Objective  To examine whether there were differential rates of hepatitis C virus (HCV) incidence in injecting drug–using youths who did and did not report involvement in survival sex work.

Design  Data were derived from 2 prospective cohort studies of injecting drug users (May 1, 1996, to July 31, 2007). Analyses were restricted to HCV antibody–negative youths who completed baseline and at least 1 follow-up assessment.

Setting  Vancouver, British Columbia, Canada.

Participants  Of 3074 injecting drug users, 364 (11.8%) were youths (aged 14-24 years) with a median age of 21.3 years and a duration of injecting drug use of 3 years.

Main Exposure  Survival sex work involvement.

Main Outcome Measure  The Kaplan-Meier method and Cox proportional hazards regression were used to compare HCV incidence among youths who did and did not report survival sex work.

Results  Baseline HCV prevalence was 51%, with youths involved in survival sex work significantly more likely to be HCV antibody positive (60% vs 44%; P = .002). In baseline HCV antibody–negative youths, the cumulative HCV incidence at 36 months was significantly higher in those involved in survival sex work (68.4% vs 38.8%; P < .001). The HCV incidence density was 36.8 (95% confidence interval [CI], 24.2-53.5) per 100 person-years in youths reporting survival sex work involvement at baseline compared with 14.1 (9.4-20.3) per 100 person-years in youths not reporting survival sex work. In multivariate Cox proportional hazards analyses, survival sex work was the strongest predictor of elevated HCV incidence (adjusted relative hazard, 2.30; 95% CI, 1.27-4.15).

Conclusion  This study calls attention to the critical need for evidence-based social and structural HCV prevention efforts that target youths engaged in survival sex work.