HIV Among Indigenous peoples: A Review of the Literature on HIV-Related Behaviour Since the Beginning of the Epidemic

Implementation Science for HIV Prevention and Treatment in Indigenous Communities: a Systematic Review and Commentary

PURPOSE OF REVIEW

We systematically reviewed implementation research conducted in Indigenous communities in the Americas and the Pacific that focused on improving delivery of HIV preventive or treatment services. We highlight strengths and opportunities in the literature and outline principles for Indigenous-led, HIV-related implementation science.

RECENT FINDINGS

We identified 31 studies, revealing a consistent emphasis on cultural tailoring of services to Indigenous communities. Common barriers to implementation included stigma, geographic limitations, confidentiality concerns, language barriers, and mistrust. Community involvement in intervention development and delivery emerged as a key facilitator, and nearly half of the studies used community-based participatory research methods. While behavioral HIV prevention, especially among Indigenous youth, was a major focus, there was limited research on biomedical HIV prevention and treatment. No randomized implementation trials were identified. The findings underscore the importance of community engagement, the need for interventions developed within Indigenous communities rather than merely adapted, and the value of addressing the social determinants of implementation success. Aligned to these principles, an indigenized implementation science could enhance the acceptability and reach of critical HIV preventive and treatment services in Indigenous communities while also honoring their knowledge, wisdom, and strength.

Land-Based Retreats as a Method for Building Enabling Environments for HIV Prevention with Northern and Indigenous Adolescents in the Northwest Territories, Canada: Mixed-Methods Findings

The Northwest Territories (NWT), Canada has high rates of sexually transmitted infections (STI) that elevate HIV acquisition risks. We conducted a mixed-methods study to explore the potential of land-based peer leader retreats (PLR) in building HIV prevention enabling environments among Northern and Indigenous youth in the NWT. PLRs are grounded in Indigenous principles and ways of knowing, acknowledging the land as a physical, spiritual, emotional, and intellectual being with the potential to facilitate (re)connection to culture, community, and self. We conducted one-week PLRs between 2016 and 2021 with adolescents aged 13-17 in the NWT. PLRs addressed HIV/STIs, safer sex, and gender equity. We conducted post-retreat focus groups (FGs) and pre/post-retreat surveys with youth participants (n = 353), and post-retreat FGs with PLR facilitators (n = 252). We applied thematic analysis to FGs and assessed pre/post-retreat changes in HIV/STI knowledge and safer sex efficacy (SSE) using paired sample t-tests. We assessed factors associated with post-test SSE and HIV/STI knowledge using multivariable linear regression. Youth participants (n = 353; mean age: 14.5, standard deviation [SD]: 1.3) were mostly Indigenous (71%) and women (66%). Participant narratives revealed PLRs enhanced technical communication (e.g., correct condom use). There were significant post-retreat HIV/STI knowledge increases; change score increases were lower for Indigenous participants. Qualitative narratives described how PLRs fostered transformative communication (e.g., sexual consent). There were significant post-retreat increases in SSE, and these were lower among men and sexually diverse (vs. heterosexual) participants. Land-based PLRs offer the potential to build technical and transformative communication to facilitate HIV prevention with youth in Canada's North.

'Sometimes white doctors are not very friendly or inclusive': a Critical Race Theory analysis of racism within and beyond sexual health settings

Many Two-Spirit, gay, bisexual, transgender, and other queer Black, Indigenous, people of colour in Canada encounter racism when testing for sexually transmitted and blood-borne infections. Our objective in this study was to understand how racism shapes testing experiences for these communities in Ontario, Canada. Four peer researchers conducted recruitment and data collection in consultation with a community advisory board. Focus groups and interviews took place with 21 participants and their narrative accounts were analysed using reflexive thematic analysis. Participants identified three interrelated issues when testing: (1) experiencing judgement and discomfort due to racism; (2) lack of community and cultural indicators in testing spaces; and (3) barriers to accessing testing centres and services. Systemic racism was linked to each of these barriers, including increased distance to testing centres due to racial segregation. Participant accounts signal the need for antiracist testing spaces and practices. Key implications include the need for antiracism training for health service providers and others working with Two-Spirit, gay, bisexual, transgender, and other queer Black, Indigenous, people of colour, and the organisations that serve them, in order to make testing spaces safer. Dismantling systemic racism is imperative to achieve health equity for members of these communities.

Perspectives on digital testing services for sexually transmitted and blood-borne infections from Two-Spirit, gay, bisexual, transgender, and other queer Black, Indigenous, people of colour living in Ontario, Canada

OBJECTIVES

Increased sexually transmitted and blood-borne infections (STBBI) testing can reduce the burden of disease among Two-Spirit, gay, bisexual, transgender, and other queer Black, Indigenous, people of colour (2SGBTQ+ BIPOC). However, this population encounters barriers, such as discrimination, when accessing in-person STBBI testing services. Digital STBBI testing, such as self-testing/collection kits ordered online and digital requisitions, may address some of these barriers. Our aim was to understand acceptability of free digital STBBI testing among 2SGBTQ+ BIPOC living in Ontario, Canada.

DESIGN

We approached this analysis using Implementation Science and Critical Race Theory. We conducted interviews and focus groups with 21 2SGBTQ + BIPOC individuals from 2020-2021. Participants were asked about their perceptions of the benefits and drawbacks of digital STBBI testing, populations that would benefit from using these services, and recommendations for how these services may be implemented in Ontario. Interviews and focus groups were transcribed verbatim and analyzed using reflexive thematic analysis.

RESULTS

Six themes emerged. Digital STBBI testing services: (1) May reduce oppression experienced by 2SGBTQ + BIPOC when testing in-person; (2) Should address the unique needs that 2SGBTQ + BIPOC experience due to other intersecting identities they possess; (3) Should adapt their services to suit the varying cultural contexts and living circumstances of 2SGBTQ + BIPOC; (4) Should be accessible to 2SGBTQ + BIPOC who hold diverse or no documentation; (5) Should be offered in multiple languages; (6) May be inaccessible to those without Internet access or devices.

CONCLUSION

Digital STBBI testing is one strategy that may reduce discrimination experienced by 2SGBTQ + BIPOC when getting tested in-person. However, digital STBBI testing services may not address all the needs of 2SGBTQ + BIPOC. Racism and other forms of oppression embedded into in-person and digital testing services will need to be addressed to meet the needs of this diverse population.

The Coloniality of drug prohibition

There have been several recent commentaries which have highlighted the relevance of the postcolonial perspective to drug prohibition and called for the decolonisation of drug policy (Daniels et al., 2021; Hillier, Winkler & Lavallée, 2020; Lasco, 2022; Mills, 2019). While these are significant interventions in the field, sparse drugs scholarship has engaged more directly with well-developed literature and concepts from Critical Indigenous Studies (Moreton-Robinson, 2016) and Indigenous Standpoint Theory (Moreton-Robinson, 2013; Nakata, 2007) and reflected on its applicability to the drug and alcohol field. In contrast to the postcolonial perspective, which understands colonisation as a historical event with contemporary impacts, Indigenous scholarship conceptualises colonisation as an active and ongoing part of how the settler-state continues to impose itself. From this vantage point I explore coloniality as a system of power and reflect on the way prohibition acts as a key arm of the settler-colonial state. The paper explores the way concepts like vulnerability, marginality, overrepresentation, disproportionality and addiction involve colonial violence, knowledge practices and narratives which are central to the way coloniality is maintained and continues to assert itself in contemporary settler societies.

It's all about connection: Determinants of social support and the influence on HIV treatment interruptions among people living with HIV in British Columbia, Canada

BACKGROUND

Social support has previously been found to be associated with improved health outcomes of individuals managing chronic illnesses, including amongst people living with HIV (PLWH). For women and people who use injection drugs who continue to experience treatment disparities in comparison to other PLWH, social support may have potential in facilitating better treatment engagement and retention. In this analysis, we examined determinants of social support as measured by the Medical Outcomes Study - Social Support Survey (MOS-SSS) scale, and quantified the relationship between MOS-SSS and HIV treatment interruptions (TIs) among PLWH in British Columbia, Canada.

METHODS

Between January 2016 and September 2018, we used purposive sampling to enroll PLWH, 19 years of age or older living in British Columbia into the STOP HIV/AIDS Program Evaluation study. Participants completed a baseline survey at enrolment which included the MOS-SSS scale, where higher MOS-SSS scores indicated greater social support. Multivariable linear regression modeled the association between key explanatory variables and MOS-SSS scores, whereas multivariable logistic regression modeled the association between MOS-SSS scores and experiencing TIs while controlling for confounders.

RESULTS

Among 644 PLWH, we found that having a history of injection drug use more than 12 months ago but not within the last 12 months, self-identifying as Indigenous, and sexual activity in the last 12 months were positively associated with MOS-SSS, while being single, divorced, or dating (vs. married), experiences of lifetime violence, and diagnosis of a mental health disorder were inversely associated. In a separate multivariable model adjusted for gender, ethnicity, recent homelessness, sexual activity in the last 12 months, and recent injection drug use, we found that higher MOS-SSS scores, indicating more social support, were associated with a lower likelihood of HIV treatment interruptions (adjusted odds ratio: 0.90 per 10-unit increase, 95% confidence interval: 0.83, 0.99).

CONCLUSIONS

Social support may be an important protective factor in ensuring HIV treatment continuity among PLWH. Future research should examine effective means to build social support among communities that have potential to promote increased treatment engagement.

All-cause hospitalisation among people living with HIV according to gender, mode of HIV acquisition, ethnicity, and geographical origin in Europe and North America: findings from the ART-CC cohort collaboration

BACKGROUND

Understanding demographic disparities in hospitalisation is crucial for the identification of vulnerable populations, interventions, and resource planning.

METHODS

Data were from the Antiretroviral Therapy Cohort Collaboration (ART-CC) on people living with HIV in Europe and North America, followed up between January, 2007 and December, 2020. We investigated differences in all-cause hospitalisation according to gender and mode of HIV acquisition, ethnicity, and combined geographical origin and ethnicity, in people living with HIV on modern combination antiretroviral therapy (cART). Analyses were performed separately for European and North American cohorts. Hospitalisation rates were assessed using negative binomial multilevel regression, adjusted for age, time since cART intitiaion, and calendar year.

FINDINGS

Among 23 594 people living with HIV in Europe and 9612 in North America, hospitalisation rates per 100 person-years were 16·2 (95% CI 16·0-16·4) and 13·1 (12·8-13·5). Compared with gay, bisexual, and other men who have sex with men, rates were higher for heterosexual men and women, and much higher for men and women who acquired HIV through injection drug use (adjusted incidence rate ratios ranged from 1·2 to 2·5 in Europe and from 1·2 to 3·3 in North America). In both regions, individuals with geographical origin other than the region of study generally had lower hospitalisation rates compared with those with geographical origin of the study country. In North America, Indigenous people and Black or African American individuals had higher rates than White individuals (adjusted incidence rate ratios 1·9 and 1·2), whereas Asian and Hispanic people living with HIV had somewhat lower rates. In Europe there was a lower rate in Asian individuals compared with White individuals.

INTERPRETATION

Substantial disparities exist in all-cause hospitalisation between demographic groups of people living with HIV in the current cART era in high-income settings, highlighting the need for targeted support.

FUNDING

Royal Free Charity and the National Institute on Alcohol Abuse and Alcoholism.

Prevalence of HIV-1 infection and associated characteristics in a Brazilian indigenous population: a cross-sectional study

BACKGROUND

Despite significant progress in the areas of prevention, diagnosis, and treatment, HIV continues to result in a substantial number of fatalities on a global scale each year. Gaining insights from epidemiological data can prove instrumental in the development of health promotion strategies, particularly within vulnerable populations, such as indigenous groups. Consequently, our study aimed to investigate the prevalence of HIV infection within the indigenous population residing in the second-largest region of Brazil. Additionally, we sought to explore the subtypes of HIV-1 and detect any drug-resistance mutations present within this population.

METHODS

In this cross-sectional study, we aimed to evaluate the prevalence of HIV-1 infection and explore its associated characteristics within the indigenous population residing in the villages of Jaguapiru and Bororó, located in the Dourados area of Mato Grosso do Sul (MS), Brazil. Blood samples were collected for rapid HIV screening, serological tests, nucleic acid amplification, and HIV subtyping. Additionally, the HIV-1 viral load and CD4+ T lymphocyte count of the people living with HIV (PLHIV) were assessed at the time of recruitment and 24 weeks later.

FINDINGS

Out of the 2190 invited individuals, 1927 (88%) were included in this study. The average age of the participants was 34.2 (±13.8) years, with a majority of 74% being female. Moreover, 68.44% of the participants identified themselves as belonging to the Guarani-Kaiowa ethnic group. HIV seroprevalence was 0.93% (18/1927), and 73.22% (1411/1927) were unaware of their serological status. The prevalence of HIV-1 was higher in single indigenous people [10/617 (1.62%)], who received government benefits [14/1021 (1.37%)], had less than five years of formal education [11/685 (1.61%)], had sexual intercourse with users of injectable drugs [2/21 (9.52%)], with history of sexually transmitted infections (STIs) [10/62 (16.2%)] and incarceration [3/62 (4.84%)]. Of 18 positive samples, 44.4% (8/18) were successfully amplified, and HIV-1 subtype C was prevalent. Furthermore, we identified HIV-1 drug resistance mutations in four patients, specifically from the classes of Protease Inhibitor, Nucleoside Reverse Transcriptase Inhibitor, and Non-Nucleoside Reverse Transcriptase Inhibitor. Notably, three of these patients exhibited a high viral load even after 24 weeks of undergoing antiretroviral therapy. Out of the 18 PLHIV, 66.66% (12/18) had a viral load below 1000 copies/mL, while 50% (9/18) had a CD4+ T lymphocytes count greater than 350 cells/mL after 24 weeks of treatment.

INTERPRETATION

Despite the concerted efforts to control HIV infection, the prevalence observed in the indigenous population under study surpassed that reported in other Brazilian indigenous groups. This disparity highlights the disproportionate impact of the disease on this particular group. The detection of drug-resistance mutations further emphasizes the critical need to expand diagnostic coverage, closely monitor treatment strategies, and maintain ongoing molecular surveillance. These measures are imperative for enhancing HIV management within this vulnerable population.

FUNDING

This study was partially funded by Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Fundação de Apoio ao Desenvolvimento do Ensino, Ciência e Tecnologia do Estado de Mato Grosso do Sul (FUNDECT), Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Secretaria do Estado de Saúde (SES) of Governo do Estado de Mato Grosso do Sul, and Universidade Federal da Grande Dourados (UFGD).

Experiences of HIV among global Indigenous populations through the lens of the UN Declaration on the Rights of Indigenous Peoples

Since its introduction in 2007, the UN Declaration on the Rights of Indigenous Peoples (UNDRIP) has been adopted by 144 countries worldwide. In a ten-point statement released in 2017, Indigenous leaders in the HIV and AIDS community established a list of truths and actions to be used for advocacy to end AIDS among Indigenous Peoples through self-determination, justice, and human rights. 15 years after the UNDRIP and 5 years after the 10-point statement, this Review asks where we are in terms of upholding the UNDRIP and the International Indigenous HIV and AIDS Community statement in relation to HIV and AIDS, and what is needed to better uphold and respond to these directives. HIV in Indigenous populations continues to intersect with multiple forms of oppression, racism, and discrimination, which are yet to be eliminated from laws, policies, and practices. Eradicating white supremacy and Indigenous-specific racism across all health systems is a bare minimum requirement to uphold Indigenous rights within health care, and must be accompanied by support for Indigenous, self-determined, culturally tailored, and community-specific health and wellness services.

Precarious Housing Associated with Unsuppressed Viral load, sub-optimal Access to HIV Treatment and Unmet Health care Needs, Among Women Living with HIV in Metro Vancouver, Canada

We investigated associations between (1) housing status (four categories measuring housing stability) and outcomes along the HIV care continuum (not currently on antiretroviral therapy [ART]; sub-optimal ART adherence [< 95% in the last 3-4 weeks]; unsuppressed viral load [> 200 copies/ml], median CD4 < 200 in the last six months), and (2) housing status and unmet primary, dental and mental health care needs in the last six months among WLWH. Housing status was defined according to the Canadian Definition of Homelessness and had four categories: unsheltered (i.e., living in ≥ 1 unsheltered location [e.g., street, abandoned buildings]), unstable (i.e., living in ≥ 1 unstable location [e.g., shelter, couch surfing]), supportive housing (i.e., only living in supportive housing), and stable housing (i.e., only living in one's own housing; reference). At baseline, in the last six months, 47.3% of participants reported unstable housing, followed by 24.4% unsheltered housing, 16.4% stable housing, and 11.9% supportive housing. Overall, 19.1% of the full sample (N = 336, 2010-2019) reported not currently on ART; among participants on ART, 28.0% reported sub-optimal ART adherence. Overall, 32.1% had recent unsuppressed viral load. Among a subsample (n = 318, 2014-2019), 15.7% reported unmet primary care needs, 26.1% unmet dental care needs, and 16.4% unmet mental health care needs. In adjusted models, being unsheltered (vs. stable housing) was associated with not currently on ART, unsuppressed viral load, and unmet primary and dental care needs. Housing and health services need to be developed with and for WLWH to address structural inequities and fulfill basic rights to housing and health.

Factors influencing adherence to anti-retroviral therapy in amazonian indigenous people living with HIV/AIDS

BACKGROUND

Indigenous communities in Peru has been historically affected by high mortality rates attributable to HIV-AIDS infection, associated with a low access to health services, and socio-cultural barriers. In this context, the study aimed to describe factors associated with antiretroviral treatment adherence in people from Awajun and Wampis indigenous communities, living with HIV-AIDS in a Peruvian Amazonian region.

METHODS

A cross-sectional study was completed with a consecutive sample of people from indigenous communities (Awajun or Wampis) living with HIV, who were receiving antiretroviral treatment for at least the last three months. Participants were recruited between October 1 and December 30, 2021, from four districts of Bagua and Condorcanqui provinces in the Amazonian region. An ad-hoc questionnaire was used to collect information about demographic, economic, and socio-cultural factors and access to health services. The Simplified Medication Adherence Questionnaire (SMAQ) was used to evaluate adherence to antiretroviral therapy. Multivariate logistic regression analysis with backward stepwise was performed to explore factors that might influence adherence.

RESULTS

Of the 208 participants, 28.8% reported complete adherence to antiretroviral treatment. The multivariate logistic regression showed that occupation (aPR: 1.86; 95%CI 1.15-3.02), economic income (aPR: 0.64; 95%CI 0.41-0.99), and adverse reactions to antiretroviral therapy (aPR: 0.36; 95%CI 0.18-0.70) were related to complete adherence to medication.

CONCLUSION

Only a third of participants reported complete adherence to antiretroviral therapy. Factors associated with adherence to antiretroviral medication were related to socioeconomic conditions and adverse reactions to the therapeutic scheme. Interventions to improve adherence in indigenous people living with HIV should consider these factors in order to develop effective implementation strategies.

A HIV diagnosis and treatment cascade for Aboriginal and Torres Strait Islander peoples of Australia

Aboriginal and Torres Strait Islander (hereafter Aboriginal) people are a priority population for HIV care in Australia; however, no HIV cascade exists for this population. We developed annual HIV cascades for 2010-2017 specific to Aboriginal peoples. By 2017, an estimated 595 Aboriginal people were living with HIV (PLWH); however, 14% remained undiagnosed. Cascade steps below global targets were: PLWH aware of their diagnosis (86%), and retention in care (81% of those who had received any care in previous two years in a sentinel network of clinics). For people retained in care, treatment outcomes surpassed global targets (92% receiving treatment, 93% viral suppression). Increases occurred across all HIV cascade steps over time; however, the least improvement was for retention in care, while the greatest improvement was achieving viral suppression. The HIV cascade for Aboriginal peoples highlights both gaps and strengths in the Australian HIV care system, and importantly highlights where potential interventions may be required to achieve the global UNAIDS targets.

The Prevalence of HIV Infection in Minority Indigenous Populations of the South-East Asia and Western Pacific Regions: A Systematic Review and Meta-analysis

A random effects meta-analysis was used to estimate the pooled prevalence of HIV infection within minority indigenous populations of the South-East Asia (SEAR) and Western Pacific Regions (WPR). Sub-group analyses were conducted, and the sources of heterogeneity explored through meta-regression. The majority of studies were undertaken in high HIV risk subpopulations. There was a paucity of data for many countries with data from China representing 70% of the comparative studies. Within minority indigenous populations the pooled prevalence of HIV infection was 13.7% (95% CI 8.9, 19) and 8.4% (95% CI 6.3, 10.7) among other populations. The prevalence differential between populations was significant in the WPR (adjusted odds ratio 1.1, 95% CI 1.0, 1.2). Across both regions, in contrast to other populations, minority indigenous did not experience any significant reduction in HIV prevalence over the years of data collection. There was large heterogeneity in the prevalence of HIV across studies.

Understanding reasons for lack of acceptance of HIV programs among indigenous Papuans: a qualitative study in Indonesia

BACKGROUND

Melanesians are indigenous Papuans racially and culturally different from most Indonesians. The Melanesia region is characterised by high poverty and inequalities, even though it has the highest revenue. Furthermore, Papua has the highest HIV prevalence rate, 24-fold higher than that of other regions. Therefore, this study aimed to examine the resistance of indigenous people residing in eastern Indonesia towards HIV programs.

METHODS

This is a qualitative study analysed using grounded theory. Data were collected from July to September 2018 through semi-structured face-to-face interviews involving 23 Papuans. The interviews were conducted in Bahasa Indonesia, audio-recorded, summarised and transcribed for analysis.

RESULTS

The results showed that being a good Papuan emerges from four interconnected categories, including culture and religion, dealing with modernisation, integrated HIV program and stigma reduction. As a substantive theory underpinning the indigenous people's experiences with HIV programs, 'Keep being a good Papuan' was a way of overcoming problems and dealing with modernism to eliminate HIV. This largely focuses on the local culture, implying any adjustment should keep their tradition and welcome modernism.

CONCLUSIONS

The future of the HIV programs should be agreed upon, funded, implemented, measured and achieved by stakeholders. This could be achieved by elaborating a supportive culture and community-based interventions. Furthermore, the implementation should be prioritised to integrate and improve the programs' quality to take into account community needs and the available resources.

Racism and antiracism in nursing education: confronting the problem of whiteness

Background

Systemic racism in Canadian healthcare may be observed through racially inequitable outcomes, particularly for Indigenous people. Nursing approaches intending to respond to racism often focus on culture without critically addressing the roots of racist inequity directly. In contrast, the critical race theory approach used in this study identifies whiteness as the underlying problem; a system of racial hierarchy that accords value to white people while it devalues everyone else.

Methods

This qualitative study seeks to add depth to the understanding of how whiteness gets performed by nursing faculty and poses antiracism education as a necessary tool in addressing the systemic racism within Canadian healthcare. The methodology of poststructural discourse analysis is used to explore the research question: how do white nursing faculty draw on common discourses to produce themselves following introductory antiracism education?

Results

Analysis of data reveals common patterns of innocent and superior white identity constructions including benevolence, neutrality, Knowing, and exceptionalism. While these patterns are established in other academic fields, the approaches and results of this study are not yet common in nursing literature.

Conclusions

The findings highlight the need for antiracism education at personal and policy levels beginning in nursing programs.

Indigenous men’s pathways to ‘living the right kind of life and walking the right path’ post incarceration in Canada: understanding the impacts of systemic oppression, and guidance for healing and (w)holistic sexual health

Indigenous men around the world hold expertise over their own lives. Informed by this perspective, this study centres this experience to better understand what is needed to improve sexual health outcomes among a group of men with a history of incarceration. Semi-structured interviews were conducted with 10 Indigenous men with such a history. Through thematic analysis the study identified two major themes: 1) the impacts of systemic oppression; 2) the value of guidance in walking the right path. Men identified colonial trauma and the associated mental, physical, emotional and spiritual wounds stemming from systemic oppression as continuing to impact their wellbeing. Men also described the systems of support necessary to help guide them on their journeys through incarceration, rehabilitation and building strong and nurturing relationships. Findings from the study provide important guidance from Indigenous men for future more holistic sexual health intervention programming.

"Every One of Us Is a Strand in That Basket": Weaving Together Stories of Indigenous Wellness and Resilience From the Perspective of Those With Lived and Living Experience With HIV/Hepatitis C Virus

ABSTRACT

This article primarily focuses on the stories shared by Indigenous women with living and/or lived experiences of HIV/hepatitis C virus from the Vancouver Downtown East Side who attended the "Awakening our Wisdom" retreat. Weaving together the story of an Indigenous approach to research that informed the design of the retreat and the findings that emerged, a basket is formed that highlights the ways settler-colonialism within Canada has produced a system of health care that has neglected the Indigenous experience. The emerging themes of Connection, Disconnection, and Reconnection offers teachings for Indigenous journeys of resilience and wellness for those living with HIV/hepatitis C virus. These findings may help health care practitioners identify health care places and spaces that are in need of decolonization and offer, from an Indigenous perspective, the next steps forward for a health care system that promotes Indigenous engagement and retention in care.

Social Determinants of Disease: HIV and COVID-19 Experiences

PURPOSE OF REVIEW

The differential impact of the COVID-19 and HIV pandemics on marginalized communities has renewed calls for more robust and deeper investigation into structural and social causes of health inequities contributing to these infections, including underlying factors related to systematic racism. Using the Social Determinants of Health (SDOH) framework, we analyzed parallel and divergent factors associated with COVID-19 and HIV/AIDS and the prevalence of disparate disease in diverse communities. We utilized PRISMA guidelines to identify relevant literature (N = 210 articles) that resulted in a review of 125 articles included in our synthesis.

RECENT FINDINGS

With racial health inequities as a core contributor to disease vulnerability, we also identified other factors such as economic stability, social and community support, the neighborhood and built environment, healthcare access and quality, and education access and quality as important socioecological considerations toward achieving health equity. Our review identifies structural and systematic factors that drive HIV and COVID-19 transmission. Our review highlights the importance of not solely focusing on biomedical interventions as solutions to ending HIV and COVID-19, but rather call for building a more just public health and social service safety net that meets the needs of people at the intersection of multiple vulnerabilities.

“Wherever I Go, I Have It Inside of Me”: Indigenous Cultural Dance Narratives as Substance Abuse and HIV Prevention in an Urban Danza Mexica Community

Introduction

“Mexican American Indian” (MAI) is a large and diverse population for which little empirical research on alcohol and other drug (AOD) use and HIV is available, yet for which there is a disproportionate risk. Indigenous health narratives and participation in place- and settings-based cultural practices can be protective in chronic and co-occurring disease prevention and health promotion for Indigenous people. This study explores the role of participation in cultural dance in generating narratives of prevention and health promotion among a sample of MAIs from an Urban Danza Mexica Community (UDMC), framed within a decolonizing narratives of health (DNOH) model.

Methods

This secondary data analysis (n = 9) is drawn from a qualitative AOD and HIV health needs assessment of UDMC living in the Pacific Northwest and the Rocky Mountain West (n = 21). This study uses a community-based participatory research approach and employs narrative, Indigenized methods to analyze in-depth interviews from adult cisgender females (n = 5) and males (n = 4). The DNOH model is developed as a relational, analytic framework that contextualizes Indigenous stories in relationship to three distinct yet interconnected levels—the personal, the communal, and Indigeneity in the larger world. These levels of narrative analysis function as culturally grounded, relational pathways through which to articulate health education and promotion approaches.

Results

Narratives delve into the complex and nuanced relationships within participants' internal worlds (personal), between themselves and their Danza community (communal), and between themselves and their complex, intersectional Indigenous identities within society (Indigeneity). Stories of ancestral teachings about health and prevention shared within the Danza circle create spaces wherein participants navigate complex conversations that resist oppressive colonial narratives, reconnect with and strengthen their Indigenous identities, and strive toward ancestral visions of health and well-being.

Discussion

This study contributes to Indigenized theoretical and methodological expansion and the development of place/settings-based, narrative, cultural health interventions aimed at preventing chronic and co-occurring disease and promoting wellness among populations similar to the UDMC. Identifying cultural practices as Native Hubs (relational, socially constructed places) that foster decolonizing narratives helps increase understanding of their role in public health education and promotion through recognition of Indigenous knowledge systems and frameworks.

[Evolution of HIV infection in indigenous peoples in Central Brazil]

Distribution of the AIDS epidemic in Brazil is associated with a wide range of factors that determine different population groups' greater or lesser vulnerability. The study's objective was to analyze clinical and laboratory characteristics of HIV/AIDS in individuals 13 years or older and the evolution to death in the indigenous population assisted by the Special Indigenous Health District of the State of Mato Grosso do Sul, Brazil. A descriptive and retrospective study was performed on the clinical conditions and evolution of the disease from 2001 to 2014, based on three secondary databases. The study assessed time in progression to AIDS, time in progression to death, viral load, CD4+ T-lymphocyte count, and survival time. A total of 103 cases of HIV infection were identified, of which 48.5% progressed to AIDS, 60% in less than a year since diagnosis. Forty deaths were recorded, 77.5% of which due to HIV infection. Of those who died, only 30% had survived for more than a year. The study suggests that diagnosis of HIV infection occurred in advanced stages of the disease (i.e., late), and points to deficient diagnostic coverage. Rapid progression to death and short survival time are indicative of insufficient access to specialized health services, as well as disconnection and deficient collaboration between the Indigenous Health District, municipalities, and the state.

Incidence of socially significant infectious diseases (HIV, TB and HIV/TB coinfection) in the Arctic regions of Russia)

The study is aimed to evaluate the HIV, TB, and HIV/TB coinfection incidence per 100,000 population/year in Russian Arctic, based on official statistical data. The epidemics' incidence in Russian Arctic is uneven. The highest HIV incidence in 2019 was registered in Krasnoyarsk region (94,6), and the highest TB incidence in ChAD (136,1). ChAD was also identified as the region with the worst indicators, where the HIV incidence in 2007-2019 was evaluated at (315,8%), TB (136,1%), HIV/TB coinfection (150,0%). Despite the significant reduction in TB incidence in Arkhangelsk oblast (-63,9%), Karelia (-57,3%) and Komi (-56,2%) republics, it is alarming to observe dramatic increases in HIV incidence in the aforementioned regions (592,3%, 331,8%, 156,5% respectively). External factors influence HIV and TB incidence in most regions. Prevailing in men, HIV and TB incidence disparities between the general population and permanent residents occurred in all regions, except in ChAD and NAD, where the infections were diagnosed only among permanent residents. It is necessary to provide more detailed studies focusing on HIV, TB, and HIV/TB coinfection features in each circumpolar district in order to determine the main risk factors, especially among indigenous peoples as a vulnerable group, and to evaluate the HIV/TB collaborative services' capacity.

Trends in HIV Care Outcomes Among Adults and Adolescents-33 Jurisdictions, United States, 2014-2018

BACKGROUND

With significant improvements in the diagnosis and treatment of HIV, the number of people with HIV in the United States steadily increases. Monitoring trends in HIV-related care outcomes is needed to inform programs aimed at reducing new HIV infections in the United States.

SETTING

The setting is 33 United States jurisdictions that had mandatory and complete reporting of all levels of CD4 and viral load test results for each year during 2014-2018.

METHODS

Estimated annual percentage change and 95% confidence intervals were calculated to assess trends in stage of disease at time of diagnosis, linkage to HIV medical care within 1 month of HIV diagnosis, and viral suppression within 6 months after HIV diagnosis. Differences in percentages were analyzed by sex, age, race/ethnicity, and transmission category for persons with HIV diagnosed from 2014 to 2018.

RESULTS

Among 133,477 persons with HIV diagnosed during 2014-2018, the percentage of persons who received a diagnosis classified as stage 0 increased 13.7%, stages 1-2 (early infections) increased 2.9%, stage 3 (AIDS) declined 1.5%, linkage to HIV medical care within 1 month of HIV diagnosis increased 2.3%, and viral suppression within 6 months after HIV diagnosis increased 6.5% per year, on average. Subpopulations and areas that showed the least progress were persons aged 45-54 years, American Indian/Alaska Native persons, Asian persons, Native Hawaiian/other Pacific Islander persons, and rural areas with substantial HIV prevalence, respectively.

CONCLUSIONS

New infections will continue to occur unless improvements are made in implementing the Ending the HIV Epidemic: A Plan for America strategies of diagnosing, treating, and preventing HIV infection.

Narrative frames as choice over structure of American Indian sexual and reproductive health consequences of historical trauma

Emerging evidence suggests that the historical trauma associated with settler colonialism affects the sexual and reproductive health (SRH) of American Indian (AI) communities today. This article examines how one AI community narratively frames the influence of historical trauma within the context of community-based participatory research (CBPR) and the implications of this framing for health behaviours, internalized oppression, SRH outcomes, and future CBPR interventions. We found that AIs framed the SRH consequences of historical trauma with renderings that favoured personal choice over structural explanations. Our findings suggest future interventions could: (1) include educational components on historical trauma and the continued role settler colonialism plays in structural violence against AI bodies and communities; and (2) recognize the role that the individualized logic of westernized/white culture may play in the erasure of traditional collectivist AI culture, internalized oppression, and SRH.

Rates of new HIV diagnoses among Indigenous peoples in Canada, Australia, New Zealand, and the United States: 2009-2017

OBJECTIVE

To compare rates and trends of HIV diagnoses among Indigenous peoples in Canada (First Nations, Métis, Inuit, and other non-specified), Australia (Aboriginal and Torres Strait Islanders), the USA (American Indian, Alaska Native, Native Hawaiian, and Other Pacific Islanders), and New Zealand (Māori).

DESIGN

We employed publicly available surveillance data from 2009 to 2017 to estimate the rate per 100 000 of HIV diagnoses. Estimated annual percentage change (EAPC) in diagnosis rates was calculated using Poisson regression.

SETTING

The four countries have passive population-based HIV surveillance programs.

PARTICIPANTS

Population estimates from respective census programs were used as rate denominators.

MAIN OUTCOME MEASURES

Estimated annual HIV diagnosis rate per 100 000 and EAPC were calculated for total Indigenous peoples, women, and men.

RESULTS

As of 2017, rates of HIV were highest in Canada (16.22, 95% confidence interval (CI): 14.30--18.33) and lowest in New Zealand (1.36, 95% CI: 0.65--2.50). Australia had a rate of 3.81 (95% CI: 2.59--5.40) and the USA 3.22 (95% CI: 2.85--3.63). HIV diagnosis rates among the total Indigenous population decreased in Canada (-7.92 EAPC, 95% CI: -9.34 to -6.49) and in the USA (-4.25 EAPC, 95% CI: -5.75 to -2.73) but increased in Australia (5.10 EAPC, 95% CI: 0.39--10.08). No significant trends over time were observed in New Zealand (2.23 EAPC, 95% CI: -4.48 to 9.47).

CONCLUSION

Despite limitations to conducting cross-national comparisons, there are substantial differences in HIV diagnosis rates in these four countries that may be reflective of divergent national policies and systems that affect the health status of Indigenous peoples.

A rapid review of Indigenous boys' and men's sexual health in Canada

Indigenous boys and men in Canada face adverse social and structural circumstances that affect their ability to achieve and maintain sexual health. Research about Indigenous sexual health, however, is largely limited to matters relating to women and statistics on sexually transmitted infections. A rapid review of research was conducted to determine what is currently known about Indigenous boys' and men's sexual health in Canada. Given the prevalence of research documenting quantitative disparities, the current review included qualitative research only. Thirteen included studies explored a wide range of topics relating to sexual health and an overarching intersection between social conditions and individual health outcomes was observed. The results of this review reveal significant gaps in the literature relating to the holistic sexual health of Indigenous boys and men and highlight important domains of sexual health to consider in future research. Findings suggest that sexual health programmes that promote traditional Indigenous knowledge and intergenerational relationships may be effective for promoting sexual health among Indigenous boys and men.

Sociocultural, behavioural and political factors shaping the COVID-19 pandemic: the need for a biocultural approach to understanding pandemics and (re)emerging pathogens

Although there has been increasing focus in recent years on interdisciplinary approaches to health and disease, and in particular the dimension of social inequalities in epidemics, infectious diseases have been much less focused on. This is especially true in the area of cultural dynamics and their effects on pathogen behaviours, although there is evidence to suggest that this relationship is central to shaping our interactions with infectious disease agents on a variety of levels. This paper makes a case for a biocultural approach to pandemics such as COVID-19. It then uses this biocultural framework to examine the anthropogenic dynamics that influenced and continue to shape the COVID-19 pandemic, both during its initial phase and during critical intersections of the pandemic. Through this understanding of biocultural interactions between people, animals and pathogens, a broader societal and political dimension is drawn as a function of population level and international cultures, to reflect on the culturally mediated differential burden of the pandemic. Ultimately, it is argued that a biocultural perspective on infectious disease pandemics will allow for critical reflection on how culture shapes our behaviours at all levels, and how the effects of these behaviours are ultimately foundational to pathogen ecology and evolution.

Vital Signs: Status of Human Immunodeficiency Virus Testing, Viral Suppression, and HIV Preexposure Prophylaxis - United States, 2013-2018

Background

Approximately 38,000 new human immunodeficiency virus (HIV) infections occur in the United States each year; these infections can be prevented. A proposed national initiative, Ending the HIV Epidemic: A Plan for America, incorporates three strategies (diagnose, treat, and prevent HIV infection) and seeks to leverage testing, treatment, and preexposure prophylaxis (PrEP) to reduce new HIV infections in the United States by at least 90% by 2030. Targets to reach this goal include that at least 95% of persons with HIV receive a diagnosis, 95% of persons with diagnosed HIV infection have a suppressed viral load, and 50% of those at increased risk for acquiring HIV are prescribed PrEP. Using surveillance, pharmacy, and other data, CDC determined the current status of these three initiative strategies.

Methods

CDC analyzed HIV surveillance data to estimate annual number of new HIV infections (2013–2017); estimate the percentage of infections that were diagnosed (2017); and determine the percentage of persons with diagnosed HIV infection with viral load suppression (2017). CDC analyzed surveillance, pharmacy, and other data to estimate PrEP coverage, reported as a percentage and calculated as the number of persons who were prescribed PrEP divided by the estimated number of persons with indications for PrEP.

Results

The number of new HIV infections remained stable from 2013 (38,500) to 2017 (37,500) (p = 0.448). In 2017, an estimated 85.8% of infections were diagnosed. Among 854,206 persons with diagnosed HIV infection in 42 jurisdictions with complete reporting of laboratory data, 62.7% had a suppressed viral load. Among an estimated 1.2 million persons with indications for use of PrEP, 18.1% had been prescribed PrEP in 2018.

Conclusion

Accelerated efforts to diagnose, treat, and prevent HIV infection are needed to achieve the U.S. goal of at least 90% reduction in the number of new HIV infections by 2030.

Epidemiological aspects of HIV infection and AIDS among indigenous populations

OBJECTIVE

To describe the epidemiological aspects of HIV infection and AIDS among indigenous peoples of the state of Mato Grosso do Sul, Brazil.

METHODS

This is a descriptive epidemiological study on the occurrence and distribution of HIV infection and AIDS in the indigenous population assisted by the Distrito Sanitário Especial Indígena (Indigenous Special Health District) Mato Grosso do Sul between 2001 and 2014, based on three secondary databases. Annual rates of HIV and AIDS detection and prevalence were calculated, considering case distribution according to village, Health Base Pole and sociodemographic variables. Accumulated rates of detection, mortality and case fatality were calculated by ethnic group and for the Health Base Pole with the highest number of cases.

RESULTS

The HIV detection rate fluctuated between 0.0 and 18.0/100 thousand people in the study period. For AIDS, there was no notification before 2007, but in 2012 its rate reached 16.6/100 thousand. HIV prevalence grew between 2001 and 2011, and it continuously grew for AIDS starting from 2007. The highest HIV detection rates occurred among Guarani peoples (167.1/100 thousand) and for AIDS, among the Kaiowá peoples (79.3/100 thousand); mortality and fatality rates were higher among the Kaiowá. Regarding the Dourados Health Base Pole, the AIDS detection rate increased, and the mortality and fatality rates decreased.

CONCLUSIONS

HIV infection and AIDS have been increasing among indigenous peoples, with distribution of the disease mainly in the Health Base Poles of the southern region of the state, where greater economic and social vulnerability are also observed. The endemic character of HIV and AIDS can become epidemic in some years given the existence of cases in other villages in the state. Its occurrence among the Guarani and Kaiowá populations indicates the need for expanded diagnosis, access to treatment and prevention measures.

Perspectives on restoring health shared by Cree women, Alberta, Canada

The purpose of this study was to explore nehiyaw iskwêwak (Cree women's) perceptions and beliefs about how to restore balance to health. Fifteen indigenous women from Northern Alberta, Canada, participated in a 3-day cultural retreat on beauty and art in British Columbia, Canada, in May 2015. At the end of the retreat, these women were invited to participate in a talking circle and asked, 'What does restoring balance look like?' A constructivist grounded theory approach was used to explore individual and collective perspectives on restoring health. Nehiyaw iskwêwak provided a vision of health using metaphors from the natural environment. Starting points and core characteristics of health were grounded in relationship with self, others, place and the land, suggesting interventions grounded in land-based pedagogy and focused on restoring relationship and secure attachment might be effective for this population. Nehiyaw iskwêwak also said interventions should start at the individual level; as the individual restores balance mentally, emotionally, physically and spiritually, a long-term ripple effect can be initiated through the generations and community when these women in turn support the strengthening and nurturing of relations (e.g. parents, siblings, friends, children, grandchildren) for the next seven generations.

Experiences of the HIV Cascade of Care Among Indigenous Peoples: A Systematic Review

Indigenous leaders remain concerned that systemic oppression and culturally unsafe care impede Indigenous peoples living with HIV from accessing health services that make up the HIV cascade of care. We conducted a systematic review to assess the evidence related to experiences of the HIV care cascade among Indigenous peoples in Australia, Canada, New Zealand, and United States. We identified 93 qualitative and quantitative articles published between 1996 and 2017 reporting primary data on cascade outcomes disaggregated by Indigenous identity. Twelve involved data from Australia, 52 from Canada, 3 from New Zealand and 26 from United States. The majority dealt with HIV testing/diagnosis (50). Relatively few addressed post-diagnosis experiences: linkage (14); retention (20); treatment initiation (21); adherence (23); and viral suppression (24). With the HIV cascade of care increasingly the focus of global, national, and local HIV agendas, it is critical that culturally-safe care for Indigenous peoples is available at all stages.

Exploring the Role of Sex and Sexual Experience in Predicting American Indian Adolescent Condom Use Intention Using Protection Motivation Theory

Introduction: American Indian (AI) youth experience poor sexual health outcomes. Research indicates the Protection Motivation Theory (PMT) is a robust model for understanding how sexual risk and protective behaviors are associated with condom use intention (CUI). Studies indicate the constructs of the PMT which influence CUI vary by sex and sexual experience. This analysis explores associations between PMT constructs and CUI by sex and sexual experience among AI youth who participated in the Respecting the Circle of Life (RCL) trial, a sexual and reproductive health intervention. Methods: We analyzed baseline data from the sample of 267 AIs, ages 13-19, who participated in the evaluation. We examined CUI and PMT construct scores by sex and sexual experience utilizing generalized estimated equations and multiple regression models to test which PMT constructs were associated with CUI across sex and sexual experience. Results: Twenty-two percentage of participants were sexually experienced; 56.8% reported CUI at baseline. We found several differences in scores in PMT constructs by sex and sexual experience including self-efficacy, response efficacy, vulnerability, severity, and extrinsic rewards. We also found constructs varied that were associated with CUI varied across sex and sexual experience. No PMT constructs were associated with CUI among sexually experienced youth. Conclusion: Results provide support for developing, selecting and delivering sexual health programs by sex and sexual experience in American Indian communities. Girls programs should focus on internal satisfaction and self-worth while boys should focus on negative impacts of not using condoms. Programs for youth who are not sexually active should focus on negative impacts of not using condoms. Programs for sexually inactive youth should work to change peer norms around condom use and improve knowledge about the efficacy of condom use.

Characteristics of Invasive Fungal Infections among HIV Individuals from an Indigenous Origin in Mexico

In individuals with HIV/AIDS, 47% of the deaths are attributed to invasive fungal infections (IFIs), despite antiretroviral (ARV) therapy. This is a retrospective study carried out in the Hospital Regional de Alta Especialidad Oaxaca (HRAEO), southwest Mexico, where IFIs that occurred during 2016⁻2017 are described. A total of 55 individuals were included. Histoplasmosis (36%) and possible-IFIs in neutropenic fever (20%) were the most frequent cases, followed by cryptococcosis (14%). The HIV/AIDS subpopulation corresponded with 26 cases (47%), all from an indigenous origin. The incidence of IFIs among them was 24% (95% CI = 15⁻33%). The CD4+ T cells median was 35 cells/mL (IQR 12⁻58). Four cases (15%) of unmasking IRIS were identified, three of histoplasmosis and one coccidioidomycosis. Co-infections were found in 52% (12/23), and tuberculosis in 50% (6/12) was the most frequent. The mortality rate was 48%. The general characteristics of the HIV individuals who died were atypical pneumonia (70% vs. 9%, p = 0.01), acute kidney injury, (70% vs. 9%, p = 0.008) and ICU stay (80% vs. 9%, p = 0.002). In conclusion, IFIs are diagnosed in one out of four individuals with HIV/AIDS along with other complicated infectious conditions, leading to major complications and a high mortality rate.

Being and Becoming a Helper: Illness Disclosure and Identity Transformations among Indigenous People Living With HIV or AIDS in Saskatoon, Saskatchewan

Saskatoon has nearly half of the diagnoses of HIV in Saskatchewan, Canada, with an incidence rate among Indigenous populations within inner-city contexts that is 3 times higher than national rates. Previous research does not adequately explore the relations between HIV vulnerabilities within these contexts and the experiences of illness disclosure that are informed by identity transformations, experiences of stigma, and social support. From an intersectionality framework and a constructivist grounded theory approach, this research involved in-depth, semistructured interviews with 21 Indigenous people living with HIV and/or AIDS in Saskatoon, both male and female. In this article, we present the key themes that emerged from the interviews relating to experiences of HIV disclosure, including experiences of and barriers to the disclosure process. In the end, we highlight the important identity transformation and role of being and becoming a "helper" in the community and how it can be seen as a potential support for effective community health interventions.

Pilot testing Fostering Open eXpression among Youth (FOXY), an arts-based HIV/STI prevention approach for adolescent women in the Northwest Territories, Canada

Fostering Open eXpression among Youth (FOXY) is an arts-based HIV prevention program developed by Northern Canadians to address sexual health, HIV, sexually transmitted infections (STIs), sexuality, and healthy relationships among Northern and Indigenous youth in Canada. We conducted a pilot study with Indigenous and Northern young women aged 13-17 years from 17 communities in the Northwest Territories to evaluate whether, in comparison to pre-intervention, FOXY participants demonstrated increased knowledge of STIs, increased safer sex self-efficacy, and increased resilience. Wilcoxon test results indicated significant increases in STI knowledge scores and safer sex self-efficacy scores. Findings suggest that FOXY holds promise as an effective method of delivering sexual health information through peer education, and increasing STI knowledge, safe sex self-efficacy, and resilience.

Acceptability of an Adapted HIV Prevention Intervention for Native American Adolescents

Relatively few HIV evidence-based interventions (EBIs) among Native Americans have been developed, adapted, evaluated, and/or published in the scientific literature. An adolescent HIV EBI was adapted in three phases: (1) securing input from a Native American Advisory Board; (2) modifying the EBI to be more consistent with Native American culture; and (3) conducing a pilot with 14 Native American adolescents to examine acceptability and cultural congruence between the adapted intervention and the youth's culture based on Likert-scale ratings and a focus group. The adaptations included diverse Native American social and cultural stories that assisted with responsible decision-making skills. The adolescents consistently rated each intervention session as highly acceptable. A difference in knowledge from pre-survey (M = 13.93, SD = 3.08) to post-survey (M = 17.14, SD = 2.25) was statistically significant; t(13) = 4.166, p < .0005. The adapted curriculum did appear culturally responsive based on the pilot test results.

Survival After HIV Infection Stage 3 (AIDS) Diagnosis, by Population Density Areas, United States, 2005-2010

OBJECTIVES

We examined the survival rates after diagnosis of HIV infection stage 3 (AIDS) in the United States by population density area of residence at diagnosis.

METHODS

We used data from the National HIV Surveillance System to calculate survival rates among people aged ≥13 with HIV infection stage 3 (AIDS) diagnosed from 2005 through 2010. We determined survival rates for more than 12, 24, and 36 months after diagnosis; overall and by demographic characteristics; and across 3 population density area categories (large metropolitan statistical areas [MSAs, ≥500 000 people], small-to-medium MSAs [50 000 to 499 999 people], and nonmetropolitan areas [<50 000 people]).

RESULTS

The survival rates for more than 12, 24, and 36 months after diagnosis were highest among people residing in large MSAs (90.2%, 87.2%, and 84.9%, respectively) and lowest among people residing in nonmetropolitan areas (87.3%, 84.1%, and 81.4%, respectively). With a few exceptions, survival rates were lower in those residing in nonmetropolitan areas than those residing in large MSAs and small-to-medium MSAs across most subgroups by age at diagnosis, race/ethnicity, sex, transmission category, region of residence, and year of diagnosis. Between 2005 and 2010, significant year-to-year increases occurred in the proportion of people surviving more than 36 months after diagnosis across all 3 population density area categories (estimated annual percentage change: large MSAs [0.88; 95% confidence interval (CI), 0.56-1.20]; small-to-medium MSAs [0.94; 95% CI, 0.06-1.83]; and nonmetropolitan areas [1.26; 95% CI, 0.07-2.46]).

CONCLUSIONS

Although survival rates for those with HIV infection stage 3 (AIDS) improved in all 3 population density area categories, efforts to remove barriers to care and promote treatment adherence in nonmetropolitan areas will be necessary to eliminate survival disparities.

A qualitative study on the intersectional social determinants for indigenous people who become infected with HIV in their youth

BACKGROUND

Indigenous young people are currently highly overrepresented in the HIV epidemic in Canada, especially in the Prairie Provinces, such as Manitoba. Understanding HIV-vulnerability in Indigenous peoples must begin with understanding that social determinants are intersectional and linked to the historical legacy of European colonization. In this paper findings that detail the influence of the intersectional social determinants on Indigenous people who become infected with HIV in their youth are presented.

METHODS

The qualitative research design of phenomenology was used as it afforded the opportunity to understand Indigenous young people from their frames of reference and experiences of reality, resulting in a phenomenological understanding of their perspectives and experiences of the early years of living with HIV. A total of 21 Indigenous young people took part open-ended interviews.

RESULTS

The stories that the Indigenous young people shared revealed their deeply interconnected social worlds, and how social determinants including abuse, trauma, being part of the child welfare system, and housing and food security were connected throughout various stages of their lives. Such stages included childhood, adolescence and young adulthood (the time of HIV infection), and later adulthood for older participants with the social determinants having multiple influences on their health trajectories.

CONCLUSIONS

The findings highlight the need for policies and programs that are broadly focused, addressing multiple social determinants together. Overall, there needs to be more emphasis on the multiple social determinants in the life situations of all Indigenous youth. Reducing the health and social disparities in Indigenous youth is key to reducing the number of young Indigenous people diagnosed with HIV. The findings also shed light on the importance of listening to young Indigenous people who have experienced HIV diagnosis and life following diagnosis.

Increased mortality among Indigenous persons in a multisite cohort of people living with HIV in Canada

OBJECTIVE

Compare all-cause mortality between Indigenous participants and participants of other ethnicities living with HIV initiating combination antiretroviral therapy (cART) in an interprovincial multi-site cohort.

METHODS

The Canadian Observational Cohort is a collaboration of 8 cohorts of treatment-naïve persons with HIV initiating cART after January 1, 2000. Participants were followed from the cART initiation date until death or last viral load (VL) test date on or before December 31, 2012. Cox proportional hazard models were used to estimate the effect of ethnicity on time until death after adjusting for age, gender, injection drug use, being a man who has sex with men, hepatitis C, province of origin, baseline VL and CD4 count, year of cART initiation and class of antiretroviral medication.

RESULTS

The study sample consisted of 7080 participants (497 Indigenous, 2471 Caucasian, 787 African/Caribbean/Black (ACB), 629 other, and 2696 unknown ethnicity). Most Indigenous persons were from British Columbia (BC) (83%), with smaller numbers from Ontario (13%) and Québec (4%). During the study period, 714 (10%) participants died. The five-year survival probability was lower for Indigenous persons (0.77) than for Caucasian (0.94), ACB (0.98), other ethnicities (0.96) and unknown ethnicities (0.85) (p &lt; 0.0001). In an adjusted proportional hazard model for which missing data were imputed, Indigenous persons were more likely to die than Caucasian participants (hazard ratio = 2.69, p &lt; 0.0001).

CONCLUSION

The mortality rate for Indigenous persons was higher than for other ethnicities and is largely reflective of the BC population. Addressing treatment challenges and identifying HIV- and non-HIV-related causes for mortality among Indigenous persons is required to optimize their clinical management.

Outbreaks in the age of syndemics: New insights for improving Indigenous health

Conventional approaches for the prevention and control of communicable diseases within Indigenous contexts may benefit from new insights arising from the growing interest in syndemics. Syndemics is a term used to describe a conceptual framework for understanding diseases or health conditions, and how these are exacerbated by the social, economic, environmental and political milieu in which a population is immersed. The use of conventional approaches for outbreak prevention and control remains the bedrock of intervention in the field of communicable diseases; yet on their own, these strategies are not always successful, especially within contexts of marginalization and disadvantage. A broader approach is needed; one that examines the systemic factors involved, understands how various policies and systems support or hinder effective responses and identifies the structural changes needed to create more supportive environments and increase the resilience of the population. In an Indigenous context, whether the focus is on hepatitis C, tuberculosis, HIV or water-borne diseases, it is important to recognize that a) social determinants contribute to the emergence and persistence of outbreaks, b) conventional approaches to communicable disease control are necessary but not sufficient, and c) using a "syndemics lens" can leverage action at multiple levels to tackle the root causes of poor health and inform more effective strategies for improving Indigenous health and reducing health inequities.

The changing trends and profile of pneumocystosis mortality in the United States, 1999-2014

Pneumocystosis (PCP) mortality in the U.S. has received less attention in recent years. This study describes recent trends in mortality and the estimated burden of PCP in the U.S., using the national multiple cause of death data during 1999-2014. PCP mortality rates were calculated for age, sex, race and year. Demographic differences were presented for decedents with and without a human immunodeficiency virus (HIV) co-diagnosis. Matched odds ratios (MOR) were generated to describe associations between non-HIV conditions and PCP mortality. In total, 11 512 PCP deaths occurred during 1999-2014. Annual age-adjusted PCP mortality decreased over this time period, from 0.479 to 0.154 per 100 000 population (1999 vs 2014 respectively). Over two-thirds of decedents were male and Blacks had the highest mortality as compared to Whites. HIV co-diagnosis accounted for 48% of all PCP deaths in 2014 vs 71% in 1999. Comorbid conditions such as connective tissue disorders (MOR=12.29; 95% confidence interval=[10.26, 14.71]) were associated with a PCP diagnosis. Productivity losses amounted to >$12 billion during the study period. Although widespread use of antiretroviral therapy and PCP prophylaxis for HIV infection likely contributed to the overall decline in PCP deaths during 1999-2014, a continual need exists to prevent and treat this fungal disease in immune-compromised populations that are not infected with HIV.

The Continuum of HIV Care in Rural Communities in the United States and Canada: What Is Known and Future Research Directions

The nature of the HIV epidemic in the United States and Canada has changed with a shift toward rural areas. Socioeconomic factors, geography, cultural context, and evolving epidemics of injection drug use are coalescing to move the epidemic into locations where populations are dispersed and health care resources are limited. Rural-urban differences along the care continuum demonstrate the implications of this sociogeographic shift. Greater attention is needed to build a more comprehensive understanding of the rural HIV epidemic in the United States and Canada, including research efforts, innovative approaches to care delivery, and greater community engagement in prevention and care.

Epidemiology and Outcomes in Critically Ill Patients with Human Immunodeficiency Virus Infection in the Era of Combination Antiretroviral Therapy

Purpose. The impact of critical illness on survival of HIV-infected patients in the era of antiretroviral therapy remains uncertain. We describe the epidemiology of critical illness in this population and identify predictors of mortality. Materials and Methods. Retrospective cohort of HIV-infected patients was admitted to intensive care from 2002 to 2014. Patient sociodemographics, comorbidities, case-mix, illness severity, and 30-day mortality were captured. Multivariable Cox regression analyses were performed to identify predictors of mortality. Results. Of 282 patients, mean age was 44 years (SD 10) and 169 (59%) were male. Median (IQR) CD4 count and plasma viral load (PVL) were 125 cells/mm³ (30–300) and 28,000 copies/mL (110–270,000). Fifty-five (20%) patients died within 30 days. Factors independently associated with mortality included APACHE II score (adjusted hazard ratio [aHR] 1.12; 95% CI 1.08–1.16; p < 0.001), cirrhosis (aHR 2.30; 95% CI 1.12–4.73; p = 0.024), coronary artery disease (aHR 6.98; 95% CI 2.20–22.13; p = 0.001), and duration of HIV infection (aHR 1.07 per year; 95% CI 1.02–1.13; p = 0.01). CD4 count and PVL were not associated with mortality. Conclusions. Mortality from an episode of critical illness in HIV-infected patients remains high but appears to be driven by acute illness severity and HIV-unrelated comorbid disease rather than degree of immune suppression.

Social determinants of health and retention in HIV care in a clinical cohort in Ontario, Canada

Continuous HIV care supports antiretroviral therapy initiation and adherence, and prolongs survival. We investigated the association of social determinants of health (SDH) and subsequent retention in HIV care in a clinical cohort in Ontario, Canada. The Ontario HIV Treatment Network Cohort Study is a multi-site cohort of patients at 10 HIV clinics. Data were collected from medical charts, interviews, and via record linkage with the provincial public health laboratory for viral load tests. For participants interviewed in 2009, we used three-category multinomial logistic regression to identify predictors of retention in 2010-2012, defined as (1) continuous care (≥2 viral loads ≥90 days in all years; reference category); (2) discontinuous care (only 1 viral load/year in ≥1 year); and (3) a gap in care (≥1 year in 2010-2012 with no viral load). In total, 1838 participants were included. In 2010-2012, 71.7% had continuous care, 20.9% had discontinuous care, and 7.5% had a gap in care. Discontinuous care in 2009 was predictive (p < .0001) of future retention. SDH associated with discontinuous care were Indigenous ethnicity, being born in Canada, being employed, reporting hazardous drinking, and non-injection drug use. Being a heterosexual male was associated with having a gap in care, and being single and younger were associated with discontinuous care and a gap in care. Various SDH were associated with retention. Care discontinuity was highly predictive of future gaps. Targeted strategic interventions that better engage those at risk of suboptimal retention merit exploration.

ABBREVIATIONS

AOR: adjusted odds ratio; ART: antiretroviral therapy; AUDIT: Alcohol Use Disorders Identification Test; CES-D: Center for Epidemiologic Studies Depression Scale; CIs: confidence intervals; HIV: human immunodeficiency virus; IQR: interquartile range; MSM: men who have sex with men; NA-ACCORD: North American AIDS Cohort Collaboration on Research and Design; OCS: Ontario HIV Treatment Network Cohort Study; OHTN: Ontario HIV Treatment Network; OR: odds ratio; PHOL: Public Health Ontario Laboratories; REB: Research Ethics Board; SDH: social determinants of health; US: United States.

Creating conditions for Canadian aboriginal health equity: the promise of healthy public policy

In the Canadian context, the persistence and growth of Aboriginal health and social inequity signals that we are at a critical public health policy juncture; current policy reflects an historic relationship between Aboriginal people and Canada that fails the contemporary health needs of Canada's Aboriginal peoples. In this review, we highlight the need for healthy public policy that recognizes and prioritizes the rights of Canada's Aboriginal people to achieve health equity. Drawing from a structural approach, we examine the historical scope and comprehensive breadth of the Indian Act in shaping modern Aboriginal health and social inequities. Canada's failure to implement a national public policy for Aboriginal health reflects the proliferation of racism in modern day Canada, and a distinctly lacking political will at the federal level. Despite these structural challenges, there is great promise in community self-determination in health care and the role of community-led research as advocacy for policy reform. In our conclusion, we turn to the Report on the Truth and Reconciliation Commission of Canada (2015) and draw upon the concept of reconciliation as a fundamental precursor for Aboriginal health equity. The burden of systemic change needed to promote healthy public policy cannot be carried by any single group of advocates; it is a shared responsibility that will require the collaboration and integration of various actors and knowledges.

The Cedar Project WelTel mHealth intervention for HIV prevention in young Indigenous people who use illicit drugs: study protocol for a randomized controlled trial

BACKGROUND

Despite successes in preventing and treating HIV, Indigenous people in Canada continue to face disproportionately high rates of HIV infection. Programs that support healing from lifetime trauma, support connection to culture, and reduce drug-related harms are critical to preventing HIV among young Indigenous people who use drugs. The Cedar Project WelTel mHealth intervention proposed here is a structured mobile-phone initiative to connect young Indigenous people who use drugs with Cedar Case Managers in a community-based setting. The intervention consists of a package of supports, including a mobile phone and cellular plan, weekly two-way text messaging, and support from Cedar Case Managers.

METHODS

The Cedar Project WelTel mHealth study is a multi-site Zelen pre-randomized trial to measure the effect of a two-way supportive text-message intervention to reduce HIV vulnerability among young Indigenous people who use illicit drugs in two Canadian cities. The trial is nested within the Cedar Project, an ongoing cohort study addressing HIV and hepatitis C vulnerability among young Indigenous people who use drugs in Vancouver and Prince George, British Columbia. The Cedar Project Partnership, an independent body of Indigenous Elders, leaders, and health/social service experts, governs all aspects of the study. Two hundred participants will be followed over a 16-month period, with HIV propensity score at 6 months as the primary outcome. Secondary outcomes include HIV propensity at 1 year, HIV risk, resilience, psychological distress, access to drug-related services, and connection to culture measured at 6 months and 1 year. Primary analysis is by intention to treat.

DISCUSSION

Culturally safe interventions that address barriers to HIV prevention while supporting the strength of young Indigenous people who use drugs are urgently needed. Despite presenting a tremendous opportunity to connect young, highly transient Indigenous people who use drugs to prevention services, supportive two-way mHealth programs have yet to be tested for HIV prevention in a community-based setting with this population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02437123 https://clinicaltrials.gov/show/NCT02437123 (registered 4 May 2015). Protocol version: 24 July 2015.