If you shoot illegal narcotics into your veins in British Columbia's capital city, you have plenty to fear. Injection drug use is a driving factor in the spread of infectious blood borne diseases like HIV/AIDS and Hepatitis C in North America. But your biggest worry, according to a newly published study, is just finding a place to stay where you won't be robbed.
Injection drug users told Victoria researchers they rank security issues such as shelter and physical safety above concerns about catching a deadly illness. And that, say researchers, means we need to rethink how we tackle AIDS prevention.
The findings, recently published in the Harm Reduction Journal, don't surprise Aid Vancouver Island staffer Erin Gibson, who was part of the research team. For a decade now Gibson has worked with AIDS patients and drug users at AIDS Vancouver Island, and she says the desperate conditions of life on the street make it hard to entertain long-term worries about viral infections that might affect you years in the future.
"You don't have time to worry about HIV if your basic survival needs aren't being met," Gibson told the Tyee in phone interview from her Victoria office. "It can be minute to minute out there, day to day. It's only after people have secure housing that I see them reduce their drug use and volunteer in programs. The things they think about then are different."
Condom use lower among homeless
Gibson and her colleagues suggest that their research findings have implications for public policy. Among their paper's conclusions:
"PWUID ( People Who Use Injection Drugs) in this study not only worry about HIV/AIDS but also about stressful factors in their daily life, which have been linked to both increased HIV/AIDS risk behaviour and decreased anti-retroviral treatment adherence. The importance PWUID give to this broad range of worry/concerns emphasizes the need to place HIV/AIDS intervention, education, and treatment programs within a broader harm-reduction framework that incorporates their perspectives on both worry and risk."
Other recent research found that homeless needle-based drug users are less likely to use a condom during sex than users who have a place to live.
Thomas Kerr of Vancouver's B.C. Centre for Excellence on HIV/AIDS, working with other researchers, studied the relationship between homelessness and risk behaviours for HIV/AIDS transmission among street-involved youth. They found that "homelessness was inversely associated with consistent condom use ... while unstable housing was positively associated with greater numbers of sex partners."
The team suggested the need for new policies "which modify environmental factors that drive risk among young street-involved populations."
'People need secure housing': VANDU's Livingston
Ann Livingston, a long time activist in Vancouver with the Vancouver Network of Drug Users, agrees that housing can be a key issue in preventing AIDS infection. She told the Tyee that homelessness was the strongest single predictor that a person in Vancouver would contract HIV/AIDS.
However, she cautioned that it was important not to be too simplistic. The kind of housing available makes a big difference. "Food and shelter and dope can be higher priorities than preventing infection," she said, "but housing that is so strict that you get thrown out if you are using isn't helpful. People need secure housing."
Laura Track, a housing campaigner with Pivot Legal, an organization dedicated to serving the needs of homeless and otherwise marginalized populations in Vancouver, also agrees that the Victoria worry research matches her observations. Like Livingston, she emphasizes the need not just for housing, but for housing that is secure and supportive for people battling with addictions.
"The research is accurate. People without housing worry about day to day survival. To imagine that anyone can overcome a barrier as significant as addiction without secure housing is foolish. For people to get well, secure, barrier-free housing is necessary."
Basic necessities come first
AIDS Vancouver Executive Director David Swan says his organization's experience is consistent with the Victoria worry research and Dr. Kerr's findings about how secure housing seems to reduce risk behaviours. He told the Tyee that secure housing not only works to help prevent HIV infection -- it also is an important variable in supporting self-care and medical treatment co-operation among people who are HIV positive.
Swan underscored the importance of safe, secure, barrier free housing as a public health issue.
"This is why we talk so much about the social determinates of health," Swan said. "At AIDS Vancouver, as much as 60 to 70 per cent of staff time goes to helping clients with basic survival needs like housing and food. If people don't have adequate access to these basics, other concerns can go to the back burner."
Fiona Gold, a street nurse in Vancouver with the BC Centre for Disease Control, said that she completely agrees with the Victoria research. Her experience on the street, she said, confirms the Victoria findings about housing as a primary concern.
"When you see someone become homeless, you see their life spinning out of control," Gold said. "We need much more supportive housing in Vancouver, with trained staff to help people navigate their challenges. Housing can bring stability that supports recovery. The 'housing first' approach makes sense to me."