Increasing trends and incidence of nonfatal overdose among women sex workers who use drugs in British Columbia: The role of criminalization-related barriers to harm reduction

Background: Structurally marginalized women who use drugs experience disproportionately elevated health and social inequities that require specialized responses to mitigate risk of overdose. This study aimed to longitudi-nally investigate incidence and predictors of first nonfatal overdose among women sex workers who use drugs. Methods: Data (2010-2019) were drawn from AESHA (An Evaluation of Sex Workers Health Access), a community-based, prospective, open cohort of > 900 women sex workers in Metro Vancouver, Canada. Inci-dence was examined and Cox regression modelled time-updated predictors of first nonfatal overdose. Time series analysis examined annual trends. Results: Among 273 eligible participants, 23% (n = 63) reported a first nonfatal overdose over follow-up with an incidence density of 5.87/100 person-years. In multivariable analysis, independent predictors of time to nonfatal overdose were police-related barriers to harm reduction (Adjusted Hazard Ratio [AHR]=2.62; 95% confidence interval [CI] 1.51-4.54), binge alcohol use (AHR=2.28; 95%CI 1.16-4.45), opioid use (AHR=2.23; 95%CI 1.15-4.33), and crystal methamphetamine use (AHR=2.07; 95%CI 1.27-3.39). Time series analysis demon-strated a significantly increasing trend in first nonfatal overdose, with annual proportions increasing 0.59% (95% CI 0.39-0.78%) every year, on average. Conclusions: This study provides strong longitudinal evidence from the longest-standing cohort of sex workers in North America. Nonfatal overdose in this setting is a critical public health concern. Criminalization-related barriers to harm reduction strongly predicted nonfatal overdose. Structural changes to legal and policing prac-tices alongside gender-sensitive addiction services are urgently needed.