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Journal of Urban Health : Bulletin of the New York Academy of Medicine logoLink to Journal of Urban Health : Bulletin of the New York Academy of Medicine
. 2005 Sep;82(3):488–497. doi: 10.1093/jurban/jti076

Access and utilization of HIV treatment and services among women sex workers in Vancouver’s downtown eastside

Kate Shannon 1, Vicki Bright 2, Janice Duddy 2, Mark W Tyndall 1,3,✉
PMCID: PMC3456060  PMID: 15944404

Abstract

Many HIV-infected women are not realizing the benefits of highly active antiretroviral therapy (HAART) despite significant advancements in treatment. Women in Vancouver’s Downtown Eastside (DTES) are highly marginalized and struggle with multiple morbidities, unstable housing, addiction, survival sex, and elevated risk of sexual and drug-related harms, including HIV infection. Although recent studies have identified the heightened risk of HIV infection among women engaged in sex work and injection drug use, the uptake of HIV care among this population has received little attention. The objectives of this study are to evaluate the needs of women engaged in survival sex work and to assess utilization and acceptance of HAART. During November 2003, a baseline needs assessment was conducted among 159 women through a low-threshold drop-in centre servicing street-level sex workers in Vancouver. Cross-sectional data were used to describe the sociodemographic characteristics, drug use patterns, HIV/hepatitis C virus (HCV) testing and status, and attitudes towards HAART. High rates of cocaine injection, heroin injection, and smokeable crack cocaine use reflect the vulnerable and chaotic nature of this population. Although preliminary findings suggest an overall high uptake of health and social services, there was limited attention to HIV care with only 9% of the women on HAART. Self-reported barriers to accessing treatment were largely attributed to misinformation and misconceptions about treatment. Given the acceptability of accessing HAART through community interventions and women specific services, this study highlights the potential to reach this highly marginalized group and provides valuable baseline information on a population that has remained largely outside consistent HIV care.

Keywords: Antiretroviral therapy, HIV/AIDS, Injection drug use, Women sex workers

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References

  • 1.Porter K, Babiker A, Bhaskaran K, Darbyshire J, Pezzotti P, Walker AS. Determinants of survival following HIV-1 seroconversion after the introduction of HAART. Lancet. 2003;362:1267–1274. doi: 10.1016/S0140-6736(03)14570-9. [DOI] [PubMed] [Google Scholar]
  • 2.Hogg RS, Heath KV, Yip B, et al. Improved survival among HIV-infected individuals following initiation of antiretroviral therapy. JAMA. 1998;279:450–454. doi: 10.1001/jama.279.6.450. [DOI] [PubMed] [Google Scholar]
  • 3.Mitty JA, Flanigan T. Community-based interventions for marginalized populations. Clin Infect Dis. 2004;38:S373–S375. doi: 10.1086/421398. [DOI] [PubMed] [Google Scholar]
  • 4.Altice FL, Mostashari F, Friedland GH. Trust and the acceptance of and adherence to antiretroviral therapy. J Acquir Immune Defic Syndr. 2001;28:47–58. doi: 10.1097/00042560-200109010-00008. [DOI] [PubMed] [Google Scholar]
  • 5.Palepu A, Tyndall MW, Li K, et al. Adherence and sustainability of antiretroviral therapy among injection drug users in Vancouver. Can J of Infect Dis. 2001;12(suppl B):32B–32B. [Google Scholar]
  • 6.Strathdee SA, Palepu A, Cornelisse PG, et al. Barriers to use of free antiretroviral therapy in injection drug users. JAMA. 1998;280:547–549. doi: 10.1001/jama.280.6.547. [DOI] [PubMed] [Google Scholar]
  • 7.Strathdee SA, O’Driscoll PT, Galai N, et al. Trends in use of optimal, suboptimal, and no HIV antiretroviral therapy. Paper presented at: XV International AIDS Conference; July 11th, 2004; Bangkok, Thailand.
  • 8.Moore AL, Kirk O, Johnson AM, et al. Virologic, immunologic, and clinical response to highly active antiretroviral therapy: the gender issue revisited. J Acquir Immune Defic Syndr. 2003;32:452–461. doi: 10.1097/00126334-200304010-00017. [DOI] [PubMed] [Google Scholar]
  • 9.Wood E, Montaner JS, Tyndall MW, Schechter MT, O’Shaughnessy MV, Hogg RS. Prevalence and correlates of untreated human immunodeficiency virus type 1 infection among persons who have died in the era of modern antiretroviral therapy. J Infect Dis. 2003;188:1164–1170. doi: 10.1086/378703. [DOI] [PubMed] [Google Scholar]
  • 10.Miller CL, Spittal PM, LaLiberte N, et al. Females experiencing sexual and drug vulnerabilities are at elevated risk for HIV infection among youth who use injection drugs. JAIDS. 2002;30:1–10. doi: 10.1097/00126334-200207010-00010. [DOI] [PubMed] [Google Scholar]
  • 11.Spittal PM, Craib KJ, Wood E, et al. Risk factors for elevated HIV incidence rates among female injection drug users in Vancouver. CMAJ. 2002;166:894–899. [PMC free article] [PubMed] [Google Scholar]
  • 12.Spittal PM, Bruneau J, Craib KJ, et al. Surviving the sex trade: a comparison of HIV risk behaviours among street-involved women in two Canadian cities who inject drugs. AIDS Care. 2003;15:187–195. doi: 10.1080/0954012031000068335. [DOI] [PubMed] [Google Scholar]
  • 13.Kral A, Bluthenthal R, Lorvick J, et al. Sexual transmission of HIV-1 among injection drug users in San Francisco, USA: risk-factor analysis. Lancet. 2001;357:1397–1401. doi: 10.1016/S0140-6736(00)04562-1. [DOI] [PubMed] [Google Scholar]
  • 14.Strathdee S, Sherman SG. The role of sexual transmission of HIV infection among injection and non-injection drug users. J Urban Health. 2003;80:iii7–iii14. doi: 10.1093/jurban/jtg078. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Astemborski J, Vlahov D, Warren D, et al. The trading of sex for drugs or money and HIV seropositivity among female intravenous drug users. Am J Public Health. 1994;84:382–387. doi: 10.2105/ajph.84.3.382. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Gollub EL, Rey D, Obadia Y, Moatti JP. Gender differences in risk behaviours among HIV+ persons with an IDU history: the link between partner characteristics and women’s higher drug-sex risks. Sex Transm Dis. 1998;25:483–488. doi: 10.1097/00007435-199810000-00008. [DOI] [PubMed] [Google Scholar]
  • 17.HIV/AIDS Epi Update. Ottawa: Bureau of HIV/AIDS, STD and TB; 2003. HIV/AIDS among Aboriginal persons in Canada: A Continuing concern; pp. 35–40. [Google Scholar]
  • 18.Craib KJ, Spittal PM, Wood E, et al. Risk factors for elevated HIV incidence among Aboriginal injection drug users in Vancouver. CMAJ. 2003;168:19–31. [PMC free article] [PubMed] [Google Scholar]
  • 19.Needle RH, Trotter RT, Singer M, et al. Rapid assessment of the HIV/AIDS crisis in racial and ethnic minority communities: an approach for timely community interventions. Am J Public Health. 2003;93:970–979. doi: 10.2105/AJPH.93.6.970. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Johnson BL, Haeften I, Fishbein M, Kasprzyk D, Montano D. Factors influencing IDU and non-IDU female commercial sex workers’ intentions to always use condoms for vaginal sex with their regular partners. Psychol Health Med. 2001;6:207–222. doi: 10.1080/13548500120035454. [DOI] [Google Scholar]
  • 21.Booth R, Kwiatkowski CF, Chitwood DD. Sex related HIV risk behaviours: differential risks among injection drug users, crack smokers, and injection drug users who smoke crack. Drug Alcohol Depend. 2000;58:219–226. doi: 10.1016/S0376-8716(99)00094-0. [DOI] [PubMed] [Google Scholar]
  • 22.Edlin BR, Irwin KL, Faruque S, et al. Intersecting epidemics—crack cocaine use and HIV infection among inner-city young adults. N Engl J Med. 1994;331:1422–1427. doi: 10.1056/NEJM199411243312106. [DOI] [PubMed] [Google Scholar]
  • 23.Vidal-Trecan G, Coste J, Varescon-Pousson I, Christoforov B, Boissonnas A. HCV status knowledge and risk behaviours amongst intravenous drug users. Eur J Epidemiol. 2000;16:439–445. doi: 10.1023/A:1007622831518. [DOI] [PubMed] [Google Scholar]
  • 24.Palepu A, Strathdee SA, Hogg RS, et al. The social determinants of emergency department and hospital use by injection drug users in Canada. J Urban Health. 1999;76:409–418. doi: 10.1007/BF02351499. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Murphy DA, Roberts KJ, Martin DJ, Marelich W, Hoffman D. Barriers to antiretroviral adherence among HIV-infected adults. AIDS Patient Care STDS. 2000;14:47–58. doi: 10.1089/108729100318127. [DOI] [PubMed] [Google Scholar]
  • 26.Ammassari A, Trotta MP, Murri R, et al. Correlates and predictors of adherence to highly active antiretroviral therapy: overview of published literature. JAIDS. 2002;31:S123–S127. doi: 10.1097/00126334-200212153-00007. [DOI] [PubMed] [Google Scholar]
  • 27.Chesney MA, Ickovics JR, Chambers DB, et al. Self-reported adherence to antiretroviral medications among participants in HIV clinical trials: the AACTG adherence instruments. Patient Care Committee & Adherence Working Group of the Outcomes Committee of the Adult AIDS Clinical Trials Group (AACTG) AIDS Care. 2000;12:255–266. doi: 10.1080/09540120050042891. [DOI] [PubMed] [Google Scholar]
  • 28.Kresina TF, Normand J, Khalsa J, Mitty J, Flanigan T, Francis H. Addressing the need of treatment paradigms for drug-abusing patients with multiple morbidities. Clin Infect Dis. 2004;38:S398–S401. doi: 10.1086/421403. [DOI] [PubMed] [Google Scholar]
  • 29.Macalino GE, Mitty J, Bazerman LB, Singh K, McKensie M, Flanigan T. Modified directly observed therapy for the treatment of HIV-seropositive substance users: lessons learned from a pilot study. Clin Infect Dis. 2004;38(suppl 5):S393–S397. doi: 10.1086/421402. [DOI] [PubMed] [Google Scholar]
  • 30.Altice FL, Mezger JA, Hodges J, et al. Developing a directly administered antiretroviral therapy intervention for HIV-infected drug users: implications for program replication. Clin Infect Dis. 2004;38:S376–S387. doi: 10.1086/421400. [DOI] [PubMed] [Google Scholar]
  • 31.Pollack HA, Khoshnood K, Blankenship KM, Altice FL. The impact of needle exchange-based health services on emergency department use. J Gen Intern Med. 2002;17:341–348. doi: 10.1046/j.1525-1497.2002.10663.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Aral SO, Mann JM. Commercial sex work and STD: the need for policy interventions to change societal patterns. Sex Transm Dis. 1998;25:455–456. doi: 10.1097/00007435-199810000-00002. [DOI] [PubMed] [Google Scholar]
  • 33.Strathdee SA, Patrick DM, Currie SL, et al. Needle exchange is not enough: lessons learned from the Vancouver injecting drug user study. AIDS. 1997;11:F59–F65. doi: 10.1097/00002030-199708000-00001. [DOI] [PubMed] [Google Scholar]
  • 34.Irala J, Bigelow C, Mccusker J, Hindin R, Zheng L. Rehability of self-reported human immunodeficiency virus risk behaviours in a residential drug treatment population. J Epidemiol. 1996;143:725–732. doi: 10.1093/oxfordjournals.aje.a008806. [DOI] [PubMed] [Google Scholar]

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