Chapter 5: Population-specific status report: HIV/AIDS and other sexually transmitted and blood borne infections among youth in Canada – Current research

Chapter 5 – Current HIV/AIDS Research

This chapter provides an overview of current Canadian research projects funded and underway between 2008 and 2011 related to HIV/AIDS and other STBBIs among youth.

5.1 Methodology

The information in this chapter was gathered from national and provincial organizations that provide funding to research on HIV/AIDS and other STBBIs in Canada or support venues for presentation of this research. The national organizations included:

• Canadian Institutes of Health Research (CIHR)
• Canadian Association for HIV Research (CAHR)
• Canadian Foundation for AIDS Research (CANFAR)
• Social Sciences and Humanities Research Council of Canada (SSHRC).

Information was also gathered from these provincial organizations:

• British Columbia Centre for Excellence in HIV/AIDS (BC-CfE)
• Michael Smith Foundation for Health Research (MSFHR)
• Fonds de recherche du Québec – Société et culture (FQRSC)
• Prairie Community-Based HIV Research Program
• Alberta Innovates Health Solutions
• Ontario HIV Treatment Network (OHTN).

Research projects included in this chapter and their abstracts (where available) are listed in Appendix B and meet all of the following selection criteria:

• funded by one of the above organizations between 2008 and 2011
• have a specific focus on youth
• address at least one determinant of human immunodeficiency virus (HIV) vulnerability and/or resiliency that affects health among youth
• include projects on HIV and hepatitis C (HCV) co-infection, sexually transmitted and blood borne infections (STBBIs) and sexual health, discrimination, stigma and homophobia
• based in Canada or be immediately relevant to Canadian youth.

This chapter focuses on specific populations of youth which are particularly affected by HIV and other STBBIs including: sexually diverse and gender-variant youth; Aboriginal youth; street-involved youth; youth from racialized communities; youth in prison; youth living in foster care; and youth living in rural and remote communities.

Exclusion criteria applied to research:

• related to basic science, microbiology and/or clinical medicine
• from international studies conducted abroad by Canadian researchers unless the nature of the study would provide additional insight into the lived experience of Canadian youth living with, or vulnerable to, HIV/AIDS
• related to surveillance or enhanced surveillance, as this type of research is included in Chapter 3 of this report
• research completed prior to 2008.

Research completed before 2008 was excluded as it was assumed that these projects would have been identified in the academic and grey literature review conducted for the previous chapters of this status report. However, given that there may be a gap between research and publication, some material may not be included at all. Projects listed in Appendix B were scheduled to be completed after October 2008 or later, or are currently under development.

It should be noted that research funded through basic science, microbiology or clinical medicine funding streams is highly relevant to youth living with HIV. However, these themes were excluded because the focus of this report is the lived experience of youth, including youth living with HIV, and the impact on this population of various factors that determine health.

5.1.1 Methodological limitations

One limitation of the selection criteria is that some projects received grants from more than one organization or more than one grant in a different year from the same organization. Thus, some projects may be documented in Appendix B more than once. Conversely, some funding was provided to support research salary, student grants, knowledge translation or operating costs. As a result, these funds may support more than one project over several years but only one project is outlined in the application to the funding source.

A second limitation in the selection is that abstracts and full descriptors were not available for all projects. In some cases, there may not have been a requirement to identify youth as a studied population in the summary information (abstract, key words or title). Projects with no available abstracts were included here if the title or project keywords contained any of the search terminology. Some project descriptions required further exploration and where possible, principal investigators were contacted to determine whether their projects were specifically related to youth in Canada.

In addition, research funding bodies were not identified for every province and territory, and not all abstracts identified a geographic focus for the research. Consequently, the section on geographic location (see Geographic location section) may not reflect the full scope of work taking place in each region.

Because of the breadth of research underway in the field of sexual health, the methodological limitations of this report may have resulted in some research having been excluded inadvertently. In addition, this report does not include research funded by the private sector or by pharmaceutical companies.

5.2 Overview of research projects funded between 2008-2011

5.2.1 Geographic location

In total, 59 research projects were identified using the methodology described in the section on methodology in this chapter. Of these, 43 specify a location of research.

It should be noted that several research projects in this chapter are connected to the same overall study or draw from the same cohort of participants. For example, in British Columbia, projects R5, R6, R27 and R30 all draw on data from the At-Risk Youth Study (ARYS) cohort or recruit participants from within the cohort. Similarly, projects R44 to R49 all use data from the Cedar Project.

Three national-level projects were identified. Project R15 is a pan-Canadian project that assesses intervention strategies for young HIV-positive women and factors that make sexual health promotion programs successful. Project R42 uses an arts-based approach to prevention education among Aboriginal youth and aims to include Aboriginal youth representatives from every region of Canada. Project R59 aims to enhance evaluation capacity of HIV and sexual health education programs for Canadian youth.

Twenty-two research projects were identified in British Columbia. Of these, six form part of the Cedar Project, which follows a cohort of Aboriginal youth who use drugs (R44, R45, R46, R47, R48, R49). Projects R6 and R7 investigate the impacts of crystal methamphetamine use on sexual and injection related risk behaviour, trauma and HIV infection. Project R20 examines use of online STI testing among young women. Project R22 examines determinants of health among youth with perinatally acquired HIV. Project R23 assesses the experiences of sexually exploited and vulnerable male youth in accessing health and social services. Project R26 studies patterns of illicit drug use and the environment in which they are used, and evaluates their effects on initiation of injection drug use, sexual risk behaviour and incidence of HCV and HIV among a cohort of 500 street-involved youth. Project R27 examines determinants of injection drug use initiation among street-involved youth in Vancouver. Project R28 investigates population-level interventions affecting youth sexual health within and outside of the health sector. Project R30 analyses the structural, social and physical landscape of the downtown Vancouver drug scene, and how this environment shapes experiences of safety and risk among youth who use drugs. Two related projects concentrate on youth and online STI testing (R33), one of which focuses particularly on young men (R56). Projects R34 and R35 investigate protective factors associated with injection drug use initiation among youth. Project R50 examines the social and structural contexts of HIV risk for youth and women involved in sex work. Project R51 investigates HIV and HCV vulnerability and prevention for youth and others who inject drugs.

Two research projects were identified in Manitoba. Project R19 engages newcomer communities in sexual health research, and explores cultural factors for HIV risk reduction. Project R55 addresses the social environments of youth from racialized communities.

Twelve research projects from Ontario were identified. Many of these include community-based research among urban youth from racialized communities and youth who use injection drugs. Project R1 takes a community-based research approach to enhance HIV prevention services for newcomer youth in Toronto. Project R2 studies pregnancy and HIV risk among Toronto street-involved youth. Project R8 is a capacity-building project with the goal of evaluating youth sexual health peer education programs. Project R18 examines determinants of HIV risk behaviour among South Asian youth, and evaluates a brief HIV risk prevention intervention. Project R29 assesses the HIV and HCV prevention needs of youth who smoke crack. Project R36 looks at the use of sexual health services by street-involved youth in Hamilton. Project R37 identifies the concerns of youth living with HIV in the context of sexual health. Project R38 looks at social exclusion and the health and wellbeing of gender-variant and sexual minority youth. Project R43 focuses on the issues of transphobia and homophobia experienced by urban teenagers. Projects R53 and R54 are part of the Toronto Teen Survey which examines sexual health services among diverse urban youth. These Toronto Teen Survey projects aim to inform development of a city-wide youth sexual health services strategy. Project 57 considers resilience and HIV-related stigma among youth living with HIV.

Four research projects were identified in Quebec. Projects R3 examines the development and experiences of youth living with HIV. Projects R9 and R10 are a part of the Chî Kayeh project on culturally appropriate sexual health promotion among the Cree community of James Bay. Project R32 focuses on the use of information technology to promote sexual health among Aboriginal youth.

One project is located in the Northern region among Inuit communities (R40) but the exact location is not specified. This project investigates health promotion and culturally sensitive health care among Inuit youth.

The search did not identify any currently funded projects about youth and HIV/AIDS in Alberta, Saskatchewan or the Atlantic provinces (Nova Scotia, New Brunswick, Newfoundland and Labrador and Prince Edward Island). This may be in part because some research projects do not identify a location, and also due to the scope of the methodology.

5.2.2 Specific populations of youth

All 59 projects identify a particular group of youth as a focus, which is captured in Table 5. In some cases, the project relates to more than one of the eight populations identified in the Federal Initiative to Address HIV/AIDS in Canada.

Aboriginal youth

Sixteen projects focus on Aboriginal youth. Of these, six are part of the Cedar Project (R44, R45, R46, R47, R48, R49), an ongoing prospective community-based cohort study of more than 500 Aboriginal young people (status and non-status First Nations, Inuit and Métis) between 14 to 30 years old, who self-reported use of injection or non-injection illegal drugs in the previous month in Prince George and Vancouver (Downtown Eastside), British Colombia. Projects R9 and R10 are part of the Chî kayeh project, and focus specifically on the Cree of James Bay in Quebec. This community-based research project examines a culturally appropriate health and prevention program and engages in knowledge transfer for Aboriginal youth from this community. Project R14 examines public health messages that are culturally appropriate for Aboriginal youth. Project R16 studies social environments and the impacts of colonialism on risk factors for injection drug use among Aboriginal youth. Project R31 examines interventions, such as prevention, evaluation, implementation, knowledge translation and development, to enhance prevention policy for Aboriginal youth. Project R32 considers the promotion of sexual health via information technologies and social media. Project R40 deals with culturally sensitive health promotion and capacity building among Inuit youth. Projects R41 and R42 examine an arts-based approach to develop and disseminate HIV prevention materials among Aboriginal youth.

Youth who use drugs

Eighteen projects focus on youth who use drugs. Of these, seven form part of the Cedar Project cohort study (R44, R45, R46, R47, R48, R49, R51). Many of the projects listed focus on injection drug use (R5, R6, R7, R16, R21, R26, R27, R34, R35) including patterns of use and related determinants of health such as early childhood development, personal health practices, physical and social environments. Other projects examine specific issues such as crack smoking (R29) or general illicit drug use among youth (R30, R44, R45, R46, R47, R48, R49, R51).

Project R5 examines injection drug use and HIV infection among youth. Project R6 analyses risk factors for crystal methamphetamine use and sexual and injection related risk behaviours. Project R7 explores unhealthy childhood development, including issues such as sexual abuse and trauma, as a risk factor for injection drug use and the use of crystal methamphetamine. Project R16 studies the role of social environments and youth coping skills on risk and protective factors for injection drug use. Project R21 aims to enhance public health policy and intervention programming for marginalized youth vulnerable to injection drug use and HIV infection. Project R26 focuses on social and physical environments and risk factors for injection drug use, homelessness, sex work, and risk for acquiring STBBIs. Project R27 examines factors leading to initiation, involvement and cessation of injection drug use, and other risk factors such as dealing drugs.

Project R29 examines the HIV and HCV prevention needs of youth who smoke crack. Project R30 explores gentrification and risk factors such as drug-related harms, physical violence and HIV risk behaviours. Project R34 aims to inform the development and implementation of prevention programs, and also studies coping skills and social support networks of youth who inject drugs. Project R35 surveys HIV and HCV vulnerabilities and resilience among adolescent Aboriginal women.

Street-involved youth

Ten projects address street-involved youth. Of these, seven are discussed in the section on youth who use drugs (R6, R7, R21, R26, R27, R29, R34). Project R2 is discussed in the section on street-involved young women. Project R23 examines the experiences of sexually exploited male youth in accessing health and social services. Project R36 is a community-based research project assessing youth sexual health knowledge and needs, as well as enhanced health services for marginalized street-involved youth.

Youth living with HIV

Six projects focus on youth living with HIV. Four of these involve youth who acquired HIV through vertical transmission, or in early adolescence, and address topics such as access to health and social services, social support networks, stigma and discrimination, disclosure of HIV status, and the trajectories of sexual relationships (R3, R12, R22, R37). Project R15 examines sexual health interventions for young HIV-positive women. Project R57 considers the resiliency of young people living with HIV and the stigma they experience.

Young women

Six projects focus on young women. Project R2 is community-based research about street-involved young women and explores issues such as pregnancy and HIV risk factors. Project R15 is also community-based research that looks at the social environments and social support networks of young women living with HIV. Project R20 aims to engage young women in online STI testing, especially among more vulnerable groups of young women. Project R24 is prevention research that seeks to feed into enhanced policy making and increase access to health services for female youth. Project R35 explores resiliency among young Aboriginal women who use drugs. Project R50 examines the social and gender contexts of HIV and STI risks for young women involved in sex work.

Young men

Two projects focus on young men. Project R23 investigates access to health and social services for sexually exploited male youth, while Project R56 concentrates on improving access to online sexual health and testing services for young men in British Columbia.

Youth from racialized communities

Three projects focus on youth from racialized communities. Project R18 examines determinants of HIV risk behaviour among South Asian youth in Toronto. It evaluates an HIV prevention video intervention developed in collaboration with a local AIDS service organization, the Alliance for South Asian AIDS Prevention. Projects R19 and R55 investigate cultural factors that are linked to HIV and STI vulnerability and resilience among African newcomer youth living in western Canada.

Newcomer and immigrant youth

Three projects address youth who are newcomers to Canada (R1, R19, R55). Project R1 looks at social environments and access to culturally sensitive health programs to meet the unique needs of newcomer youth in Toronto, including issues associated with racism. Project R19 examines cultural factors that increase vulnerability to HIV infection among African newcomer youth living in western Canada. Project R55 focuses on understanding cultural factors for HIV and STI risk reduction among African refugee and immigrant youth in Winnipeg.

Sexually diverse and gender-variant youth

Three projects were identified that address sexually diverse and gender-variant youth. Project R38 draws on the social determinants of health to examine the impact of social exclusion on health outcomes and health care needs of lesbian, gay, bisexual and transgender youth. Project R43 examines homophobia and transphobia among urban youth. Project R56 examines ways to engage young men in online HIV and STI testing in British Columbia, including young men who have sex with men.

General population of youth

Eleven projects address youth in the general population. The majority of these look at prevention, sexual health promotion and education (R8, R17, R25, R28 R31, R39, R53, R54, R59). Project R13 examines beliefs and attitudes that predict sexual risk behaviours among youth, while project R33 studies the use of online STI testing among youth in British Columbia.

Other populations

Five projects study other youth populations. Projects R4 and R11 focus on adolescents in the child welfare system, who have experienced sexual abuse and how this shapes sexual risk behaviours. Project R50 analyses the social and gender contexts of HIV and STI risks for young women involved in sex work. Projects R52 and R58 investigate sexual health and HIV prevention issues among youth with disabilities.

The search did not identify any currently funded projects that address youth in prison, or youth living in rural and remote communities who are not a part of the vulnerable populations listed above.

5.2.3 Determinants of health

Six projects focus on healthy childhood development. In many cases, these examine issues of violence or sexual abuse. Four projects focus on gender and six on culture, including research to support the development of culturally relevant HIV prevention interventions for different communities. Three projects address education and literacy as a determinant of health, looking at issues such as prevention and sexual health education. Three projects study the physical environments experienced by youth who are vulnerable to HIV infection.

Fifteen projects analyse social environments, including stigma and discrimination. Eleven explore issues surrounding access to health services for youth who are vulnerable to HIV/AIDS, including testing, diagnoses, treatment, and prevention services. Eleven projects investigate personal health practices and coping skills, while nine consider protective factors and social support networks.

5.2.4 Community research capacity, research dissemination, health policy research and knowledge transfer

Community research

Three projects focus explicitly on developing community research capacity. Project R8 aims to build capacity within communities to conduct evaluation research on youth sexual health peer education programs. Project R19 involves a collaborative partnership between African immigrant and refugee youth, community-based organizations and university researchers. Project R40 uses a community-based research approach involving community-based organizations and community members in the research process.

Community-based responses

Nine projects consider community-based responses to HIV among youth. Project R8 focuses on building capacity to conduct community-based research on evaluating youth sexual health peer education programs. Project R9 examines implementation of the Chî kayeh program in Cree communities. Project R17 looks at approaches to HIV prevention, support and community-based research among youth. Project R40 focuses on strengthening community-based approaches to HIV/AIDS education, screening and treatment among Canadian Inuit youth. Project R41 uses arts-based approaches to develop Aboriginal youth leadership in HIV prevention. Project R43 studies the Teens Resisting Urban Transphobia and Homophobia (TRUTH) project. Projects R47 and R48 aims to facilitate knowledge translation of Cedar Project findings to community members and leaders. Project R53 is a community-based survey to assess sexual health services among diverse urban youth in Toronto.

Health policy

Three projects look at health policy research. Project R21 goals include generating insights that public health agencies and other decision makers can use to implement evidence-based programs and policies dealing with youth and HIV. Project R24 examines the impact of policy decisions and service delivery models on HIV prevention in young women. Project R31 focuses on translating primary HIV prevention research into prevention policy.

Knowledge transfer

Eight projects support knowledge transfer activities. Project R9 focuses on applying information gathered in implementing the Chî kayeh program to develop an implementation guide. Project R25 aims to share international knowledge on the use of information communication technology to promote the sexual health of adolescents and young adults. Project R41 proposes to hold six community workshops to teach arts-based approaches to prevention in Aboriginal communities. Project 42 supports Aboriginal youth to develop and screen short films on HIV prevention in their communities. Projects R47 and R48 are related to the Cedar Project; R47 is a leadership forum and R48 seeks to facilitate the involvement of young Aboriginal people and Elders in knowledge translation and exchange. Project R54 supports knowledge translation and exchange from the Toronto Teen Survey. Project R55 facilitates discussions around sexual health, STIs and HIV/AIDS for African immigrant and refugee youth living in Winnipeg.

Education

Three projects focus on education about HIV and STI prevention. Project R3 follows the trajectory of youth with perinatally acquired HIV in order to inform an education and prevention program that takes into account the issues facing this population. Project R40 is focused on strengthening community-based approaches to HIV/AIDS education, screening and treatment for Canadian Inuit youth. Project R52 is geared towards improving education and communication strategies for discussing sexuality issues with youth who have a disability.

Prevention

Ten projects study prevention. Project R1 aims to enhance HIV prevention services for newcomer youth in Toronto. Project R9 is the Chî kayeh project, which examines prevention and sexual health promotion in Cree communities. Project R17 analyses approaches to HIV prevention among youth. Project R18 includes the evaluation of a short HIV prevention video. Project R19 studies prevention and risk reduction in newcomer communities in Western Canada. Project R31 concentrates on prevention research in marginalized communities. Project R32 looks at HIV/AIDS prevention within First Nations communities and includes a focus on promotion of sexual and reproductive health. Project R34 examines factors that prevent injection drug use initiation among youth. Project R36 explores the use of sexual health services by street-involved youth in Hamilton. Project R41 uses an arts-based approach to develop Aboriginal youth leadership in prevention.

Intervention

Ten projects focused on interventions. Project R9 assesses the implementation of the Chî kayeh sexual health, HIV and STI prevention program in Cree communities. Project R15 explores intervention approaches that make sexual health promotion programs for young, HIV-positive women successful. Project R18 evaluates an HIV risk prevention intervention among South Asian youth in Toronto. Project R20 reviews an online STI testing project in British Colombia, while project R33 explores online STI testing interventions among youth. Project R28 investigates population-level interventions aimed at improving youth sexual health. Project R32 examines sexual health promotion and HIV prevention using information technology among Aboriginal youth. Projects R41 and R42 propose to hold workshops with Aboriginal youth to teach arts-based approaches to prevention. Project R56 seeks to improve access to online sexual health and testing services for young men in British Columbia.

Evaluation

Three projects evaluate various initiatives. Project R10 is an evaluation research project on how the Chî kayeh iyaakwaamiih program is being adopted in the Aboriginal educational context of the James Bay Cree in Quebec. Project R18 includes the evaluation of an HIV risk prevention intervention for South Asian youth in Toronto. Project R59 explores what is needed to enhance evaluation capacity on youth HIV and sexual health education programs.

5.2.5 Resilience

Although this report highlights the vulnerability of certain populations of youth, it is important to note that youth and their communities have demonstrated considerable resilience in responding to HIV vulnerability. Three projects address this resilience among youth (R34, R46, R49). Project R34 explores factors that prevent street-involved youth from initiating injection drug use. Project R46 studies resiliency among Cedar Project participants, specifically against HIV vulnerability and drug use. Project R49 seeks to gain better understanding of which protective factors prevent greater negative health outcomes among the Cedar Project participants who have experienced sexual trauma.

5.3 Areas for further research

The following list highlights areas where future research could address gaps in knowledge about youth and HIV/AIDS. Geographical disparities, specific youth populations and determinants of health and resilience were identified as particularly requiring more research to understand better the complex role that determinants of health play on the vulnerability and resilience of youth to HIV/AIDS. Though the following list should not be considered exhaustive, it was developed through an examination of the research gaps emerging from chapters 4 and 5 and discussion with Working Group members.

Geography

• youth living in rural and remote areas
• youth living in First Nations communities on-reserve, and Métis or Inuit communities
• Aboriginal youth living in urban centres
• youth who migrate from rural and remote to urban areas
• youth living in the Prairies and the Atlantic region
• youth who migrate throughout the country

Specific populations

• sexually diverse and gender-variant youth (e.g. gay, bisexual, transgender and other male youth who have sex with males, and questioning youth)
• female street youth (e.g. how HIV and STI risk is affected by the interplay of multiple socio-economic factors and gender)
• male youth who have experienced sexual abuse
• male heterosexual youth (e.g. effective sexual health promotion interventions for this population)
• newcomer, immigrant and youth from racialized communities (e.g. sexual health, racism, HIV and STI vulnerability, including among those who are sexually diverse and gender-variant)
• Aboriginal youth (e.g. vulnerability and resilience of female Aboriginal youth; First Nations, Inuit and Métis-specific research in the context of culturally appropriate prevention materials)
• youth living with HIV (e.g. romantic relationships and disclosure; role and experiences of the family–parents and siblings–of HIV-positive youth; social support network; sexual health and HIV prevention/information needs; experiences of and access to health services and treatment; use of the Internet for social support and knowledge)
• youth in foster care or group homes
• youth in prison
• youth living with physical or intellectual disabilities
• evaluation of interventions for specific populations of youth

Determinants of health

• emotional consequences of childhood emotional, sexual or physical abuse on vulnerability and resilience to HIV and STIs among youth
• impact of positive parental-child relationships on resilience and protective factors
• gender-based analysis research approach
• sexual health education (e.g. access, evaluation, identification of best practices)
• formal employment, income and HIV vulnerability
• physical environments and its impacts on HIV and STI vulnerability (e.g. social housing, prison, foster care or group homes)
• role and influence of social media on youth sexual behaviour
• impact of bullying, homophobia and stigma on sexually diverse and gender-variant youth
• mental health, HIV and STIs vulnerability (e.g. poor body image, self-harm, depression, anxiety, suicidal ideation)
• impact of criminal prosecutions for HIV non-disclosure on youth
• role of parents and older siblings on resiliency of youth living with HIV
• biology and genetic endowment (e.g. impacts of physical or intellectual disabilities on HIV and STI vulnerability, foetal alcoholism syndrome)

Resilience

• factors that protect and promote resilience among youth, including specific populations of youth such as sexually diverse and gender-variant, girls and youth from racialized communities, both at the individual and broader socio-structural levels