International Journal of Drug Policy - 2014

Volume 25 Issue 3 May 2014

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Page 39 of 153

540 K.N. Deering et al. / International Journal of Drug Policy 25 (2014) 533–542 the models where police harassment was identified as a key confounder, after adjusting for police harassment, the significant association between exchanging sex while high and increased percent of commercial areas was removed, but the association between exchanging sex for drugs and increased percent of parks remained (AOR: 1.38, 95%CIs: 1.07–1.78) (Table 5b). For the buffers developed surrounding places of servicing, in multivariable analysis, reduced odds of exchanging sex while high (AOR: 0.69, 95%CIs: 0.53–0.89) were significantly associated with increased length of alleys. Reduced odds of exchanging sex for drugs were associated with increased percent of commercial zoning (AOR: 0.72, 95%CIs: 0.57–0.92), increased count of lighting (AOR: 0.73, 95%CIs: 0.56–0.93) and increased percent of building footprint (AOR: 0.75, 95%CIs: 0.60–0.95). Elevated odds of exchanging sex for drugs were significantly associated with increased percent of parks (AOR: 1.58, 95%CIs: 1.14–2.18) (Table 6a). For the relationships where police harassment was identified as a key confounder, the association between exchanging sex for drugs and increased per- cent of parks (AOR: 0.74, 95%CIs: 0.58–0.93) and increased building footprint (AOR: 0.76, 95%CIs: 0.60–0.97) remained (Table 6b). Conclusions Novel social epidemiological and spatial methods that integrate neighbourhood environment and individual-level data can help us understand how social, physical and structure features of place shape potential health harms for marginalized populations. In par- ticular, our exploratory research suggests that a 'spatial isolation' index within street-based sex work scenes can help illuminate how physical and structural features of the built environment may increase dual drug use and sexual risks, and inform policy and interventions. We hypothesized that each built environment indicator rep- resented a measure of 'spatial isolation' from some service or resource that is important in contributing towards reducing nega- tive health outcomes among SWs (e.g., health services, safer sex and drug equipment resources and personal safety resources), and that increased spatial isolation would be associated with increased vulnerability to health harms as represented by increased sex-for-drug exchanges and exchanging sex while high. In devel- oping our index, we were unable to validate externally that our index measured what we intended it to and were limited by availability of variables in external databases. However, our results were in the direction we would expect based on previous research and in line with our hypotheses. Increased spatial isolation surrounding street-based/outdoor SWs' main places of servicing clients, as measured with an index that took into account the effects of multiple built environment indicators and was intended to provide an overall measure of SWs' spatial isolation from resources and services, was significantly associated with exchang- ing sex for drugs. When assessed individually in multivariable analysis for built environment indicators surrounding SWs' main places of solicitation and servicing, elevated odds of sex-for-drug exchanges were significantly associated with an indicator of the built environment hypothesized to be associated with greater spa- tial isolation (increased percent of parks). Moreover, reduced odds of sex-for-drug exchanges were significantly associated with built environment indicators surrounding SWs' main places of servic- ing hypothesized to be associated with decreased spatial isolation (increased percent commercial areas, increased count of lighting, increased building footprint). Given evidence highlighting the connections between police harassment of SWs and spatial isolation of SWs to places fur- ther away from public spaces and commercial areas, as well as away from places where health and harm reduction services are accessed (Hubbard, 1998; Kerr & Wood, 2005; Lowman, 1992, 2000; Shannon, Kerr, Allinott, et al., 2008; Shannon, Rusch, et al., 2008), our index can be viewed as a potential marker for such policing practices, in addition to its more direct interpretation as an overall representation of isolation from resources and services. This observation is supported by results (not shown) suggesting bivariate relationships between reduced police harassment with- out arrest and increased: percent commercial zoning (P = 0.001); number of light posts (P = 0.032); and percent building footprint (P = 0.089) (i.e., markers of spatial isolation). Heavier police pres- ence has been associated with increased risk for transmission of blood-borne or sexually transmitted infections to SWs and drug users through a number of spatial pathways; for example, heavier arrest rates have negatively affected the association between increased spatial access to sterile syringes and the use of safe drug use equipment (Cooper, Des Jarlais, Ross, et al., 2012; Cooper, Des Jarlais, Tempalski, et al., 2012); increased police presence and previ- ous arrests/harassment by police have been associated with rushed negotiations with clients or rushed and unsafe drug use, inject- ing and doing sex work in unsafe spaces and having safer sex and drug use equipment confiscated (Kerr & Wood, 2005; Shannon et al., 2008a; Small, Kerr, Charette, Schechter, & Spittal, 2006); and being able to access safer indoor drug use spaces has alle- viated the pressures of policing and violence in public drug use spaces and facilitated use of safer drug use equipment (Fairbairn, Small, Shannon, Wood, & Kerr, 2008). Such research helps explain our association between increased spatial isolation as measured by our index and exchanging sex for drugs. Moreover, our results showed that without adjusting for police harassment, working in areas with increased percent of commercial zones was associated with reduced risk for exchanging sex while high; however in multi- variable analysis, this association was removed when adjusting for police harassment, which was identified as a key confounder in this relationship and had the strongest association with exchanging sex while high (5.7-fold elevated odds) relative to other confounders. Spatial and place-based research on risk environments are crit- ical to health policy as study results "can locate precisely places of potential risk environments, social vulnerability and where struc- tural interventions are urgently needed" (Tempalski & McQuie, 2009). Given that our results indicate that SWs with dual drug use and sexual risks may be at heightened risk of spatial isola- tion that could enhance their risks our study suggests a number of policy implications that are spatially oriented. Research suggests that development and scale-up of safer environment interventions (e.g., mobile outreach (Deering et al., 2011; Janssen, Gibson, Bowen, Spittal, & Petersen, 2009)) that modify the physical environments of street-based/outdoor SWs can be instrumental in reducing sex- ual and drug-related harms. In addition, in line with global calls (Ahmed, Kaplan, Symington, & Kismodi, 2011; Nosyk & Wood, 2012; Shannon, 2010; Shannon & Csete, 2010; Wood, McKinnon, Strang, & Kendall, 2012), there is strong evidence and global pol- icy support (e.g., WHO/UN guidelines, Global Commission for HIV and the Law) for decriminalization of communicating for purposes of sex work in public/outdoor spaces ('communicating code') to ensure access to safer indoor spaces for sex work with supportive policies (e.g., occupational health and safety standards, support- ive and safer policies towards drug use) that support SWs ability to better control sexual transactions and reduce health harms to SWs (Ghose, Swendeman, & George, 2011; Kerrigan et al., 2003; Krusi et al., 2012; Shahmanesh, Patel, Mabey, & Cowan, 2008; Withers, Dornig, & Morisky, 2007). The shift away from policing tactics towards street-based/outdoor sex work that result in sex work spaces being moved into areas where there is limited access to health and safety resources could increase dialogue between SWs and police and contribute to the development of street- based/public sex work spaces that satisfy the needs of SWs along

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