The Association Between Residential Eviction and Syringe Sharing among Street-Involved Youth in Vancouver, Canada Andreas Pilarinos PhD Student Interdisciplinary Studies Graduate Program University of British Columbia Good afternoon. Today I will be presenting findings from a study examining syringe sharing and residential eviction among street-involved youth in Vancouver, Canada. Research Trainee British Columbia Centre on Substance Use

Conflicts of Interest None to declare

Background Street-based injection drug use constitutes significant public health concern Particularly among injection drug users (IDU) who share syringes Significant reductions in syringe sharing among adult populations in Vancouver Needle exchange(s) Supervised Injection Facilities - Insite Street-based Injection drug use constitutes a significant public health concern due to its association with the transmission of blood-born pathogens such as HIV and HCV as well as other severe health-related harms Particularly the case among IDUs who share syringes, where there is a marked increase in the likelihood of the transmission of infectious diseases Evidence suggests that there have been significant reductions in syringe sharing among adult populations (over 20% to 6%), Due to needle exchanges opening of North America’s first safe injection facility UNAIDS, 2006; Kerr et al., 2010

Background Syringe sharing remains a prevalent practice among street-involved youth Identified risk factors include: homelessness, difficulty accessing needles, binge drug use, and injection cocaine use Less is known about the association between residential eviction and syringe sharing Exisitng lit. show that syringe sharing a prominent practice among street-involved youth in Vancouver The relationship between homelessness and syringe sharing has been explored in depth previously, both among street-involved adult and youth populations With that said, much less is known about the relationship between residential eviction and syringe sharing, especially among youth Des Jarlais et al., 2007; Wood et al., 2002; Bozinoff et al., 2017

Objective to longitudinally examine the association between residential eviction and syringe sharing among a cohort of street-involved youth in Vancouver, Canada To longitudinally examine whether residential eviction was associated with syringe sharing among the ARYS cohort

Methods At Risk Youth Study (ARYS), an ongoing prospective cohort study of street-involved youth ages 14-26 Recruited through self-referral and street-based outreach from the Greater Vancouver region At baseline and semi-annually, participants complete an interviewer-administered questionnaire Participants were recruited from the At Risk Youth Study (or ARYS), an ongoing prospective cohort study of street-involved youth/young adults in Vancouver, Canada ages 14-26. “street-involved” refers to youth who are currently or recently homeless or who recently accessed services for homeless youth Participants have been recruited via self-referral and street-based outreach At baseline and semi-annually participants complete an interviewer-administered questionnaire.

Sample Selection Restricted to 2007 – 2014 When question on residential eviction was asked Youth who reported injection drug use over the study period The study sample was restricted to 2007 – 2014 period Was when question pertaining to residential eviction was included on the questionnaire Additional restriction: youth who reported injection drug use over the study period

Analysis Key explanatory variable of interest: residential eviction in the last six months “Have you been evicted in the last 6 months?” Primary outcome: Syringe sharing in the last six months Borrowing: “Have you used a syringe that was already used by someone else?” Lending: “Have you lent your used syringe to someone else?” Residential eviction: evicted from a regular place (i.e. family, friends, social housing, foster home, etc.)

Analysis Model controlled for the following covariates: Age, gender, ethnicity Binge drug use Daily illicit drug use Difficulty accessing syringes Public injection Incarceration Accessing drug treatment Multivariable generalized estimating equation (GEE) was used To assess the association between our explanatory and outcome variable, we selected secondary explanatory factors that we hypothesized might be associated with both residential eviction and syringe sharing. Other variables included: age at baseline; gender; ethnicityl, etc… All variables, excluding age, gender, and ethnicity, refer to circumstances and behaviours over the previous six months and were treated as time-updated covariates on the basis of semi annual follow-up data. we examined descriptive statistics using Pearson's χ2-test for binary variables (Fisher’s exact test when cell counts were less than or equal to 5) and the Wilcoxon rank-sum test for continuous variables. we then used generalized estimating equation (GEE) analyses with logit link function to assess the association between residential eviction and syringe sharing.

Sample characteristics Total of 405 youth reported injection drug use Contributed to 1,131 observations Median number of follow-ups: 2 (IQR 1-3) Baseline characteristics: Median age 22.7 years (IQR 21 – 24) 142 (35.1%) female 114 (28.1%) reported experiencing residential eviction 149 (36.8%) youth reported syringe sharing

Results Of 114 (28.1%) who reported experiencing residential eviction 25% reported more than one eviction event 86 (75.4%) reported one eviction event 19 (16.7%) reported two evictions 7 (6.1%) reported three evictions, 2 (1.8%) reported four evictions during follow-up.

Results GEE analysis of residential eviction and syringe sharing among street-involved youth (n=405)* Characteristic Adjusted Odds Ratio (95% CI) Residential eviction yes vs. no 1.72 (1.16 – 2.57) In multivariable analyses, recent residential eviction (adjusted odds ratio (AOR) = 1.72, 95% confidence interval (CI): 1.16–2.57 p=0.007) remained significantly and positively associated with syringe sharing after adjusting for confounding *Model adjusted for: age, ethnicity, binge drug use, daily illicit drug use, difficulty accessing syringes, public injecting, incarceration, and accessing drug treatment

Discussion Findings are supported by existing literature that report: a high prevalence of syringe sharing among street- involved youth youth who are unstably house or who experience homelessness are more likely to share syringes Findings complement existing research that has demonstrate that : Rates of syringe sharing remain high among street-involved youth in Vancouver, Canada And that youth who are unstably housed or experience homelessness have higher rates of risky substance use behaviours - the current study expands on this area of research by demonstrating that experiencing residential eviction is also associated with syringe sharing

Discussion Eviction may displace youth to other neighborhoods, reducing access to harm reduction services Once homeless, youth more likely to: Come into contact with police Experience violence Use drugs in public settings potential explanations: street-involved youth who experience eviction may be displaced to other neighborhoods, reducing spatial access to services that provide sterile injecting equipment youth who are displaced due to residential eviction may subsequently experience homelessness, Once homeless, youth more likely to come into contact with police and/or experience violence, losing access to sterile injecting equipment more likely to use drugs in public settings, which has previously been associated with syringe sharing [33].

Discussion Stable housing is critical to reducing risky substance use among street-involved populations Housing supports are associated with housing stability and reduced risky substance use among adult populations Expanding such services for street-involved youth may produce similar improvements Among adult populations with concurrent disorders, the provision of housing supports (such as case management supports, home support services, crisis intervention services, and health care services) have been associated with significant reductions in substance use and risky practices as well as improved housing stability among street-involved adult populations As such, expanding these services for youth may produce similar benefits and reductions in risky substance use

Participants were not recruited at random Limitations Participants were not recruited at random Relied on self-report and social desirability bias may occur Observational study: Temporality cannot be inferred Our study has several limitations. First, we used self-referral and street outreach for recruitment, a procedure which does not produce a truly random sample, to access this “hidden” population of street-involved youth. Second, we relied on self-reported data and therefore social desirability bias may occur. That said, we suspect that this would bias our findings towards the null if it did occur. Third, because this is an observational study, temporality cannot be inferred, though we hypothesize that syringe sharing was an outcome of residential eviction.

Conclusions Youth in this setting reported experiencing residential eviction, which was independently associated with syringe sharing. Our study that syringe sharing was independently associated with residential eviction among street-involved youth in Vancouver

Implications Policy interventions that provide street-involved youth with access to a continuum of housing options may mitigate residential eviction and high-risk substance use among this population it is evident that interventions that reduce syringe sharing among street-involved youth are needed, particularly among those experiencing residential eviction. By expanding access to housing options that espouse a continuum of care (ranging from low-threshold to abstinence-based housing) we have the potential to reduce experiences of residential eviction and related risky substance use practices, such as syringe sharing, among street-involved youth populations

Acknowledgements All study participants who generously gave their time Study Co-Authors (Mary Clare Kennedy, Ryan McNeil, Huiru Dong, Thomas Kerr, Kora DeBeck) BCCSU Staff, Graduate Students, and Administrative Support Community groups and others who support this work