1. 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

2. Conflicts of Interest
None to declare

3. 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

4. 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

5. 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

6. 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
“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.

7. 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

8. 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.)

9. 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.

10. 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

11. 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.

12. 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

13. 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

14. 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].

15. 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

16. 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.

17. 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

18. 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

19. 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