Displacement, urban gentrification and declining access to HIV/STI, sexual health, and outreach services amongst women sex workers between 2010-2014: Results of a community-based longitudinal cohort Shira M. Goldenberg,1,2 Ofer Amram,3 Melissa Braschel,1 Sylvia Machat,1 Kate Shannon,1,4 on behalf of the AESHA Team  1. Gender and Sexual Health Initiative 2. Faculty of Health Sciences, Simon Fraser University 3. Elson S. Floyd College of Medicine, Washington State University 4. Faculty of Medicine, University of British Columbia 22nd International AIDS Conference, July 25, 2018 Thank co-authors, community partners and participants I have no conflicts of interest to declare

Background Mounting interest in better understanding the impact of social geography in HIV inequities Prior research shows that policing, stigma, community harassment can displace sex workers to unsafe environments Elevated HIV/STI risks, reduced health access Marked increases in gentrification in Vancouver in recent years (2010-onwards) Downtown Eastside (DTES) particularly impacted Significant community concerns (housing, safety) Little known about impacts on work/living environments or health access for sex workers Yolande Cole, Georgia Straight, 2011 Gentrification - movement of middle class people into inner city areas, causing the displacement of lower income working people In Vancouver’s DTES, Gentrification is proceeding at an unprecedented rate Block-by-block, low-income housing, SROs and social housing are being upscaled into new and luxury condos – termed ‘zones of exclusion’ by local community residents Special concerns about impacts on safe housing for women and sex workers, not being looked at Objectives: (1) Describe changes in social geography of work & living environments and service access among sex workers following gentrification, and (2) model impacts of exposure to the gentrification period (2014) on service utilization

An Evaluation of Sex Workers’ Health Access Methods An Evaluation of Sex Workers’ Health Access Community-based cohort of >900 sex workers Involves experiential staff + >15 community partners Eligibility: Women (incl trans), age≥14, SW in last month Time-location sampling and outreach Street, indoor, and online venues across Metro Vancouver Semi-annual questionnaire and voluntary HIV/STI/HCV testing, treatment, and referral Before-and-after GEE analysis + GIS mapping Data sources: AESHA cohort + publicly available land use data Exposure: Gentrification (2014) vs. Pre- Gentrification (2010) Outcomes: Use of HIV/STI testing, SRH and sex work services Community-based cohort of >900 sex workers operating across diverse indoor, outdoor and online spaces Current/former sex workers represented across interviewer, outreach and nursing teams Conducted before and after analysis using AESHA data; spatial mapping used public land use data and AESHA spatial data Funding: NIH R01DA028648, Mac AIDS, CIHR; PI: Kate Shannon, Co-PI: Shira Goldenberg 3

Fig 1. Changes in Patterns of Land Use in Vancouver, 2010 and 2014 Changes in Patterns of Land Use and Sex Workers’ Neighbourhood of Residence Between 2010 and 2014 Fig 1. Changes in Patterns of Land Use in Vancouver, 2010 and 2014 Fig 2. Neighbourhood In- and Out-Migration amongst SWs (2010-2014) Data source: AESHA questionnaire (n=136 sex workers) Variable: Changed primary place of residence between 2010 and 2014 Fig 1 – Blue areas represent residential land use, red represent commercial and industrial use. This figure shows that between 2010-2014, there was a shift towards residential, newly built housing in the DTES and strathcona neighborhoods Fig 2 – arrows indicate out-migration from DTES to surrounding areas We also observed an increase in distance b/w place of residence and place of service from DTES core (main/hastings), shift away from street towards online solicitation and servicing, informal indoor work Data source: DMTI Route Logistics Land Use, City of Vancouver, Jan 2010-Dec. 2014.

Changes in Uptake of HIV, STI, and Sexual Health Services Between 2010 and 2014 (n=203) Surprising declines in utilization of HIV and STI testing, SRH services, and SW specific-services between 2010 and 2014, despite intensifying test and treat efforts in Vancouver Note: All comparisons statistically significant in bivariate GEE analysis at p<0.001

Gentrification Period (2014) Linked to Declines in Utilization of HIV, STI, SRH and Sex Work Services Exposure: 2014 vs. 2010 study year Service Utilization Outcome Adjusted Odds Ratio (95% CI) Received STI testing*1 0.39 (0.26-0.61) Received HIV testing*2 0.33 (0.21-0.51) Used SRH services*3 0.21 (0.13-0.33) Used sex work-specific services*4 0.36 (0.23-0.56) *In last 6 months 1n=200; 2n=198; 3n=202; 4n=202 Note: Separate multivariable confounder GEE logistic regression models were built for each outcome. Variables considered in all models: HIV status, homelessness, non-injection drug use, place of service. Exposure to the gentrification period independently correlated with declines in HIV, STI and sexual health and sex workers programmes When we talk about HIV services and sex worker rights, we should consider economic factors such as housing -need for (1) health and housing policies that support marginalized women’s access to safer living and work environments, and (2) to support and promote access to sex worker-led and specific services, including mobile outreach Decreased uptake of services linked to period of unprecedented gentrification in Vancouver’s DTES Despite increased HIV test-and-treat efforts in Vancouver May be attributable to displacement from areas of service concentration Efforts to promote access to safer work/living environments and support sex worker-led and specific services urgently needed

Contact: gshi-sg@cfenet.ubc.ca @GSHI_research Acknowledgements We gratefully acknowledge the expertise and contributions of our participants. Research/Administrative staff: Sarah Moreheart, Jennifer Morris, Brittany Udall, Minshu Mo, Sherry Wu, Sylvia Machat, Alka Murphy, Jenn McDermid, Emily Leake, Anita Dhanoa, Maya Henriquez, Nina Brown, Carly Glanzberg, Abby Rolston, Peter Vann, Jill Chettiar, and Colette Ryan. Community Advisory Board: WISH, SWUAV, SWAN, PACE, HUSTLE/HiM, Options for Sexual Health, Vancouver Coastal Health, BCCDC Street Nurses, ATIRA, RainCity, Pivot Legal Society, Positive Women’s Network, YouthCO, Canadian HIV/AIDS Legal Network Funding: National Institutes of Health (R01DA028648), Canadian Institutes of Health Research Foundation and New Investigator Awards, MacAIDS, Open Society Foundations Contact: gshi-sg@cfenet.ubc.ca @GSHI_research More on gentrification history Over the past few decades developers have promoted their housing units to the DTES market (began in 1960 -Inner-city regeneration began in the late 1960s in the efforts to eradicate “skid row” and revitalize the area and intensified around 2010 Methods Data sources AESHA questionnaire: Places of residence, service and solicitation City of Vancouver DMTI database: Land use data Map 2 measured % change as change in proportion of people in each neighborhood between 2010 and 2014 Spatial analysis ArcGIS (ESRI) software used to geocode and map spatial data Land use mapped in 2010 and 2014 using publically available City of Vancouver data to visually examine gentrification patterns Person-location characteristics attached to digital area maps In- vs. out-migration between 2010 and 2014 mapped by neighbourhood using AESHA data on sex workers’ locations of residence during each time period Women were included in spatial analyses if they identified a place of residence that could be geocoded (i.e., location of transitional housing, shelters, single room occupancy hotels, supportive housing, apartments, homes, or residential locations identified by homeless women) and reported working primarily in street or informal indoor settings. Formal indoor workers excluded due to limited representation within the DTES models run among those who participated in either year (n=320) and found same trends in results, but more difficult to map changes between time periods 7