Risk Behaviours Among Injecting Drug Users in Canada

HIV/AIDS Epi Updates

April 2003

Download all of the HIV/AIDS Epi Updates
82 pages (1,223 KB) in PDF format 
(How to download PDF documents)

Risk Behaviours Among Injecting Drug Users in Canada

---

Introduction

In 1999, 34.1% of the estimated 4,190 new HIV infections that occurred in Canada were among injecting drug users (IDU).¹ In contrast, 46.7% of the estimated 4,200 incident HIV infections that occurred in 1996 were among IDU.¹ Despite a slight drop in the estimated new infections among IDU in this time period, HIV among injecting drug users remains a major problem. A similar trend has been observed in the number of HIV positive cases attributed to injecting drug use, and reported to Centre for Infectious Disease Prevention and Control (CIDPC). The percentage of reported HIV positive cases attributed to injecting drug use has declined from 33.5% in 1997 to 28,7% in 1999 and 25.3% at the end of 2001.² In the absence of a vaccine for HIV, behaviour change remains the main tool for preventing HIV infection among drug injectors. Behaviour change concerns both IDU who are HIV-infected and those who are uninfected, and relates mainly to their injecting-related and sexual behaviour. This Epi Update briefly describes the drug injecting and sexual risk behaviours that have been reported for IDU in Canada.

Neither a Borrower Nor a Lender Be: The Sharing of Drug Injecting Equipment

The sharing (borrowing and lending) of needles and syringes is well-established as a means of acquiring HIV infection and is common among IDU:

• A study of IDU in Regina in 2000 found that 30% of respondents reported borrowing used needles or syringes in the past six months.³

• A cohort study of IDU in Vancouver showed that 27.6% of the participants reported sharing needles in previous six month period (administered during January 1999 to October 2000). Furthermore, 19.1% of the participants reported that they had shared even though they did not report having difficulty obtaining new, sterile needles.⁴

• Results from the SurvUDI study show that the prevalence of needle borrowing in the past six months among first time needle exchange program (NEP) attendees in Montreal has decreased from 45.1% in 1995 to 36.4% in 2000, and in Quebec City, needle borrowing has declined from 41.2% to 21.6% during the same period. While these results suggest that positive trends in sharing behaviour among IDU may be occurring in these jurisdictions, the proportions of participants who report sharing needles are still relatively high.⁵

• In a study conducted in Saskatoon in 1998, 53% of IDU reported sharing of needles and 24% had shared needles in the six months preceding the study.⁶

The borrowing and lending of other injecting equipment (e.g., spoons, filters, and water), often referred to as ?indirect sharing,? have also been found to be associated with HIV infection. Research indicates that indirect sharing also occurs frequently among IDU:

• Results from the Ottawa arm of the SurvUDI study showed that 42.0% of IDU shared equipment other than needles in the past six months, and 20.0% shared only such equipment.⁷

• In the Regina IDU study, 44% of participants reported borrowing used injecting equipment in the past six months. The most common item borrowed was a spoon (cooker), reported by 37% of participants, followed by needles (29%), cotton (27%), and water (24%). Forty two percent of participants also reported lending any injecting equipment in the past six months.³

• In a 1998 study in Prince Albert, Saskatchewan, 30.0% of current drug injectors (i.e., those who had injected drugs in the six months prior to the study) had borrowed cookers in the past six months, and the proportions that had borrowed filters and water in this same time period were 26.2% and 27.1% respectively.⁸

• A 1998 study in Saskatoon found that 62% of IDU reported sharing of injection equipment, of whom, about half had shared equipment in the six months preceding the study.⁶

• In a study conducted in Calgary?s NEP, 25% of the participants reported that they had shared injection equipment in the six months preceding the study.⁹

• In a cohort study in Vancouver during 1996 to 2000, 38% of men and 37% of women reported borrowing injection equipment and it was found to be one of the risk factors for seroconversion among men .¹⁰

• International studies^11-13 of IDU have identified other aspects of drug injecting, such as ?front-loading? or ?back-loading?, that may also increase the risk of HIV transmission (These are practices where two or more IDU use only one syringe to prepare a drug solution. The solution is then squirted into one or more additional syringes either via the front of the recipient syringe after removing its needle (front-loading), or via the back after removing the plunger (back-loading). However, the full extent of such risk behaviours among Canadian IDU is still under investigation.

Risky Business: Trading Unprotected Sex for Money and Drugs

Many IDU in Canada are involved in the commercial sex trade and often engage in unprotected sex with clients:

• Among IDU in a cohort study in Montreal, 18.1% of males reported that they had ever been a prostitute.¹⁴

• In a 1998 study in Winnipeg, 71.5% of female IDU and 30.2% of male IDU reported that they had ever been paid for sex. Among females, 25.0% used condoms inconsistently with their sex trade clients. Among men with male clients, 52.0% reported inconsistent condom use.¹⁵

• In a 1998 study in Saskatoon, half of the female IDU population reported having been paid for sex and 19% having exchanged sex for drugs or a place to sleep in the preceding six months.⁶ In the same study, condom use with casual partner was found to be 93% but one quarter of those did not always use a condom. Overall, 41% of the study population used condoms with regular partners.

Not Safe Enough: Sex with Regular and Casual Partners

Among IDU with regular and casual opposite-sex partners, condom use is also low:

• In the 1998 study of IDU in Winnipeg, 68.0% of women and 57.0% of men who had had regular partners in the past year reported that they never used condoms. Of those who reported having had casual partners in this time period, approximately 30.0% of both men and women never used condoms.¹⁵

• Among IDU in the 2000 Regina study, condom use with regular and casual partners was low. For example, 94% of male IDU and 92% of female IDU reported inconsistent or no condom use during vaginal sex with regular, opposite-sex partners. Of those respondents who had casual partners, 58% of men and 71% of women reported inconsistent or no use of condoms with this type of partner.³

• In a study in Calgary, 27% of the participants reported always using a condom and 37% reported never using condoms.⁹

• In the VIDUS cohort study in Vancouver during 1996-2000, 18% of men and 20% of women reported use of condom with regular sex partners and non-use of condom with a regular sex partner was the most significant risk factor for seroconversion among women. ¹⁰

Same Sex Partners and Male IDU

A substantial minority of male IDU report sexual intercourse with same sex partners:

• Among male IDU in a Vancouver study who reported having had sexual intercourse in the past six months, 7.0% reported having had only same sex partners, and 6.0% reported having had partners of both sexes in this time period.¹⁶

• In the SurvUDI study, 13.0% of male subjects report same sex partners in the past six months with few reporting consistent condom use.¹⁷

• In the Calgary study, 7% of men and 12% of women reported having had sex with the same sex partner in the six months preceding the study.⁹

• In the Omega cohort study among MSM in Montreal, 6% of the MSM reported injecting drugs, among whom 48% had borrowed used needles and 4% had exchanged sex for drugs.¹⁸

Protective Behaviour Changes or Higher Risk Practices Following an HIV Positive Test?

More research is needed to determine whether IDU continue to engage in high risk behaviours or modify their behaviours after receiving a positive HIV-antibody test:

• Among IDU in a Quebec study, 73.1% of HIV-positive drug injectors had stopped lending needles compared to 56.0% of their HIV-negative counterparts in the six months following their HIV serostatus result. However, 8.5% of HIV-positive IDU compared to 16.0% of their non-infected peers began lending needles to HIV- positive partners in this same time period. In the same study, 62.2% of HIV-positive drug injectors had stopped borrowing needles compared to 58.6% of their HIV-negative counterparts in the six months following their HIV serostatus result and 16.7% of HIV-positive IDU compared to 19.5% of their non-infected peers began borrowing needles from HIV- positive partners in this same time period.¹⁹

• In a study of IDU in Vancouver, 35.0% of subjects who were HIV-positive reported that they borrowed needles prior to learning about their serostatus. In the months following their HIV-positive test, only 21.0% of these subjects reported that they continued to borrow needles. Similarly, 37.0% of HIV-positive IDU reported needle lending prior to their positive HIV test; whereas, only 21.0% of these subjects continued this practice after receiving their positive test results.²⁰

• In a study among women in Montreal, the rate of condom use following a positive HIV test was low among IDU (19%) as compared to non-IDU of Haitian origin (30%) and non-IDU of Caucasian origin (62%).²¹

Injecting Drug Use Is a Problem Among Street Youth and Inmates

Appropriate and accessible HIV prevention programs for drug injecting street-involved youth and inmates are clearly needed:

• Results from an ongoing study of Montreal street youth (13-25 years) show that 23.2% of the sample had injected drugs in the previous six months. A total of 58.2% of injectors had borrowed a used needle at least once, and 67.5% had borrowed other injection materials. Almost 8.0% of injectors reported borrowing a used needle from an HIV-infected person. ²²

• Among female inmates in a Quebec prison, 38.0% reported injecting drugs before they were incarcerated, and about half of these women had shared needles. Of those who reported drug injection before going to prison, 11.0% admitted to injecting drugs during their incarceration, and most (80.0%) shared needles.²³

• Among male inmates in this same study, 26.0% reported that they had injected drugs before being incarcerated, and about half of these had shared needles. Of those who admitted to injecting drugs outside prison, 2.0% reported injection drug use during their incarceration, and most (92.0%) shared needles.²³

• In a Student Drug Use Survey in New Brunswick, less than 1% of grade 7,9,10, and 12 had injected drugs in one year preceding the study period.²⁴

Comment

Although several ongoing regional studies in Canada collect risk behaviour data on injecting drug users and a large number of one-time, cross-sectional surveys on risk-taking among IDU have been conducted, it is challenging, if not impossible, to compare levels of risk behaviours between data sets. In addition to disparities across study methodologies, different researchers have collected risk behaviour data using different questions or differently worded questions, different variable or concept definitions, different time frames for reported behaviours, and different response categories. It is therefore currently difficult to use available IDU risk behaviour information to identify trends or to help evaluate the effectiveness of prevention programs and policies at more than the regional or local level.

In addition, although the national HIV estimates for 1999 showed a drop in the number of new infections attributed to injecting drug use in that year, the relative lack of behavioural trend data hinder the reliable interpretation of this finding. At this stage in the HIV epidemic in Canada, the need for ongoing monitoring of risk behaviours among IDU populations from across the country is critical. A HIV- and hepatitis C (HCV)- associated risk behaviour surveillance system is being established by Health Canada at sentinel centres across Canada through collaboration with regional health authorities, community stakeholders, and researchers. The pilot phase of this surveillance system was undertaken in October/November 2002 at Regina, Victoria, and Sudbury and Toronto; linkages are also being made with IDU studies in Quebec. The surveillance survey is planned to be conducted on an annual basis. The tracking of injecting and sexual risk behaviours over time would provide important trend data that could be used to inform prevention program design and would help evaluate program effectiveness. Such behavioural data could also be used to interpret changes in HIV prevalence and incidence among IDU and would serve as an early warning system for HIV spread in this population. Behavioural surveillance of key sub-groups of IDU, namely street-involved youth and inmates, are also needed to formulate an appropriate response to the evolving HIV epidemic among IDU in Canada.

References

1. Geduld J, Archibald CP. National trends of AIDS and HIV in Canada. CCDR 2000; 26:193-201.

2. HIV and AIDS in Canada. Surveillance Report to June 30, 2002. Health Canada. Website: www.hc-sc.gc.ca/pphb-dgsppp/hast-vsmt/public_e.html.

3. Siushansian J, Hay K, Findlater R, Bangura H, Archibald C, Young E. The Regina Seroprevalence Study: A profile of Injection Drug Use in a Prairie City. Report prepared for the Regina Health District, Division of HIV/AIDS Epidemiology and Surveillance, CIDPC, 2000.

4. Wood E, Tyndall, MW, Spittal PM, Li K, Kerr T, Hogg RS, Montaner JSG, O?Shaughnessy MV, Schechter MT. Unsafe injection practices in a cohort of injection drug users in Vancouver: Could safer injection rooms help? CMAJ 2001; 164 (4) 405.

5. Alary M, Parent R ,Hankins C, Claessens C, SurvUDI Working Group. Synergy between risk factors and the persistence of high HIV incidence among injection drug users in the SurvUDI study. Can J Infect Dis 2002 Vol 13 Suppl A, 316, 49A.

6. Laurie M L, Green K L. Health risks and opportunities for harm reduction among injection drug-using clients of Saskatoon?s needle exchange program. Can J Public Health 2000;91(5):350-2.

7. Leonard L, Hansen J, Hotz S. The vulnerable 20%: a shift towards injection drug users who engage in indirect sharing., Can J Inf Dis 1999;10(Suppl A):60B #C368P.

8. Siushansian J, Hay K, Findlater R, Bangura H, Archibald C, Young E.. The Prince Albert seroprevalence study (PASS): prevalence of HIV, hepatitis B, and hepatitis C and high risk behaviours among injection drug users and their sexual partners. Report prepared for the Prince Albert Health District and Saskatchewan Health, Division of HIV/AIDS Epidemiology and Surveillance, CIDPC, 2001.

9. Guenter C D, Fonseca K, Nielsen D M, Wheeler V J, Pim C P. HIV prevalence remains low among Calgary?s needle exchange program participants. Can J Public Health 2000;91(2):129-32.

10. Spittal P M, Craib K J P, Wood E et al. Risk factors for elevated HIV rates among female injection drug users in Vancouver. CMAJ 2002;166(7):894-9.

11. Koester S. Following the blood: syringe re-use leads to blood-borne virus transmission among injection drug users. J Acq Imm Defic Synd and Hum Retrovirol 1998;18:S139.

12. Greenfield L, Bigelow G, Brooner R. HIV risk behaviour in drug users: increased blood ?booting? during cocaine injection. AIDS Educ Prev 1992;4:95-107.

13. Needle R, Coyle S, Cesari H et al. HIV risk behaviour associated with the injection process: multi-person use of drug injection equipment and paraphernalia in injection drug user networks. Subst Use Misuse 1998;33:2303-2423.

14. Bruneau J, Lamothe F, Soto J et al. Sex-specific determinants of HIV infection among injection drug users in Montreal. CMAJ 2001;164:767-773.

15. Elliott L, Blanchard J, Dawood M et al. The Winnipeg injection drug epidemiology (W.I.D.E.) study: a study of the epidemiology of injection drug use and HIV infection in Winnipeg, Manitoba. Final Report submitted to the Division of HIV Epidemiology, LCDC, 1999.

16. Tyndall M. Vancouver response: March 2001. Presentation made at the Centre for Infectious Disease Prevention and Control, Consultation Meeting on MSM/IDU Data Issues, March 2001.

17. Hankins C, Parent R, Alary M et al. Risk factors associated with HIV infection in the SurvIDU. Can J Inf Dis 1999;10(Suppl A):44B #C309.

18. Dufour A, Alary M, Otis J et al. Risk behaviours and HIV infection among men having sexual relations with men: Baseline characteristics of participants in the Omega cohort study, Montreal, Quebec, Canada. Can J Public Health 2000;91(5):345-9.

19. Brogly S B, Bruneau J, Lamothe F, Vincelette J, Franco E L. HIV Positive notification and behaviour changes in Montreal injection drug users. AIDS Educ Prev 2002;14(1):17-28.

20. Coulter S, Tyndall M, Currie S et al. Impact of a positive HIV test on subsequent behaviours among injection drug users. Paper presented at the 9^th Annual Canadian Conference on HIV/AIDS Research. Montreal, Quebec. April 2000.

21. Hankins C, Gendron S, Tran T, Lamping D, Lapointe N. Sexuality in Montreal women living with HIV. AIDS CARE 1997;9(3):261-271.

22. Roy E, Haley N, Boivin J et al. Prevalence of HIV Infection and risk behaviours among Montreal street youth. International Journal of STD & AIDS 2000; 11:241-247.

23. Dufour A, Alary M, Poulin C et al. Prevalence and risk behaviours for HIV infection among inmates of a provincial prison in Quebec City. AIDS 1996;10:1009-15.

24. A report on ?Provincial Student Drug Use Survey-Highlights 2002". New Brunswick, Department of Health and Wellness.

For more information please contact:

---

Health Canada

---