Short report
The Cedar Project: A comparison of HIV-related vulnerabilities amongst young Aboriginal women surviving drug use and sex work in two Canadian cities

https://doi.org/10.1016/j.drugpo.2007.07.005Get rights and content

Abstract

Background

In Canada, Aboriginal women and youth continue to be overrepresented amongst new cases of HIV, and are considered at increased risk for sex and drug-related harm. Young women involved in sex work are particularly vulnerable. The purpose of this study is to determine HIV-related vulnerabilities associated with sex work amongst young Aboriginal women in two Canadian cities.

Methods

This study is based on a community-based cohort of Aboriginal young people (status and non-status First Nations, Inuit and Métis) between the ages of 14 and 30 who used injection or non-injection illegal drugs (street drugs) in the previous month. Participants lived in Vancouver, Canada, or Prince George, a remote, northern Canadian city. Between October 2003 and July 2005, 543 participants were recruited by word of mouth, posters, and street outreach. A baseline questionnaire was administered by Aboriginal interviewers, and trained nurses drew blood samples for HIV and HCV antibodies and provided pre- and post-test counselling. This study included 262 young women who participated at baseline. Analyses were conducted to compare socio-demographics, drug use patterns, injection practices, sexual experiences, and HIV and HCV prevalence between young women who reported being involved in sex work in the last 6 months (n = 154) versus young women who did not (n = 108). Logistic regression was used to identify factors independently associated with recent sex work involvement.

Results

Both sexual violence and drug using patterns were found to be markedly different for women having recently been involved in sex work. Multivariate analysis revealed daily injection of cocaine (AOR = 4.4; 95% CI: 1.9, 10.1 and smoking crack (AOR = 2.9; 95% CI: 1.6, 5.2) in the previous 6 months, and lifetime sexual abuse (AOR = 2.5; 95% CI: 1.4, 4.4) to be independently associated with sex work.

Interpretation

Harm reduction and treatment programs that address historical and lifetime trauma amongst Aboriginal people and prioritize emotional and physical safety for young Aboriginal women involved in sex work are required.

Introduction

In Prince George, Canada, the Ramsay case, involving a judge sentenced to 7 years in prison for sexually assaulting four Aboriginal teenaged girls has garnered national media attention (Armstrong, 2004). More recently, there has been speculation that a serial killer may be involved in the disappearance of young Aboriginal women along Highway 16; a highway linking northern communities of British Columbia such as Burns Lake, Smithers and Prince George (Trick, 2006). Since Judge Ramsay's sentencing there has been considerable outcry by Aboriginal and child rights advocates who have observed that the health and social crisis affecting young Aboriginal women is much larger than any single sexual assault or murder investigation (Amnesty International, 2004, pp. 23–24; MacDonald, 2005, pp. 11–13). The United Nations Committee on the Elimination of Discrimination against Women (CEDAW) has further expressed concern over the effects of provincial government cut backs and the closing of services, on the health and social well-being of marginalised women, including Aboriginal women (U.N. CEDAW, 2003, p. 6).

Recent studies conducted in British Columbia's Lower Mainland have demonstrated that impoverished Aboriginal women in Vancouver involved in sex work and/or injection street drug use continue to be exposed to disproportionate levels of drug-related harm, HIV infection, and predation (Bowen et al., 2006, Craib et al., 2003; Farley, Lynne, & Cotton, 2005; Miller et al., 2006, Spittal et al., 2003). Unfortunately, these observations are consistent with many settings internationally where women exchanging sexual services for basic needs and to sustain drug dependence suffer from elevated rates of violence and health-related harms, including HIV infection (Church, Henderson, Barnard, & Hart, 2001; Potterat et al., 2004; Romero-Daza, Weeks, & Singer, 2003; Roxburgh, Degenhardt, & Copeland, 2006).

There is growing concern amongst Aboriginal communities and Aboriginal AIDS service providers that HIV will continue to overwhelm young Aboriginal women already facing multiple levels of discrimination (Red Road HIV/AIDS Network, 2006; Vernon, 2001). Despite evidence demonstrating that Aboriginal women around the world are overrepresented in visible, street-based sex work (Farley et al., 2005; Harcourt, van Beek, Heslop, McMahon, & Donovan, 2001; Plumridge & Abel, 2001; Roxburgh et al., 2006), there is recognition that there are very few community-driven research efforts that address the vulnerabilities of young Aboriginal women involved in sex work (Assistant Deputy Ministers’ Committee, 2001). Further, the intersecting epidemics of poverty, HIV, and violence that threaten the lives of Aboriginal women involved in sex work remain poorly addressed (Craib et al., 2003, Spittal et al., 2003, Spittal et al., 2006).

Approximately 3600–5100 Aboriginal persons were living with HIV in Canada in 2005 (Public Health Agency of Canada, 2006). This represents around 7.5% of all prevalent HIV infections, whilst Aboriginal persons comprise only 3.3% of the Canadian population. The same reporting further indicates that HIV is increasingly affecting Aboriginal women and youth. In Canadian provinces where ethnicity is reportable (excluding Ontario and Quebec), between 1998 and 2005, women represented 47.3% of new positive HIV test reports amongst Aboriginal people, as compared to 20.5% non-Aboriginals people. In addition, one-third of new positive HIV tests reports amongst Aboriginal persons represented those under 30, as compared to a quarter amongst non-Aboriginal persons. Approximately 60% of new infections amongst these young Aboriginal people were attributable to injection drug use, significantly higher than amongst non-Aboriginal young people.

In Canada, current knowledge addressing the HIV vulnerabilities of young Aboriginal people who use illegal drugs is mostly relevant to those residing in large city centres, such as the Downtown Eastside (DTES) of Vancouver (Public Health Agency of Canada, 2006, pp. 52–57). There is an urgent need to address the potential for an epidemic of HIV infection in other more under-resourced areas of the province similar to the one reported in Vancouver’ DTES in the mid-1990s (Strathdee et al., 1997). Concerns over the paucity of available data prompted the initiation of a new two city cohort study to address the specific HIV-related vulnerabilities of Aboriginal young people who use illegal drugs. The study, now called the Cedar Project, is the only cohort study of young Indigenous people involved in illegal drug use in North America.

The objectives of this current study are to compare socio-demographics, drug use patterns, injection practices, sexual experiences, and HIV and HCV prevalence amongst young Aboriginal women who use illegal drugs and are involved in recent sex work, with those women who are not. The study is based out of both downtown Prince George, a forestry and mining town in the northern interior of British Columbia, and in Vancouver's DTES. In this study Aboriginal ethnicity is based upon self-reported identification as a descendent of the First Peoples of Canada, and is inclusive of status and non-status First Nations, Inuit and Métis (for details on the definitions see RCAP, 1996, pp. 1–22, Vol. 1).

Section snippets

Methods

Guidelines provided in the Tri-Council Policy Statement on Ethical Conduct for Research Involving Human Subjects were followed in the development and conduct of this study, with particular attention to Section 6.0 pertaining to research involving Aboriginal subjects. Our First Nation's collaborators, including Aboriginal AIDS Service Organizations, were involved in the conception, design and implementation of the Cedar Project. The Cedar Project Partnership reviewed the results of this analysis

Results

A total of 262 females completed the baseline questionnaire between October 2003 and July 2005, and were therefore included in this analysis. Amongst them, 154 participants (59%) reported that in the past 6 months they were involved in sex work, whilst 185 (71%) reported having been involved in sex work at some point in their lifetime. The median age at enrolment was 23 years old. Out of all females in this study, 169 (65%) reported ever having injected drugs; out of 260 participants, 34 (13%)

Discussion

In this study we found an independent association between recent sex work involvement and the lifetime experience of sexual abuse, recent daily injection cocaine use and recent daily non-injection crack use. A common explanation for the profound health disparities experienced by Indigenous people all over the world, including Australia and New Zealand, is the historical trauma associated with the process of colonisation (Archibald, 2006, Horton, 2006). The colonial process and legislated

Conflict of interest

None.

Acknowledgements

We are indebted to the study participants for their continued participation in the Cedar Project. Our study staff, Caitlin Johnston, Vicky Thomas, Teresa George, Kat Norris, Sidney Crosby, Steve Kain, Kathy Churchill and Jamie Larson, must be thanked for their continued conviction and contributions. Special thanks to the Cedar Project Partnership; the Prince George Friendship Centre, Carrier Sekani Family Services, the Northern Health Authority, Positive Living North, The Red Road Aboriginal

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