Kate Shannon’s research while affiliated with University of British Columbia and other places

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Publications (252)


Period prevalence of primary care use at each six-month study period amongst a community-based cohort of women sex workers in Metro Vancouver, Canada, 2014–2021 (N = 643)
Social-structural barriers to primary care among sex workers: findings from a community-based cohort in Vancouver, Canada (2014–2021)
  • Article
  • Full-text available

January 2025

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7 Reads

BMC Health Services Research

Miriam T. H. Harris

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Kate Shannon

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[...]

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Background Due to social-structural marginalization, sex workers experience health inequities including a high prevalence of sexually transmitted and blood-borne infections, mental health disorders, trauma, and substance use, alongside a multitude of barriers to HIV and substance use services. Given limited evidence on sex workers’ broader primary healthcare access, we aimed to examine social-structural factors associated with primary care use among sex workers over 7 years. Methods Data were derived from An Evaluation of Sex Workers Health Access (AESHA), a community-based open prospective cohort of women (cis and trans) sex workers in Metro Vancouver, from 2014 to 2021. Descriptive statistics were used to summarize the proportion of primary care use in the past six months and to assess primary care trends over time from 2014–2021. We used multivariate logistic regression with generalized estimating equations (GEE) to identify social-structural factors associated with primary care access (seeing a family doctor in the last six months), after adjusting for confounders. Results Amongst the 646 participants, most (87.4%) accessed primary care at some point during the study period, and primary care use in the last 6 months was relatively stable (ranging from 60–78%) across each follow-up period. At first available observation, participants faced a high burden of sexually transmitted and blood-borne infections (STBBIs) (48.0%, 11.5%, and 10.4% were HCV, HIV, or STI seropositive, respectively), 56.8% were diagnosed with a mental health disorder, 8.1% had recently overdosed, and 14.7% were recently hospitalized. In multivariable GEE analysis, exposure to intimate partner violence was associated with reduced primary care use (Adjusted odds ratios (AOR) 0.63, 95% Confidence interval (CI): 0.49—0.82), and limited English fluency was marginally associated (AOR 0.76 CI: 0.51—1.14). Conclusions This study characterized primary care use and its social-structural determinants among sex workers over 7 years. Participants faced a high burden of STBBIs and other health disparities, and a proportion faced gaps in primary care utilization. Scale-up of trauma-informed, culturally and linguistically tailored, sex worker-friendly primary care models are needed, alongside structural interventions to decriminalize and destigmatize sex work and substance use.

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Baseline characteristics of women sex workers in Metro Vancouver who completed the social cohesion scale, Vancouver, Canada, 2010–2022 (N = 918)
Bivariate GEE analysis of individual and interpersonal, macrostructural, community and work environment factors with social cohesion among women sex workers in Vancouver, Canada, 2010–2022 (N = 918)
Relationship between social cohesion and recent physical/sexual violence and use of sex work-specific services among sex workers in Vancouver, BC, [2010–2022] (n = 918)
The protective association of social cohesion on sex workers’ experiences of violence and access to community support: Impacts of resource sharing, trust and connection among a community-based cohort in Metro Vancouver, Canada (2010–2022)

December 2024

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28 Reads

Objectives To measure recent social cohesion (resource sharing, trust and support) and its association with (1) sexual/physical violence, and (2) engagement with sex work-specific services among women sex workers in Metro Vancouver, Canada. Methods Prospective data (January 2010-August 2022) were drawn from an open cohort of 900+ women sex workers. We developed multivariable logistic regression confounder models with generalized estimating equations (GEE) to examine associations between social cohesion and recent (1) physical/sexual violence and (2) engagement with sex work-specific services. Results Of 918 participants, 36.8% were Indigenous and 32.1% were Black/Women of Colour. At baseline, the median social cohesion score was 19 (IQR 16–22), out of 36, with higher levels among participants who work with other sex workers. In separate multivariable confounder models with GEE, social cohesion was associated with lower odds of recent physical/sexual violence (Adjusted Odds Ratio 0.98 per point on scale, 95% Confidence Interval 0.97, 0.99) and recent use of sex work-specific services, although only statistically significant for physical/sexual violence. Conclusions Findings support the need to eliminate policing of work environments that promote sex workers’ social cohesion and physical safety through full decriminalization.


Stigma trajectories, disclosure, access to care, and peer-based supports among African, Caribbean, and Black im/migrant women living with HIV in Canada: findings from a cohort of women living with HIV in Metro Vancouver, Canada

November 2024

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14 Reads

BMC Public Health

Background African, Caribbean, and Black im/migrant women experience a disproportionate burden of HIV relative to people born in Canada, yet there is scarce empirical evidence about the social and structural barriers that influence access to HIV care. The objectives of this study is to estimate associations between African, Caribbean, and Black background and stigma and non-consensual HIV disclosure outcomes, and to understand how experiences of stigma and im/migration trajectories shape access to HIV care and peer supports among African, Caribbean, and Black im/migrant women living with HIV in Canada. Methods This mixed-methods analysis draws on interviewer-administered questionnaires and semi-structured interviews with self-identifying African, Caribbean, and Black women living with HIV in the community-based SHAWNA (Sexual Health and HIV/AIDS: Women’s Longitudinal Needs Assessment) cohort. Bivariate and multivariable logistic regression using generalized estimating equations (GEE) were performed to estimate associations between African, Caribbean, and Black background and stigma and non-consensual HIV disclosure outcomes. Drawing on a social and structural determinants of health framework, qualitative analysis of interviews elucidated the interplay between migration trajectories, stigma, racialization, and HIV. Results Amongst our participants (n = 291), multivariable GEE analysis revealed that African, Caribbean, and Black participants (n = 15) had significantly higher odds of recently being outed without consent as living with HIV (AOR 2.34, 95% CI 0.98–5.57). Additionally, African, Caribbean, and Black participants had higher odds of recent verbal or physical abuse due to their HIV status (AOR 2.11, 95% CI 0.65–6.91). Reflecting on their im/migration trajectories, participants’ narratives (n = 9) highlighted experiences of political violence and conflict, trauma, stigma, and discrimination associated with HIV in their place of origin and the racialization and stigmatization of HIV in Canada. Fear of disclosure without consent was linked to barriers of accessing care and peer-based supports. Conclusion Our findings indicate that im/migration trajectories of African, Caribbean, and Black women living with HIV are critically related to accessing HIV care and supports in Canada and compound HIV stigma and discrimination. HIV disclosure without consent complicates access to care and social/peer support, underscoring the need for privacy, confidentiality, and the importance of building trust in the context of clinical encounters. The results of this study emphasize the critical need for culturally sensitive trauma-informed care models rooted in peer-based approaches.


Bivariate and multivariable GEE models for the association between precarious/ temporary migration status and lacking health coverage among women sex workers in Metro Vancouver, BC (N = 644), 2014-2021.
Bivariate and multivariable GEE models for the association between being a racialized Asian im/migrant and lacking health coverage among women sex workers in Metro Vancouver, BC (N = 644), 2014-2021.
Gaps In Health Coverage For Racialized Im/Migrant Sex Workers In Metro Vancouver: Findings of a Community-Based Cohort Study (2014-2021)

October 2024

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11 Reads

Journal of Migration and Health

Background Sex workers face substantial health inequities related to sexual health and gender-based violence, many of which are amplified for the large proportion of workers who are racialized im/migrants. While criminalization and stigma are known barriers to health care for this population, we know little about health insurance coverage, and in particular how this relates to im/migration experience and racialization. We examined associations between im/migration status, duration, and racialization on gaps in health insurance coverage in a cohort of women sex workers. Methods Analyses used data from a prospective, community-based cohort of women sex workers in Vancouver, BC (Sept 2014-August 2021). Interviewer-administered questionnaires were by experiential (current/former sex workers) and community-based staff. We developed multivariable logistic regression confounder models with generalized estimating equations (GEE) to examine associations between migration and racialization exposures of interest and health insurance coverage. Results Of 644 sex workers, 411 (63.8%) reported lacking health insurance coverage for services needed during the 7-year study. In multivariable GEE analysis, precarious im/migration status (adjusted odds ratio (AOR) 2.37, 95% confidence interval (CI) 1.56 – 3.60), recent (AOR 4.22, 95% CI 2.42 – 7.35) and long-term (AOR 2.13, 95% CI 1.54 – 2.96) migration, and being a racialized Asian im/migrant (AOR 3.06, 95% CI 2.14 – 4.39) were associated with recent lack of health insurance coverage. Conclusion Policy and program reforms are needed to decouple health insurance access from immigration status, remove mandatory waiting periods for health insurance coverage, and ensure that provincial insurance provides sufficient coverage for marginalized women's healthcare needs.


Stigma, Discrimination and Other Social-Structural Factors Associated with Barriers to Counselling or Therapy among Women Living with HIV Who have Experienced Violence in Metro Vancouver, Canada

September 2024

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9 Reads

AIDS and Behavior

Women living with HIV face high social and structural inequities that place them at heightened risk for gender-based violence and mental health conditions, alongside health services access inequities, with almost no research done to better understand access to mental health services. This study therefore examined social and structural factors associated with barriers to counselling or therapy amongst women living with HIV who experienced lifetime physical and/or sexual violence in Metro Vancouver, Canada. Bivariate and multivariable logistic regression using generalized estimating equations (GEE) were used and adjusted odds ratios (AOR) and 95% Confidence Intervals ([95%CIs] are reported). From Sept/15-Aug/21, 1695 observations were collected among 279 participants. In multivariable analysis, with all variables measured in the last six months, experiencing any barriers to counselling or therapy was significantly associated with having thoughts or attempts of suicide (AOR:1.64 [1.02–2.66]), lacking coverage for health care (AOR:1.60 [1.17–2.18]), and everyday discrimination (AOR:1.02 [1.00-1.04]) and anticipated (AOR:1.57 [1.04–2.36]), enacted (AOR:1.48 [1.02–2.16]) or internalized (AOR:1.53 [1.07–2.20]) HIV stigma. Access to interdisciplinary mental health care services should be improved. Social and structural interventions to reduce HIV stigma and discrimination are urgently needed.


Structural Barriers to Primary Care Among Sex Workers: Findings from a Community- Based Cohort in Vancouver, Canada (2014–2021)

August 2024

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37 Reads

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1 Citation

Background: Due to structural marginalization, sex workers experience health inequities including a high prevalence of sexually transmitted and blood-borne infections, mental health disorders, trauma, and substance use, alongside a multitude of barriers to HIV and substance use services. Given limited evidence on sex workers’ broader primary healthcare access, we aimed to examine structural factors associated with primary care access among sex workers over a 7-year period. Methods Data were derived from An Evaluation of Sex Workers Health Access (AESHA), a community-based open prospective cohort of women (cis and trans) sex workers in Metro Vancouver, from 2014 to 2021. Descriptive statistics were used to summarize the proportion of primary care use in the past six months and to assess primary care trends over time from 2014-2021. We used multivariate logistic regression with generalized estimating equations (GEE) to identify structural factors associated with primary care access (seeing a family doctor in the last six months), after adjusting for confounders. Results: Amongst 646 participants, most (87.4%) accessed primary care at some point during the study period, and primary care use in the in the last 6 months was relatively stable (ranging from 60-78%) across each follow-up period. At first available observation, participants faced a high burden of sexually transmitted and blood-borne infections (STBBIs) (48.0%, 11.5%, and 10.4% were HCV, HIV, or STI seropositive, respectively), 56.8% were diagnosed with a mental health disorder, 8.1% had recently overdosed, and 14.7% were recently hospitalized. In multivariable GEE analysis, exposure to intimate partner violence was associated with reduced access to primary care (Adjusted odds ratios (AOR) 0.63, 95% Confidence interval (CI): 0.49 - 0.82), and limited English fluency was marginally associated (AOR 0.76 CI: 0.51 - 1.14). Conclusions: This study characterized primary care access and its structural determinants among sex workers over 7-years. Participants faced a high burden of STBBIs and other health disparities, and a proportion faced gaps in primary care access. Scale-up of trauma-informed, culturally and linguistically tailored, sex worker-friendly primary care models are needed, alongside structural interventions to decriminalize and destigmatize sex work and substance use.


Association between sex work occupational stigma and inconsistent condom use: findings from a community-based cohort of women sex workers in Vancouver, Canada (2014–2022)

August 2024

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15 Reads

Journal of Epidemiology and Community Health

Background Women sex workers face substantial health inequities due to structural barriers including criminalisation and stigma. Stigma has been associated with HIV-related inequities among marginalised populations, however, we know less about the impacts of sex work-specific occupational stigma on HIV/sexually transmitted infection (STI) risk among women sex workers. Given these research gaps and the disproportionate burden of stigma faced by sex workers, we evaluated the association between sex work occupational stigma and recent inconsistent condom use with clients, over an 8-year period (2014–2022). Methods Baseline and semiannual questionnaire data from a prospective, community-based cohort of sex workers in Vancouver, Canada from September 2014 to February 2022 were used. We employed complete-case bivariate and multivariate logistic regression analysis using generalised estimating equations to analyse the relationship between sex work occupational stigma and inconsistent condom use for vaginal/anal sex with clients in the past 6 months. Results Among 574 participants, the cumulative prevalence of inconsistent condom use by clients and sex work occupational stigma in the last 6 months was 32.1% (n=184) and 59.9% (n=344), respectively, over the 8-year period. In adjusted multivariable analysis, exposure to sex work occupational stigma was associated with almost twofold increased odds of recent inconsistent condom use with clients (adjusted OR 1.93, 95% CI 1.23 to 3.03) over the 8-year period. Conclusion Multilevel interventions addressing the role of occupational stigma are needed for HIV and STI prevention efforts, including scale-up of sex worker-led/delivered sexual health services and structural changes to decriminalise and destigmatise sex work.


Increases in housing rules and surveillance during COVID-19: impacts on overdose and overdose response in a community-based cohort of sex workers who use drugs in Vancouver, BC

August 2024

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21 Reads

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1 Citation

Harm Reduction Journal

Introduction Since the beginning of the COVID-19 pandemic, COVID-19 risk mitigation measures have expanded to include increased rules and surveillance in supportive housing. Yet, in the context of the dual public health emergencies of COVID-19 and the unregulated drug toxicity crisis, we have not evaluated the unintended health and social consequences of such measures, especially on criminalized women. In order to address this dearth of evidence, our aim was to assess the association between increased housing rules and surveillance during COVID-19 and (a) nonfatal overdose, and (b) administration of naloxone for overdose reversal among women sex workers who use drugs in Vancouver, BC. Methods This study is nested within An Evaluation of Sex Workers Health Access (AESHA), a community-based prospective cohort of women sex workers in Metro Vancouver (2010–present). Using cross-sectional data collected during the first year of COVID-19 (April 2020–2021), we developed separate multivariable logistic regression confounder models to examine the independent associations between experiencing increased housing rules and surveillance during COVID-19 on (a) nonfatal overdose, and (b) administration of naloxone for overdose reversal in the last 6 months. Results Amongst 166 participants, 10.8% reported experiencing a recent non-fatal overdose and 31.3% recently administered naloxone for overdose reversal. 56.6% reported experiencing increased rules and surveillance within their housing during COVID-19. The prevalence of non-fatal overdose and administering naloxone was significantly elevated among those exposed to increased housing rules and surveillance during COVID-19 versus those who were unexposed (83.3% vs. 52.1%; 75.0% vs. 48.2%, respectively). In separate multivariate confounder models, exposure to increased housing rules and surveillance during COVID-19 was independently associated with increased odds of administering naloxone [AOR: 3.66, CI: 1.63–8.21], and marginally associated with non-fatal overdose [AOR: 3.49, CI: 0.92–13.27]. Conclusion Efforts to prioritize the right to safe, adequate and affordable housing must avoid reinforcing an overly coercive reliance on surveillance measures which, while often well-intended, can negatively shape residents’ well-being. Furthermore, public health responses to pandemics must include criminalized populations so that measures do not exacerbate overdose risk. Implementation of a regulated drug supply is recommended, alongside housing policies that promote residents' rights, safety, and health.


Pandemic-related challenges accessing food and primary healthcare among sex workers during the COVID-19 pandemic: findings from a community-based cohort in Vancouver, Canada

June 2024

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37 Reads

BMC Public Health

Introduction Globally, the COVID-19 pandemic upended healthcare services and created economic vulnerability for many. Criminalization of sex work meant sex workers were largely ineligible for Canada’s government-based financial pandemic relief, the Canadian Emergency Response Benefit. Sex workers’ loss of income and inability to access financial support services during the pandemic resulted in many unable to pay rent or mortgage, and in need of assistance with basic needs items including food. Little is known about the unique experiences of sex workers who faced challenges in accessing food during the pandemic and its impact on healthcare access. Thus, we aimed to identify the association between pandemic-related challenges accessing food and primary healthcare among sex workers. Methods Prospective data were drawn from a cohort of women sex workers in Vancouver, Canada (An Evaluation of Sex Workers’ Health Access, AESHA; 2010-present). Data were collected via questionnaires administered bi-annually from October 2020-August 2021. We used univariate and multivariable logistic regression with generalized estimating equations to assess the association between pandemic-related challenges accessing food and challenges accessing primary healthcare over the study period. Results Of 170 participants, 41% experienced pandemic-related challenges in accessing food and 26% reported challenges accessing healthcare. Median age was 45 years (IQR:36–53), 56% were of Indigenous ancestry, 86% experienced intimate partner violence in the last six months, and 62% reported non-injection substance use in the last six months. Experiencing pandemic-related challenges accessing food was positively associated with challenges accessing primary healthcare (Adjusted Odds Ratio: 1.99, 95% Confidence Interval: 1.02–3.88) after adjustment for confounders. Conclusions Findings provide insight about the potential role community-based healthcare delivery settings (e.g., community clinics) can play in ameliorating access to basic needs such as food among those who are highly marginalized. Future pandemic response efforts should also take the most marginalized populations’ needs into consideration by establishing strategies to ensure continuity of essential services providing food and other basic needs. Lastly, policies are needed establishing basic income support and improve access to food resources for marginalized women in times of crisis.



Citations (76)


... Decriminalization could be a life affirming policy if it were shaped to undo status quo approaches to drug law. Currently, an average of six people die every day directly from the poisoned drug supply in BC (Death Review Panel, 2023), and many more people endure other forms of preventable harm and violence (Care Not Cops, 2024;Kalicum et al., 2024;McDermid et al., 2024; Office of the Provincial Health Officer, 2024; Swaich et al., 2023). ...

Reference:

Criminalizing public space through a decriminalization framework: The paradox of British Columbia, Canada
Increases in housing rules and surveillance during COVID-19: impacts on overdose and overdose response in a community-based cohort of sex workers who use drugs in Vancouver, BC

Harm Reduction Journal

... Transphobia and homophobia are identified as primary barriers to health services access among people with marginalized and minoritized sexual and gender identities [30]. Research from our settings suggests that women living with HIV with marginalized and minoritized sexual and gender identities experience poor treatment by health professionals and are more likely than cisgender (cis)/heterosexual women to be unable to access health services when needed [31]. A number of other social, mental health and mental health services inequities intersect with and are embedded within systems of oppression and violence, and are overrepresented among women living with HIV, including criminalization, incarceration, criminalized injection and non-injection drug use, poverty and economic, employment and food insecurity [32,33]. ...

Access to and quality of care for sexual and gender minority women living with HIV in Metro Vancouver, Canada: Results from a longitudinal cohort study

... Research could also examine associations between EWE, poverty, and HIV-related stigma, as EWEs harm livelihoods and increase poverty [49,50], and prior studies with people with HIV found poverty stigma was associated with worse HIV outcomes [51,52], and food and housing insecurity were associated with trajectories of higher HIV stigma [53,54]. Indeed, people with HIV discussed disclosure concerns as an ART barrier during EWE-related evacua- ...

Brief Report: Social Factors Associated With Trajectories of HIV-Related Stigma and Everyday Discrimination Among Women Living With HIV in Vancouver, Canada: Longitudinal Cohort Findings
  • Citing Article
  • November 2023

JAIDS Journal of Acquired Immune Deficiency Syndromes

... Over the last 3 years, criminalized women, including sex workers and people who use drugs (PWUD), have been disproportionately impacted by the dual public health emergencies of COVID-19 and the unregulated drug toxicity crisis [1,2]. Past evidence has demonstrated that, in general, sex workers who use drugs experience heightened targeting, harassment and surveillance, due in part to their overlapping identities as sex workers and drug users, both of which are highly criminalized and stigmatized. ...

Negative changes in illicit drug supply during COVID-19: Associations with use of overdose prevention and health services among women sex workers who use drugs (2020–2021)
  • Citing Article
  • November 2023

International Journal of Drug Policy

... These details form the basis for critically appraising how gender was measured. 12 Researchers may seek to appraise data according to current guidelines alongside principles such as maintaining a balance between inclusivity and data utility, allowing for participant autonomy in describing their gender and minimising potential harms. 6 8 We can use OxWell to illustrate how researchers might critically appraise existing gender data. ...

Gender & Sex in Methods & Measurement Research Equity Toolkit Tool #6: Working With Pre-existing, Secondary and Older Data

... This end-demand approach, adopted by an increasing number of global jurisdictions (e.g., Norway, Sweden, France) (Bail et al., 2019;NSWP, 2011;Platt et al., 2018), frames sex workers as victims of violence and exploitation, rather than as workers with rights and occupational protections, and third parties as perpetrators, rather than coworkers. This framing is based on the conflation of sex work with human trafficking, restricting sex workers' freedoms under the guise of their protection and has severe consequences for sex workers' occupational conditions, particularly for Black, Indigenous and People of Colour (BIPOC), im/migrant (Machat et al., 2019;McBride et al., 2022), and queer and trans workers (Koenig et al., 2023;Scheim et al., 2023). End-demand approaches to sex work, borne from anti-trafficking discourses, serve to further entrench white supremacy while increasing the need for carceral institutions, such as police departments (Agustín, 2006;Durisin, 2022;Raguparan, 2017). ...

Intersecting structural barriers to reporting violence among men and non-binary sex workers under end-demand criminalization in Canada
  • Citing Article
  • July 2023

SSM - Qualitative Research in Health

... Due to the dynamic nature of gender, the questions and options will likely need to change over time to reflect current understandings of gender. Researchers can thus ask the original question included in the survey and explain why they included this potentially dated item (i.e., to support consistency of measurement) and then include a more responsive and inclusive measure (Lowik et al., 2022c). The challenge for researchers is using gender (and other) measures that provide some consistency across studies but that are also inclusive of affirming, reflective, and evolving processes that truly respect the dynamic complexities of our communities. ...

Gender & Sex in Methods & Measurement Research Equity Toolkit Tool #5: Methodological Responsiveness Across Time

... Accessing culturally safe HIV support services was out of reach for most participants, and rather than having their privacy protected, many participants recounted experiences of having their HIV status disclosed without consent. Many IWLWH experience disclosure of their status without their consent, through social and health services, family, and partners, which has been linked to numerous negative impacts including increased risk of prosecution and violence (Barreto et al., 2018, Krüsi et al., 2016. This resonates with existing research that has highlighted the disproportionate experiences of violence, stigma, and breach of privacy WLWH experience (Kennedy et al., 2015;Krüsi et al., 2016). ...

HIV disclosure without consent linked to increased violence against women living with HIV in a Canadian setting
  • Citing Article
  • May 2023

... The high prevalence of STBBIs among PWEC is driven by numerous barriers to care, including stigma (22)(23)(24), concerns about privacy (23,24), and di culties navigating the healthcare system (22,23,25). Research has shown that stigma is often linked to social circumstances such as unstable housing and substance use rather than the STBBI diagnosis itself (22,23). ...

"They Give you a bus Ticket and They Kick you Loose": A Qualitative Analysis of Post-Release Experiences among Recently Incarcerated Women Living with HIV in Metro Vancouver, Canada
  • Citing Article
  • May 2023

... Previous Vancouver-based research has found outdoor sex work spaces face high levels of police surveillance due to the overlapping criminalization of sex work, drug use and poverty, forcing sex workers to work in secluded areas and away from other workers and sex work-specific services [42,43,46]. In the context of Vancouver, precarious or low-income workers, unhoused communities, and people living in single-room occupancy buildings, including many sex workers, are also being severely impacted by an ongoing housing crisis and city-enforced evictions and destruction of encampments [47,48]. All of which impact sex workers' access to collaborative and/or supportive outdoor and indoor work environments. ...

Housing Instability and Evictions Linked to Elevated Intimate Partner and Workplace Violence Among Women Sex Workers in Vancouver, Canada: Findings of a Prospective, Community-Based Cohort, 2010-2019
  • Citing Article
  • April 2023

American Journal of Public Health