in the past 6 months (n¼ 108).
Table 3 Generalized linear mixed model unadjusted and adjusted relationships between sex- and drug-related HIV vulnerabilities and being highly transient over the past six months (2005–2010) UOR
95%CI
p value
AORn
95%CI
p value
Sexual vulnerabilities Consistent condom use Participated in sex work Experienced sexual assault
1.00 3.57 2.49
0.67, 1.48 2.09, 6.09 1.27, 4.89
0.981 o 0.001 0.008
– 3.52 2.48
– 2.06, 6.05 1.26, 4.86
– o 0.001 0.008
Drug-related vulnerabilities Injected drugsa Daily or more opiate injectionb Daily or more methamphetamine injectionb Daily or more cocaine injectionb Need help injectingb Needle sharingb Injected in publicb
4.83 0.94 0.43 1.98 1.65 2.17 2.85
2.93, 7.97 0.53, 1.68 0.13, 1.35 1.15, 3.42 0.95, 2.88 0.98, 4.83 1.64, 4.96
o 0.001 0.839 0.147 0.014 0.074 0.057 o 0.001
4.54 – – 2.16 – – 2.87
2.71, 7.61 – – 1.26, 3.72 – – 1.65, 5.00
o 0.001 – – 0.005 – – o 0.001
Note: all variables refer to sex and drug related vulnerabilities occurring in the prior six months. n
a b
adjusted for city, sex, and age. among those reporting ever having injected drugs (n¼ 242). among those reporting injecting in the past 6 months (n ¼187).
Programs that respond to the needs of young Aboriginal people in moments of transition, including acute housing crisis, relationship breakdown, and moving into new environments, are urgently required to prevent episodic homelessness and spirals into vulnerability. Aboriginal young people must be involved in the design and governance of culturally safe programs that recognize both the impacts of historical injustices and the inherent resilience and strength of Aboriginal youth.
City of residence appeared to be an important determinant of transience among the young Aboriginal people included in this study. This is the first study of HIV vulnerability to capture the nature and magnitude of housing instability in Prince George. One in five participants in this small, Northern city had slept in six or more different places in the prior six months. This likely reflects a lack of affordable housing options, including single room occupancy hotels, often found in larger cities. Some of the high
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transience observed in Prince George is also likely accounted for by visits to reserves. Cedar Project participants from both cities are diverse, representing many of B.C.'s 203 First Nations communities. It is possible that participants enrolling in the Cedar Project in Prince George maintain stronger ties with family and home communities, compared to participants living in Vancouver. This finding suggests the importance of measuring housing instability in ways that take into account both the context and service landscape of places, as well as the physical dimensions of housing. 4.2. Drug use and residential transience Residential transience observed in this study was associated with increased vulnerability to multiple high-risk outcomes, including drug use. Young, highly mobile participants were more likely to inject drugs compared to their less transient counterparts. Those who were highly mobile were more than twice as likely to inject cocaine daily and nearly three times more likely to inject in public. Frequent moves may play an important role in drug use intensity and safe injection practices. Transience may exacerbate injection-related risk as young people use injection drugs to selfmedicate the pain of trauma or deal with the stress of housing instability (Brave Heart, 2003). Secure housing may help to stabilize drug use by reducing the need for drugs as an emotional coping mechanism or to stay warm when sleeping outdoors, as well as by providing a private space away from areas of high drug activity. Being highly transient is likely a barrier to engagement in services, including drug treatment, harm reduction, and other HIV prevention services (German et al., 2007). Although participants may have a roof over their head most of the time, frequent moves may limit safe injection behaviors and increase visits to high-risk settings (German et al., 2007). Better housing has the potential to make drug use safer by providing a place to store needles, as well as give young Aboriginal people the privacy to slow down injection, moderate dosage, and take careful precautions that impact their health (Rhodes, 2002; Rhodes et al., 2006; Small et al., 2007). In the absence of safe, secure and adequate housing, it is crucial that unstably housed young Aboriginal people have access to alternative safe places to inject and access to culturally safe drug-related services (DeVerteuil and Wilson, 2010). 4.3. Sex work and residential transience The continuing murder and disappearance of Aboriginal women involved in sex work on Canadian streets has been highlighted by the Missing Women's Inquiry, Highway of Tears investigations, and reports from social justice groups (Oppal, 2012; Amnesty International, 2004; Human Rights Watch, 2013). However, young Aboriginal men and women remain vulnerable to sexual violence and assault as they participate in street-based sex work in Canada's cities. It is distressing that highly transient participants in this study were more than three times more likely to participate in sex work compared to those who were less transient. Housing transitions occur at a critical point in time when sexual vulnerability among young Aboriginal people who use drugs may escalate drastically. Young Aboriginal women facing housing instability may use sex as means to secure housing in the absence of alternative ways to generate income and meet basic needs. In recent studies conducted with women involved in sex work in Vancouver, sleeping on the street was associated with a higher volume of clients and servicing clients in public spaces (Duff et al., 2011). These findings suggest significant economic dependence on paid sex among unstably housed women involved in sex work, and that sex work is “a rational, economic strategy adopted by women to meet basic subsistent needs in the face of large scale social and structural
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inequities” (Shannon et al., 2008). Anecdotally, we have heard from young women in the Cedar Project that sex work is often initiated as a means of survival, and later becomes a way of providing basic needs, such as food, diapers and baby formula, for their own children and families. Stress of finding and maintaining housing may push women to enter high-risk relationships, including those with “sugar daddies” and regular, trusted clients, as a strategy to find safety and temporary accommodation. Previous studies have illustrated that women experiencing housing instability use survival sex work and relationships with clients as a tactic to secure a temporary place to stay (Dickson-Gomez et al., 2009; Miller and Neaigus, 2002). Dependence on intimate partners for housing can heighten young people's vulnerability as it may serve to reinforce gender power inequalities and trap young women in abusive relationships (Duff et al., 2011). Unequal relationships have severe implications for negotiating condom use or power over injection for young Aboriginal women who use drugs (Miller and Neaigus, 2002). In addition, dependence on intimate partners for housing likely leaves women vulnerable in terms of tenure during a breakup or an attempt to leave a violence situation (Robertson, 2007; Benoit et al., 2003; Abele et al., 2010; Neal, 2004). Young Aboriginal women involved in sex work are likely extremely vulnerable to eviction. House rules—including curfews, guest policies, and discrimination by housing managers—often fail to meet the needs of women involved in sex work (Lazarus et al., 2011). In the absence of safe spaces to work, street-based sex workers are pushed into marginal spaces where they have less control over the sexual encounter, including over condom use and risk of assault or arrest (Shannon and Csete, 2010; Shannon et al., 2009, 2008). Aboriginal young people involved in survival sex work in Canada's urban centers continue to be overwhelmed by multiple layers of discrimination, criminalization, intergenerational trauma, drug related harm, and predation (Spittal et al., 2003; Mehrabadi et al., 2008). Access to safe indoor spaces to practice sex work with fewer risks is crucial for young Aboriginal women in both Prince George and Vancouver. A recent Vancouver study found that sex workers who were able to work in their own residences, with some security-related support from building management, were at less risk of assault by clients, had increased control over condom use and payment, and were better able to identify and respond to bad dates (Krüsi et al., 2012). Women living in safer sex work environments were able to work with greater dignity, safety, and collaboration with their peers. This harm reduction approach to sex work reduces the threat of punitive sanctions by police and minimizes unequal power dynamics related to outdoor sex work that put women at risk of sexual assault and coerced sex (Duff et al., 2011; Miller and Neaigus 2002). Recent successes in decriminalizing sex work are important steps in changing the environment of sex worker's rights in Canada. It is vital that young Aboriginal people involved in sex work are represented as the fight for decriminalization continues. 4.4. Sexual assault and residential transience The magnitude and strength of the relationship between being highly transient and recently experiencing sexual assault in this study is alarming. Without adequate privacy and protective shelter, young Aboriginal people, especially women, face sexual violence and predation (Kushel et al., 2003; Wenzel et al., 2000). Urgent need to find privacy and a safe place to stay in response to the threat of sexual assault may drive frequent moves among young Aboriginal people who use drugs (Robertson 2007; Kushel et al., 2003; Fast et al., 2010). Sexual violence by a spouse or roommate may result in a living situation breakdown, leading to a
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period of transience while a young person gets back on their feet. These findings may also reflect that violence and rape are a ubiquitous feature of street-level sex work (Krüsi et al., 2010; Farley et al., 2005). Indeed, this study suggests that it is not just being indoors that is important, but that women also need security of tenure and control over private spaces where they can feel safe from sexual assault.
4.5. Limitations These findings are subject to limitations. Attaining a probabilistic sample was a challenge with this population and we cannot discount the possibility that this study's recruitment methods were biased towards particularly vulnerable young Aboriginal people. However, a variety of recruitment methods to acquire a representative sample, including snowball sampling, were used. Therefore, while selection bias cannot be ruled out, we are confident that the study sample is representative of Aboriginal young people who use drugs in Vancouver and Prince George. It should be noted that globally, Indigenous communities have a diversity of experience in relation to drug use; therefore, patterns of drug use observed in this study may not be reflected among other Indigenous peoples. Further, this study relies on selfreported data; participants may under-report experiences and behaviors that are painful to recall, illegal or stigmatizing. Repeated assurances of confidentiality and establishment of rapport between participants and Aboriginal interviewers over time helps to limit this bias. Finally, it is not possible to determine if transience preceded or followed sex- and drug-related HIV vulnerability, and therefore cannot infer causality. Despite these limitations, the results of this study provide an accurate understanding of the magnitude and correlates of housing instability among young Aboriginal people in B.C.
5. Conclusions Research has focused on the impact of physical qualities of housing on HIV vulnerability. However, these findings reveal that residential transience is also closely linked to HIV vulnerability among young Aboriginal people who use drugs. Ensuring that young Aboriginal people have access to safe spaces to live, work, and inject must include policies that address residential transience as well as the absence of a roof and walls.
Acknowledgments We are deeply grateful to Cedar Project participants for continuing to share their voices and stories with us. We are indebted to the Cedar Project Partnership, including Elders Violet Bozoki and Earl Henderson, Prince George Native Friendship Centre, Carrier Sekani Family Services, Healing Our Spirit, Positive Living North, Red Road Aboriginal HIV/AIDS Network, Central Interior Native Health, Vancouver Native Health Society, Canadian Aboriginal AIDS Network, All Nations Hope, Splatsin Secwepemc Nation, Neskonlith Indian Band, and Adams Lake Indian Band, for challenging us to be both great and good in our work. Thanks to our study staff, Vicky Thomas, Sharon Springer, Amanda Wood, Jill Fikowski, Pearl Lau, and Matt Quenneville, for their dedication to the study and participants. This research was funded by the Canadian Institutes of Health Research Operating Grant number RN156278-272441.
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The Cedar Project: Residential transience and HIV vulnerability among young Aboriginal people who use drugs Kate Jongbloed a, Vicky Thomas b,c, Margo E. Pearce a, Kukpi Wunuxtsin Christian d, Hongbin Zhang b, Eugenia Oviedo-Joekes a, Martin T. Schechter a, Patricia M. Spittal a,n, for The Cedar Project Partnership1 a
School of Population and Public Health, University of British Columbia, Vancouver, Canada The Cedar Project, Centre for Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, Canada c Wuikinuxv Nation, The Cedar Project, Prince George, Canada d Splatsin te Secwepemc, British Columbia, Canada b
art ic l e i nf o
a b s t r a c t
Article history: Received 22 September 2014 Received in revised form 18 December 2014 Accepted 18 February 2015 Available online 2 April 2015
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. & 2015 Published by Elsevier Ltd.
Keywords: Aboriginal peoples HIV risk Housing stability Drug use Residential transience
1. Introduction “The narrative of Indigenous homelessness has to start at the beginning, that is, with the historical truth of the original and ongoing dispossession of Indigenous people and of its consequences for the first peoples” (Murray, 2010). Scholars of Aboriginal health have argued that Aboriginal homelessness and housing instability is a result of historic dispossession of traditional territories and forced displacement from community structures (Reading and Wien, 2009; United Native Nations Society, 2001; Menzies, 2009; Leach, 2010; Ruttan et al., 2010; Dodson, 2010; Adelson, 2005). Under the Indian Act (Indian
n
Corresponding author. Tel.: þ 1 604 806 8779; fax: þ 1 604 806 9044. E-mail address: [email protected] (P.M. Spittal). 1 Elders Violet Bozoki (Lheidli T'enneh) and Earl Henderson (Cree, Metis), Prince George Native Friendship Centre, Carrier Sekani Family Services, Positive Living North, Red Road Aboriginal HIV/AIDS Network, Central Interior Native Health, Vancouver Native Health Society, Canadian Aboriginal AIDS Network, All Nations Hope, Splatsin Secwepemc Nation, Neskonlith Indian Band, and Adams Lake Indian Band. http://dx.doi.org/10.1016/j.healthplace.2015.02.008 1353-8292/& 2015 Published by Elsevier Ltd.
Act, RSC, 1985), Canada's reserve system carved up traditional lands and closely controlled where Aboriginal people were allowed to live and travel (Adelson, 2005). Beginning in 1920, Aboriginal parents were required by law to send their children away to residential schools as part of a church-state partnership to culturally assimilate Aboriginal children. Residential schools were sites of ritualized abuse, designed to “take the Indian out of the child” (Chansonneuve, 2005). Generations of children were taught to feel ashamed of their heritage, language, customs and spiritual traditions (Christian and Spittal, 2008). In total, more than 100,000 children were forcibly removed from their homes and families between 1867 and 1986 (Royal Commission on Aboriginal Peoples, 1996). In 1951, responsibility for child welfare was delegated to Canadian provinces. At this time, only 1% of youth in care in Canada were Aboriginal (Turpel-Lafond, 2013). During the “Sixties Scoop”, thousands of Aboriginal children were apprehended and placed in foster or adoptive homes across Canada (Trocmé et al., 2004). Removal from biological parents was often permanent and children often moved several times while in care. Today, more than half of children in care in Canada's western-most province of British Columbia (B.C.) are Aboriginal, although Aboriginal people
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account for just 5% of the population (Turpel-Lafond, 2013; Statistics Canada, 2011). These government actions have systematically and deliberately dismantled Aboriginal homes, families, and communities. Severing of family and community ties has left an indelible mark on individuals and communities across generations, creating “a homeless state” (Menzies, 2009; Christian and Spittal, 2008). Today, the systemic nature of housing instability among Aboriginal people is captured in virtually every housing measure in B.C., including housing quality, affordability, residential transience, and homelessness (Canada Mortgage and Housing Corporation, 2006; Kraus et al., 2010; Kutzner and Ameyaw, 2010; Distasio et al., 2005). Aboriginal people in Canada are also significantly over-represented in Canada's HIV epidemic (Public Health Agency of Canada, 2010). Aboriginal people comprise just 3.8% of the total Canadian population, but account for 8% of people in Canada living with HIV (Public Health Agency of Canada, 2010). The rate of new infections among Aboriginal people is 3.6 times higher than non-Aboriginal people (Public Health Agency of Canada, 2010). In B.C., nearly 15% of HIV diagnoses in 2011 were among Aboriginal people (B.C. Centre for Disease Control, 2011). Aboriginal women and young people in particular have been severely impacted by the HIV epidemic (Public Health Agency of Canada, 2010; B.C. Ministry of Healthy Living and Sport, 2007; Marshall et al., 2008; Miller et al., 2006; Spittal et al., 2007). Critical to understanding the relationship between housing status and HIV infection are the ways in which housing shapes drug use practices, structures intimate relationships, and impacts individual self-worth (Rhodes et al., 2005; Aidala and Sumartojo, 2007; Dickson-Gomez et al., 2009). Lack of housing limits the physical space in which to manage the logistics of safe sex and safe injection, such as storing clean needles or negotiating condom use. Difficulties finding and maintaining housing may force young people into living arrangements with sexual partners where they feel unsafe or powerless. Further, living in public or semi-public spaces precludes the physical and emotional safety and security often found at home (Jacobson et al., 2009; Robertson, 2007). Powerful social meaning attached to having “a home of one's own” means that those living in sub-standard housing may struggle to maintain self-worth and dignity (Aidala and Sumartojo, 2007). In these ways, both the physical and place-based aspects of housing play an important intermediate role in increasing HIV vulnerability. This study examines how residential transience shapes vulnerability to HIV infection among young Aboriginal people who use illicit drugs in B.C.
2. Methods 2.1. Study sample The Cedar Project is a prospective cohort study of young Aboriginal people who use injection and non-injection drugs in Vancouver and Prince George, B.C. The methods used in the Cedar Project have been previously published in detail (Spittal et al., 2007). This study involved young people who self-identify as Aboriginal, including Métis, First Nations, Inuit and status and non-status Indians. Between 2003 and 2005, participants living primarily in the downtown areas of both cities were recruited through health care providers, street outreach, and word of mouth. Eligibility criteria included being aged 14–30 and having used illicit drugs, other than marijuana, in the month before enrollment. Drug use was confirmed using saliva screens (Oral-screen, Avitar Onsite Diagnostics). All participants met with an Aboriginal study coordinator who explained procedures, confirmed eligibility and sought informed consent. Participants completed a detailed questionnaire on socio-demographic characteristics, patterns of drug use, sexual vulnerability and use of services
administered by an interviewer at each six-month visit. Blood samples were taken and tested for antibodies to HIV and Hepatitis C at each visit. Participants were offered pre- and post-test counseling with trained nurses. They were requested, but not required, to return for test results. Each participant was given a $20 stipend at each visit to compensate for their time. All analyses presented here were restricted to participants who attended more than one interview during the study period. Of 605 participants in the Cedar Project cohort, 352 participants responded to the questions related to residential transience introduced during the fourth cycle of interviews. This follow-up, for which 260 participants returned, serves as the baseline for this study. 2.2. Study setting Cedar Project offices are located in Vancouver and Prince George, two urban centers in British Columbia. Vancouver is B.C.'s largest city, located on the province's south-west coast. Just over 40,000 Aboriginal people lived in Metro Vancouver in 2006, accounting for two percent of the population (Milligan, 2006a). Located in B.C.'s northern interior, Prince George is a forestry and mining town home to just under 9000 Aboriginal people, accounting for 11% of the population (Milligan, 2006b). Vancouver's Downtown Eastside neighborhood has been the setting of the province's largest open-air illicit drug market, and the centre of an explosive HIV epidemic (Corneil et al., 2006; Maas et al., 2007). The neighborhood is home to approximately 5000 people who use injection drugs and is characterized by extreme poverty, high crime rates, and housing instability (Maas et al., 2007). It is estimated that 40% of its residents are Aboriginal people. A high concentration of services related to substance abuse, sex work, and poverty are available in the neighborhood. However, while the service landscape of Vancouver's Downtown East Side has been well studied and documented, comparatively little is understood about Prince George's downtown core as a setting for high intensity drug use and homelessness. 2.3. Measures Participants were considered “highly transient” if they reported having slept in six or more different places in the past six months. The reference group included participants who were less transient (slept in one to five different places in the past six months). Sexual vulnerability was defined as occurring any time in the six months preceding the follow-up interview, including: condom use with regular and casual partners (always versus not always); sex work (yes versus no); and sexual assault (yes versus no). A sub-sample of participants who reported injecting in the prior six months was asked about: injection drug use (yes versus no); high frequency opiate injection (daily versus less than daily); high frequency cocaine injection (daily versus less than daily); high frequency methamphetamine injection (daily versus less than daily); needing help injecting (yes versus no); needle sharing (yes versus no); and public injection (ever versus never). Each multivariate model included variables hypothesized to confound the relationship between being highly transient and sex- and drug-related HIV vulnerability over time. These included age (in years), city of residence (Vancouver versus Prince George), and biological sex (male versus female). 2.4. Analysis Participant characteristics and housing patterns at baseline were compared between those who were highly transient and those who were not. Categorical variables were compared using Pearson's chisquared and Fisher's exact test where appropriate. Continuous variables were compared using a Student t-test. All p values presented are
K. Jongbloed et al. / Health & Place 33 (2015) 125–131
two sided. Bivariable and multivariable longitudinal models examined the relationship between being highly transient and sex- and drugrelated HIV vulnerabilities. These analyses relied on up to seven cycles of interviews between November 2005 and January 2010. To account for the correlations between repeated measures within subjects, generalized linear mixed models (GLMM) were fitted with a Gaussian–Hermite approximation. Finally, multivariable models were stratified by gender. Odds ratios and 95% confidence intervals were estimated to describe associations between housing status and sexand drug-related HIV vulnerabilities over time. Variables significant at a level of po0.05 were included in multivariable models. All statistical models were completed using R version 2.15.0 (R Development Core Team, 2012) with lme4 package. 2.5. Ethical considerations This study follows the guidelines in the Tri-Council Policy Statement on Ethical Conduct for Research Involving Humans— Chapter 9 Research involving the First Nations Inuit and Métis Peoples of Canada (CIHR et al., 2010). In addition, the study adheres to the principles of Ownership, Control, Access and Possession in relation to research with Aboriginal people (Schnarch, 2004). Aboriginal collaborators were involved in the conception, design and interpretation of this study. The University of British Columbia Providence Health Care Research Ethics Board approved the study. All participants provided informed consent.
3. Results Among 260 participants for whom baseline housing data was available, age at enrollment ranged from 15 to 33 and the median age was 24.5 years. In total, 131 (50.4%) participants reported residing in Vancouver at baseline, compared to Prince George, and 140 (53.8%) participants were female. Participants in both Prince George and Vancouver were highly mobile at baseline, with 18.5% reporting being highly transient in the six months prior to enrollment (Table 1). Prince George participants were more likely to be highly transient compared to those in Vancouver. Overall, 90% of Prince George participants reported living in two or more places in the six months prior to enrollment, compared to 74% in Vancouver. Prince George participants also reported higher rates of visiting a reserve in the prior six months. Bivariate comparisons of participant characteristics between participants who reported being highly transient and those who reported medium (2–5 places) or low (1 place) transience at baseline are summarized in Table 2. Results from longitudinal analyses (Table 3) included 1631 observations contributed by 352 participants, all of whom attended more than one follow-up interview between 2005 and 2010. Participants attended between two and seven visits; the median number of follow-up visits was six. The reference category in all models was participants who reported low or medium levels of transience in the prior six months.
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Sex work, sexual assault, and injecting drugs in the past six months were significantly associated with being highly transient in bivariate analysis. Among participants who inject drugs, high transience was associated with daily cocaine injection and injecting in public. Needed help injecting and sharing needles were marginally associated with high levels of housing transience (0.05 op o0.1). Being highly transient was independently associated with significantly elevated odds of participating in sex work and experiencing sexual assault in the previous six months. After adjusting for city, sex and age, high transience was associated with 4.54 increased odds of injecting drugs, and 2.16 increased odds of injecting cocaine daily. Injecting in public also remained significantly associated with high levels of housing transience in adjusted analysis. The highly gendered nature of sexual assault and sex work prompted a stratified analysis. Participation in sex work (AOR: 4.54, 95%CI: 2.56, 8.05) and sexual assault (AOR: 3.03, 95%CI: 1.46, 6.26) remained significant among young women but not among young men.
4. Discussion High levels of housing instability observed among young Aboriginal people who use drugs in this study are cause for alarm, as vulnerability to drug and sex-related harm appears to be greater among those who are highly transient. Although we are unable to infer causal relationships between housing status and HIV vulnerability from this study, the associations observed here suggest that finding and maintaining home is a critical component in keeping young Aboriginal people who use drugs safe and healthy. 4.1. Supporting young Aboriginal people in moments of transition Participants in both study locations reported disturbingly high levels of transience, with many moving six or more times in the previous six months. These findings are consistent with the “hyper-mobility” of Aboriginal young people reported in previous studies (Distasio et al., 2005, 2004). Others have observed that frequent moves are associated with severe mental illness, being younger, living in a low income area, and substance abuse (Lix et al., 2007, 2006). Though this study did not seek to determine the causes of transience among young Aboriginal people who use illicit drugs, it likely reflects the volatility and daily challenge of finding safety that accompanies high intensity drug use. Frequent moves may be a direct result of living in inherently temporary situations, such as shelters, couch-surfing or jail, as well as movement between cities and reserves. More than a quarter of participants in this study had visited a reserve and another quarter of participants had been incarcerated in the past six months at baseline. Crisis moments, such as evictions, breakdown of relationships, and arrest may also account for the residential transience observed in this study.
Table 1 Housing patterns of Cedar Project participants by city at baseline (2005).
Transience: number of different places slept in the past 6 months Low: 1 place Medium: 2–5 places High: 6þ places Been to a reserve in the past 6 months In detention, prison or jail in the past 6 months
Prince George (n¼129) no. (%)
Vancouver (n¼ 131) no. (%)
Total (n ¼260) no. (%)
p value
13 90 26 49 35
34 75 22 16 32
47 165 48 65 67
0.004
(10.1) (69.8) (20.2) (38.0) (27.3)
(26.0) (57.3) (16.8) (12.4) (24.6)
(18.1) (63.5) (18.5) (25.5) (26.0)
o 0.001 0.617
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Table 2 Baseline characteristics of Cedar Project participants by level of transience (2005). Highly transient (n¼ 48) no. (%)
Low or medium (n¼ 212) no. (%)
Total (n¼ 260) no. (%)
p value
Demographic characteristics Age at baseline (median, range¼ 15–33) Female gender Lived in Vancouver Identifying as gay, lesbian, bisexual or two-spirited In a relationship
25.5 30 (62.5) 22 (45.8) 8 (16.7) 43 (89.6)
24.5 110 (51.9) 109 (51.4) 25 (11.8) 186 (88.6)
24.5 140 (53.8) 131 (50.4) 33 (12.7) 229 (88.8)
0.150 0.183 0.485 0.360 0.841
Traumatic life experiences At least one parent attended residential school Ever taken from biological parents Experienced sexual abuse prior to age 13
34 (70.8) 31 (64.6) 29 (60.4)
162 (77.5) 149 (70.3) 100 (48.1)
196 (76.3) 180 (69.3) 129 (50.4)
0.327 0.440 0.123
Sexual vulnerabilities Consistent condom use (p6m)a Participated in sex work (p6m) Experienced sexual assault (p6m)
16 (48.5) 19 (43.2) 4 (8.7)
65 (41.5) 44 (20.9) 5 (2.4)
81 (42.4) 63 (24.7) 9 (3.5)
0.437 0.002 0.059
Drug-related vulnerabilities Injected drugs (p6m)b Daily or more opiate injection (p6m)c Daily or more methamphetamine injection (p6m)c Daily or more cocaine injection (p6m)c Need help injecting (p6m)c Needle sharing (p6m)c Injected in public (p6m)c Injected with a stranger (p6m)c
33 15 2 11 12 8 23 9
75 24 12 19 21 9 36 16
Health outcomes Presence of antibodies to Hepatitis C virus (HCV) Presence of antibodies to HIV
22 (52.4) 6 (13.0)
(89.2) (46.9) (6.2) (34.4) (36.4) (24.2) (71.9) (27.3 )
(75.8) (32.9) (16.4) (26.0) (28.0) (12.0) (48.0) (21.3)
108 39 14 30 33 17 59 25
63 (32.5) 26 (13.0)
(79.4) (37.1) (13.3) (28.6) (30.6) (15.7) (55.1) (23.1)
0.085 0.172 0.218 0.383 0.385 0.108 0.023 0.500
85 (36.0) 32 (13.0)
0.015 0.994
Note: p6m ¼ in the past 6 months. a b c
among those reporting having a casual or regular sexual partner (n¼ 215). among those reporting ever having injected drugs (n¼137). among those reporting injecting in the past 6 months (n¼ 108).
Table 3 Generalized linear mixed model unadjusted and adjusted relationships between sex- and drug-related HIV vulnerabilities and being highly transient over the past six months (2005–2010) UOR
95%CI
p value
AORn
95%CI
p value
Sexual vulnerabilities Consistent condom use Participated in sex work Experienced sexual assault
1.00 3.57 2.49
0.67, 1.48 2.09, 6.09 1.27, 4.89
0.981 o 0.001 0.008
– 3.52 2.48
– 2.06, 6.05 1.26, 4.86
– o 0.001 0.008
Drug-related vulnerabilities Injected drugsa Daily or more opiate injectionb Daily or more methamphetamine injectionb Daily or more cocaine injectionb Need help injectingb Needle sharingb Injected in publicb
4.83 0.94 0.43 1.98 1.65 2.17 2.85
2.93, 7.97 0.53, 1.68 0.13, 1.35 1.15, 3.42 0.95, 2.88 0.98, 4.83 1.64, 4.96
o 0.001 0.839 0.147 0.014 0.074 0.057 o 0.001
4.54 – – 2.16 – – 2.87
2.71, 7.61 – – 1.26, 3.72 – – 1.65, 5.00
o 0.001 – – 0.005 – – o 0.001
Note: all variables refer to sex and drug related vulnerabilities occurring in the prior six months. n
a b
adjusted for city, sex, and age. among those reporting ever having injected drugs (n¼ 242). among those reporting injecting in the past 6 months (n ¼187).
Programs that respond to the needs of young Aboriginal people in moments of transition, including acute housing crisis, relationship breakdown, and moving into new environments, are urgently required to prevent episodic homelessness and spirals into vulnerability. Aboriginal young people must be involved in the design and governance of culturally safe programs that recognize both the impacts of historical injustices and the inherent resilience and strength of Aboriginal youth.
City of residence appeared to be an important determinant of transience among the young Aboriginal people included in this study. This is the first study of HIV vulnerability to capture the nature and magnitude of housing instability in Prince George. One in five participants in this small, Northern city had slept in six or more different places in the prior six months. This likely reflects a lack of affordable housing options, including single room occupancy hotels, often found in larger cities. Some of the high
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transience observed in Prince George is also likely accounted for by visits to reserves. Cedar Project participants from both cities are diverse, representing many of B.C.'s 203 First Nations communities. It is possible that participants enrolling in the Cedar Project in Prince George maintain stronger ties with family and home communities, compared to participants living in Vancouver. This finding suggests the importance of measuring housing instability in ways that take into account both the context and service landscape of places, as well as the physical dimensions of housing. 4.2. Drug use and residential transience Residential transience observed in this study was associated with increased vulnerability to multiple high-risk outcomes, including drug use. Young, highly mobile participants were more likely to inject drugs compared to their less transient counterparts. Those who were highly mobile were more than twice as likely to inject cocaine daily and nearly three times more likely to inject in public. Frequent moves may play an important role in drug use intensity and safe injection practices. Transience may exacerbate injection-related risk as young people use injection drugs to selfmedicate the pain of trauma or deal with the stress of housing instability (Brave Heart, 2003). Secure housing may help to stabilize drug use by reducing the need for drugs as an emotional coping mechanism or to stay warm when sleeping outdoors, as well as by providing a private space away from areas of high drug activity. Being highly transient is likely a barrier to engagement in services, including drug treatment, harm reduction, and other HIV prevention services (German et al., 2007). Although participants may have a roof over their head most of the time, frequent moves may limit safe injection behaviors and increase visits to high-risk settings (German et al., 2007). Better housing has the potential to make drug use safer by providing a place to store needles, as well as give young Aboriginal people the privacy to slow down injection, moderate dosage, and take careful precautions that impact their health (Rhodes, 2002; Rhodes et al., 2006; Small et al., 2007). In the absence of safe, secure and adequate housing, it is crucial that unstably housed young Aboriginal people have access to alternative safe places to inject and access to culturally safe drug-related services (DeVerteuil and Wilson, 2010). 4.3. Sex work and residential transience The continuing murder and disappearance of Aboriginal women involved in sex work on Canadian streets has been highlighted by the Missing Women's Inquiry, Highway of Tears investigations, and reports from social justice groups (Oppal, 2012; Amnesty International, 2004; Human Rights Watch, 2013). However, young Aboriginal men and women remain vulnerable to sexual violence and assault as they participate in street-based sex work in Canada's cities. It is distressing that highly transient participants in this study were more than three times more likely to participate in sex work compared to those who were less transient. Housing transitions occur at a critical point in time when sexual vulnerability among young Aboriginal people who use drugs may escalate drastically. Young Aboriginal women facing housing instability may use sex as means to secure housing in the absence of alternative ways to generate income and meet basic needs. In recent studies conducted with women involved in sex work in Vancouver, sleeping on the street was associated with a higher volume of clients and servicing clients in public spaces (Duff et al., 2011). These findings suggest significant economic dependence on paid sex among unstably housed women involved in sex work, and that sex work is “a rational, economic strategy adopted by women to meet basic subsistent needs in the face of large scale social and structural
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inequities” (Shannon et al., 2008). Anecdotally, we have heard from young women in the Cedar Project that sex work is often initiated as a means of survival, and later becomes a way of providing basic needs, such as food, diapers and baby formula, for their own children and families. Stress of finding and maintaining housing may push women to enter high-risk relationships, including those with “sugar daddies” and regular, trusted clients, as a strategy to find safety and temporary accommodation. Previous studies have illustrated that women experiencing housing instability use survival sex work and relationships with clients as a tactic to secure a temporary place to stay (Dickson-Gomez et al., 2009; Miller and Neaigus, 2002). Dependence on intimate partners for housing can heighten young people's vulnerability as it may serve to reinforce gender power inequalities and trap young women in abusive relationships (Duff et al., 2011). Unequal relationships have severe implications for negotiating condom use or power over injection for young Aboriginal women who use drugs (Miller and Neaigus, 2002). In addition, dependence on intimate partners for housing likely leaves women vulnerable in terms of tenure during a breakup or an attempt to leave a violence situation (Robertson, 2007; Benoit et al., 2003; Abele et al., 2010; Neal, 2004). Young Aboriginal women involved in sex work are likely extremely vulnerable to eviction. House rules—including curfews, guest policies, and discrimination by housing managers—often fail to meet the needs of women involved in sex work (Lazarus et al., 2011). In the absence of safe spaces to work, street-based sex workers are pushed into marginal spaces where they have less control over the sexual encounter, including over condom use and risk of assault or arrest (Shannon and Csete, 2010; Shannon et al., 2009, 2008). Aboriginal young people involved in survival sex work in Canada's urban centers continue to be overwhelmed by multiple layers of discrimination, criminalization, intergenerational trauma, drug related harm, and predation (Spittal et al., 2003; Mehrabadi et al., 2008). Access to safe indoor spaces to practice sex work with fewer risks is crucial for young Aboriginal women in both Prince George and Vancouver. A recent Vancouver study found that sex workers who were able to work in their own residences, with some security-related support from building management, were at less risk of assault by clients, had increased control over condom use and payment, and were better able to identify and respond to bad dates (Krüsi et al., 2012). Women living in safer sex work environments were able to work with greater dignity, safety, and collaboration with their peers. This harm reduction approach to sex work reduces the threat of punitive sanctions by police and minimizes unequal power dynamics related to outdoor sex work that put women at risk of sexual assault and coerced sex (Duff et al., 2011; Miller and Neaigus 2002). Recent successes in decriminalizing sex work are important steps in changing the environment of sex worker's rights in Canada. It is vital that young Aboriginal people involved in sex work are represented as the fight for decriminalization continues. 4.4. Sexual assault and residential transience The magnitude and strength of the relationship between being highly transient and recently experiencing sexual assault in this study is alarming. Without adequate privacy and protective shelter, young Aboriginal people, especially women, face sexual violence and predation (Kushel et al., 2003; Wenzel et al., 2000). Urgent need to find privacy and a safe place to stay in response to the threat of sexual assault may drive frequent moves among young Aboriginal people who use drugs (Robertson 2007; Kushel et al., 2003; Fast et al., 2010). Sexual violence by a spouse or roommate may result in a living situation breakdown, leading to a
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period of transience while a young person gets back on their feet. These findings may also reflect that violence and rape are a ubiquitous feature of street-level sex work (Krüsi et al., 2010; Farley et al., 2005). Indeed, this study suggests that it is not just being indoors that is important, but that women also need security of tenure and control over private spaces where they can feel safe from sexual assault.
4.5. Limitations These findings are subject to limitations. Attaining a probabilistic sample was a challenge with this population and we cannot discount the possibility that this study's recruitment methods were biased towards particularly vulnerable young Aboriginal people. However, a variety of recruitment methods to acquire a representative sample, including snowball sampling, were used. Therefore, while selection bias cannot be ruled out, we are confident that the study sample is representative of Aboriginal young people who use drugs in Vancouver and Prince George. It should be noted that globally, Indigenous communities have a diversity of experience in relation to drug use; therefore, patterns of drug use observed in this study may not be reflected among other Indigenous peoples. Further, this study relies on selfreported data; participants may under-report experiences and behaviors that are painful to recall, illegal or stigmatizing. Repeated assurances of confidentiality and establishment of rapport between participants and Aboriginal interviewers over time helps to limit this bias. Finally, it is not possible to determine if transience preceded or followed sex- and drug-related HIV vulnerability, and therefore cannot infer causality. Despite these limitations, the results of this study provide an accurate understanding of the magnitude and correlates of housing instability among young Aboriginal people in B.C.
5. Conclusions Research has focused on the impact of physical qualities of housing on HIV vulnerability. However, these findings reveal that residential transience is also closely linked to HIV vulnerability among young Aboriginal people who use drugs. Ensuring that young Aboriginal people have access to safe spaces to live, work, and inject must include policies that address residential transience as well as the absence of a roof and walls.
Acknowledgments We are deeply grateful to Cedar Project participants for continuing to share their voices and stories with us. We are indebted to the Cedar Project Partnership, including Elders Violet Bozoki and Earl Henderson, Prince George Native Friendship Centre, Carrier Sekani Family Services, Healing Our Spirit, Positive Living North, Red Road Aboriginal HIV/AIDS Network, Central Interior Native Health, Vancouver Native Health Society, Canadian Aboriginal AIDS Network, All Nations Hope, Splatsin Secwepemc Nation, Neskonlith Indian Band, and Adams Lake Indian Band, for challenging us to be both great and good in our work. Thanks to our study staff, Vicky Thomas, Sharon Springer, Amanda Wood, Jill Fikowski, Pearl Lau, and Matt Quenneville, for their dedication to the study and participants. This research was funded by the Canadian Institutes of Health Research Operating Grant number RN156278-272441.
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