Use of clinic- and community-based overdose prevention services by sex workers who use drugs: findings from a community-based cohort in Vancouver, Canada (2017–2024)

BACKGROUND: Sex workers who use drugs are disproportionately impacted by the current overdose crisis and face many structural barriers to health and harm reduction services. Delivered in either community (e.g., embedded in supportive housing) or clinic (e.g., hospitals) settings, overdose prevention services are crucial harm reduction interventions. Gaining insight into which services sex workers use, and whether sex worker-specific programs impact this use, is key to identifying targeted prevention strategies and enhancing the continuum of overdose care for this population. METHODS: Data were derived from An Evaluation of Sex workers' Health Access (AESHA), a prospective, community-based cohort of women (trans-inclusive) sex workers in Vancouver, Canada (March 2017-March 2024). We plotted biannual trends in use of overdose prevention services, comparing community-based and clinic-based services (Aim 1), and used generalized linear mixed models to characterize uptake of overdose prevention services, including potential differences between community and clinic-based services (Aim 2). Finally, we evaluated the association between use of sex worker-specific programs and uptake of overdose prevention services, including potential differences between community or clinic-based services over the 7-year study period (Aim 3). RESULTS: Among 503 sex workers who used drugs, 82.1% (N = 413) used any overdose prevention services over the seven-year study. Uptake of community-based versus clinic-based overdose prevention services was 70.2% (N = 353) and 60.2% (N = 303), respectively. Use of sex worker-specific programs was positively associated with use of overdose prevention services (adjusted odds ratio [AOR] 2.18, 95% confidence interval [CI] 1.82-2.62), and this association was strongest for community-based services (AOR 2.66, 95% CI 2.21-3.20) as opposed to clinic-based services (AOR 1.73, 95%CI 1.41-2.13). CONCLUSION: Uptake of overdose prevention services among sex workers is relatively high, but faced concerning declines over the study period, highlighting the need for additional interventions to scale-up access. Use of sex worker-specific programs facilitated wider access to overdose prevention services. Findings underscore the importance of expanding sex worker-specific and peer-led programs as part of scaling up overdose prevention efforts.