Profile of Hepatitis C & Injection Drug Use in Canada

HCV and At-Risk Populations

Street-involved youth, women, Aboriginal populations, and prison populations are important target groups for interventions designed to control HCV. This section discusses some of the unique characteristics that place these groups at greater risk.

Street-Involved Youth

The use and misuse of drugs is particularly high among street-involved youth (Anderson, 1993; Radford et al., 1989; Smart and Adlaf, 1991). The term 'street-involved youth' refers to children and adolescents who become socially dislocated from their mainstream counterparts and who experience marginal or chronic homelessness (Hagan and McCarthey, 1997). It is generally believed that a major pathway to this marginal lifestyle is the experience of physical, emotional and/or sexual abuse at home (Radford et al., 1989). There are no scientifically valid estimates of the street-involved youth population in Canada, but estimates have ranged as high as 150,000 (Covenant House, 1988).

Unfortunately there is very little Canadian information on the extent and nature of IDU among youth in general, and street-involved youth in particular. There is even less information on the factors underlying the transition from non-injection drug use to injection drug use. An understanding of these factors is critical to the development of prevention initiatives designed to prevent the spread of HCV infection in this population.

In 1995, a prospective cohort study of Montreal street-involved youth (15-22 years of age) was initiated. The results revealed that a high proportion of street-involved youth (36%) has used injection drugs and 23% had injected in the previous six months. The proportion of Montreal street-involved youth infected with HCV was found to be 18% and 4% for HIV (Roy et al., 1996; 1998). On average, girls tended to start injecting at a younger age than boys (16 vs. 17.3 years). Over half of those who had injected had borrowed needles and 67% had shared injecting equipment.

Four other Canadian studies provide further information on the extent and nature of drug use among street-involved youth. The first is a national multi-site study, conducted in 10 Canadian cities, based on interviews with 712 street-involved youth aged 15-20 years (Radford et al., 1989). Two separate studies were conducted in Toronto, one in 1990 with 145 street-involved youth (Smart et al., 1990) and the other conducted in 1992 with 217 youth (Smart et al., 1992). In Halifax, interviews were conducted in 1991 with 200 youth less than 24 years of age (Anderson, 1993). Finally, interviews were conducted in 1993 in Vancouver with 100 streetinvolved youth aged 19 and younger (McCreary Centre Society, 1994).

In the 1988 Canadian multi-site study, 12% of street-involved youth reported injecting drugs in their lifetime (Radford et al., 1989). In Toronto, 28% injected drugs in their lifetime and 4% have shared needles during the past year (Smart et al., 1992). In Halifax, about one in nine street-involved youth had injected drugs (Anderson, 1993). IDU rates were higher in Vancouver, with 48% of males and 32% of females reporting lifetime drug injection (McCreary Centre Society, 1994).

Information obtained in the Winnipeg Injection Drug Epidemiology Study (Elliot and Blanchard, 1998) found that 22% of individuals had injected with a used needle the first time they ever injected. At the time of first injection, 49% were under 20 years old. These results speak to the young age at which people are initiating IDU and engaging in highly risky injection practices.

Similar results were obtained in a study conducted by Belanger et al. (1996) that examined the predictors of needle-sharing among participants in a needle exchange program in Quebec City. The results showed that younger participants, under the age of 20 years, were more likely than older participants to report sharing needles in the six months prior to the study. Needle-sharing was also related to multiple drug use, which in turn was more common among young users. Although these results are not directly related to 'street' youth, they underscore the need for efforts targeted at younger injectors.

The authors provided several hypotheses to explain the observed relationship between a young age and risky injection practices. First, young users of injection drugs may be more open to exploring different types of drugs and engaging in poly-drug use, whereas older users may have settled with a particular drug. Second, preventive messages may have had less impact because younger users have had less exposure to such messages. Finally, IDU may be more of a social behavior for young users, bringing with it increased opportunity for needle-sharing. In contrast, injecting among older adults may represent more of a solitary lifestyle activity (Belanger et al., 1996).

An important study conducted in Australia specifically examined the level of information regarding HCV transmission among young injectors (Carruthers and Loxley, 1995). The sample included 234 12 to 20 year old users of injection drugs. Although the majority (80%) had heard of HCV, only 50% considered the infection to be a serious problem. Unfortunately, there is no information available related to knowledge levels of HCV among young Canadians.

Women

Very few studies have addressed the issues specific to women who inject drugs. Notwithstanding the lack of information, women who inject drugs are increasingly visible. For instance, women comprised 35% of the approximately 6000 registrants of a Vancouver needle exchange. A similar proportion of women were represented in the Vancouver Injection Drug Use Study (VIDUS) (Whynot, 1998).

A few studies have observed that girls start to inject at a younger age than boys. For instance, among street-involved youth in Montreal, the average age that girls started injecting was 16 years, compared to 17.3 years for boys (Roy et al., 1996; 1998). In a study of youth in British Columbia correctional facilities, more young females (10.2%) than males (3.4%) reported IDU (Rothon et al., 1997). Analyses revealed that females 16 to 19 years of age were 5.3 times more likely than males aged 16 to 19 to have engaged in IDU. Females were also more likely than males to have had sex with a user of injection drugs. Similar results were found in a study conducted in New South Wales with youth in custody (Copeland et al., 1998). Girls were more likely than boys to have injected drugs and shared injecting equipment. In addition, lack of knowledge regarding the transmission of HIV, HCV and HBV was more pronounced among females, despite their higher rates of potential exposure to these viruses.

For women, sexual or physical abuse is often a predisposing factor in IDU and a barrier to reduction of risky behaviors (Gilbert et al., 1997). To understand IDU among women, it is important to consider their social networks (Barnard, 1993; Whynot, 1998). Research has found that women are less likely than men to inject illicit drugs alone and more likely to be influenced by others to inject drugs (Whynot, 1998). Women are often less able to resist pressure by their male partners to share needles or engage in unsafe sexual practices. As Barnard (1993) notes, the dominant male culture surrounding IDU inhibits a woman's ability to negotiate safe practices, particularly if the women are young and without social support.

Aboriginal People in Canada

Indigenous peoples have many social disadvantages that are frequently associated with the use and misuse of drugs, including poverty, low education, unstable family structure, physical abuse and poor social support networks (Scott, 1997). The number of Aboriginal people in Canada who inject drugs is not known. It is reasonable to assume, however, that Aboriginal people are at particular risk of HCV infection, in part because they are over-represented in groups practicing high risk behaviors, such as prisoners, the chronically unemployed and the homeless.

Shields (2000) examined high-risk behaviours and hepatitis C status among 519 youth 15-24 years of age who identified their ethnic origin as Aboriginal. Participants were recruited through drop-in centers in seven major Canadian cities. Just under one-quarter (21%) reported injecting drugs at least once in their lives. In the WIDE study (Elliot and Blanchard, 1998), 1068 participants from Winnipeg who had ever injected drugs were identified through community clinics, needle exchange programs, treatment programs, street contacts and public health nurses. A disproportionately high number of those surveyed self-identified as Aboriginal (compared to the proportion of Aboriginal people living in Winnipeg). Specifically, 64% of those who had ever injected drugs were Aboriginal.

Information from British Columbia on HIV/AIDS in Aboriginal communities also underscores the issue of IDU in this population. A major difference in Aboriginal AIDS cases versus non- Aboriginal cases is the frequency with which IDU is cited as a risk factor. This is particularly evident among Aboriginal women. Nationally, 50% of Aboriginal women and 19% of Aboriginal men have IDU as their primary risk factor for HIV infection. For non-Aboriginal women and men, the rates of IDU are 7.4% and 3.2%, respectively. As noted by the authors, IDU has not traditionally been a topic of discussion in most Aboriginal communities. To begin to address this new and emerging issue in these communities, "it will take willingness, persistence and honesty to look at underlying causes for the use of injection drugs" (B.C. Aboriginal HIV/AIDS Task Force, 1999, p. 10).

Prison Populations

Canadians incarcerated in prison have relatively high rates of HCV and other blood-borne infections and IDU is the predominant risk factor underlying their higher risk (Jürgens, 1996). A significant portion of the prison population consists of people who currently inject drugs or did so in the past. The presence of IDU and the sharing of needles in prisons increases the spread of HCV among inmates as well as the community at large upon their release.

Studies conducted in Canadian prisons have found HCV prevalence rates between 28% and 40% (Canadian HIV/Legal Network, 1999). The most recent study of federal prison inmates (Lior et al., 1998) found 48% of inmates in the federal prison at Springhill, Nova Scotia to be users of injection drugs, of which 52% were HCV positive. Furthermore, 39% of users continued to inject drugs in prison and the majority (82%) reported sharing needles when injecting drugs.

In another study, 39 long-term inmates (20 males and 19 females) were randomly selected from two federal institutions and invited to participate in a survey examining risk-taking behaviors (Calzavara et al., 1997). The participation rate was 82%. Inside prison, 56% used any drugs during the past 12 months, 28% injected drugs inside prison in the past 10 years, and 5% injected drugs during the past 12 months of their current incarceration. Needle-sharing was more prevalent inside prison than it was outside. Just under one-quarter (21%) reported infection with hepatitis C.

Research in this area reinforces the need for appropriate services to prevent HCV transmission within the prison walls as well as the community at large. Drugs are readily available in most prisons and those who inject drugs are at high-risk for infection because of the lack of access to harm reduction resources (Marte and Gatell, 1999).

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