Attrition Across the HIV Cascade of Care Among a Diverse Cohort of Women Living With HIV in Canada

Mental health service use and shortages among a cohort of women living with HIV in Canada

BACKGROUND

The prevalence of mental health conditions among women with HIV in Canada ranges between 29.5% and 57.4%, highlighting the need for accessible mental health care. We aimed to (1) describe the availability and use of mental health services among women with HIV and (2) identify characteristics associated with reporting that shortages of these services presented a problem in their care.

METHODS

Baseline data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study were analysed. Self-reported availability and use of mental health services were examined using descriptive statistics. Participants indicated whether a lack of mental health support was a problem in their care. Logistic regression models were constructed to determine associations between sociodemographic, clinical, and psychosocial characteristics and reported problematic shortages.

RESULTS

Of 1422 women, 26.7% (n = 380) used mental health services in the last year, which most accessed through their HIV clinic. Thirty-eight percent (n = 541) reported that a shortage of mental health support was a problem in their care. Among this subset, 22.1% (n = 119) used services at their HIV clinic, 26.5% (n = 143) reported available services but did not use them, and 51.4% (n = 277) either indicated that these services were unavailable, did not know if such services were available, or were unengaged in HIV care. Factors associated with reporting problematic shortages included rural residence [adjusted odds ratio (aOR): 1.69, 95% confidence interval (CI): 1.03-2.77], higher education level (aOR: 1.43, 95% CI: 1.02-2.02), and higher HIV stigma score (aOR: 1.03, 95% CI: 1.02-1.03). Conversely, African/Caribbean/Black identity (aOR: 0.37, 95% CI: 0.26-0.54), history of recreational drug use (aOR: 0.56, 95% CI: 0.39-0.81), and Quebec residence (aOR: 0.69, 95% CI: 0.50-0.96) were associated with lower odds of reporting service shortages.

CONCLUSION

Our findings highlight the HIV clinic as the primary location of mental health service use. However, existing services may not be sufficient to reach all patients or meet specific needs. Furthermore, the low uptake among those reporting a shortage suggests a lack of connection to services or patient knowledge about their availability. Characteristics associated with reporting shortages reflect geographic and socioeconomic disparities that must be accounted for in future service design.

Polysubstance Use Profiles and HIV Viremia in a South African Cohort of Female Sex Workers: A Latent Class Analysis

BACKGROUND

Given intersecting social and structural factors, female sex workers (FSW) exhibit elevated risk of HIV and substance use. However, there is limited study of how distinct substance use typologies influence HIV treatment outcomes among FSW.

SETTING

A cross-sectional survey with objective viral load assessments of 1391 FSW enrolled into a treatment optimization-focused trial in Durban, South Africa (2018-2020).

METHODS

We used latent class analysis to uncover discrete patterns in past-month self-reported use of the following substances: heavy alcohol use, cannabis, cocaine, crack, ecstasy, methamphetamine, heroin, and Whoonga . We used Wald tests to identify multilevel predictors of latent class membership and multivariable mixture modeling to quantify associations of substance use classes with HIV viremia (≥50 RNA copies/mL).

RESULTS

Substance use (87%) and HIV viremia (62%) were highly prevalent. Latent class analysis uncovered 3 polysubstance use profiles: Heavy Alcohol Use Only (∼54%); Cannabis, Heavy Alcohol, & Crack Use (∼28%); and Whoonga & Crack Use (∼18%). Whoonga & Crack Use was associated with social and structural adversities, including homelessness, outdoor/public sex work, HIV stigma, and violence. Relative to Heavy Alcohol Use Only , HIV viremia was significantly higher in the Whoonga & Crack Use class (adjusted odds ratio 1.97, 95% confidence interval: 1.13 to 3.43), but not in the Cannabis, Heavy Alcohol, & Crack Use class (adjusted odds ratio 1.17, 95% confidence interval: 0.74 to 1.86).

CONCLUSION

HIV viremia differed significantly across identified polysubstance use profiles among South African FSW. Integrating drug treatment and harm reduction services into HIV treatment programs is key to improving virologic outcomes in marginalized communities.

Dissemination of the Women-Centred HIV Care Model: A Multimodal Process and Evaluation

BACKGROUND

Using data from a national cohort study and focus groups, the Women-Centred HIV Care (WCHC) Model was developed to inform care delivery for women living with HIV.

METHODS

Through an evidence-based, integrated knowledge translation approach, we developed 2 toolkits based on the WCHC Model for service providers and women living with HIV in English and French (Canada's national languages). To disseminate, we distributed printed advertising materials, hosted 3 national webinars and conducted 2 virtual capacity-building training series.

RESULTS

A total of 315 individuals attended the webinars, and the average WCHC knowledge increased by 29% (SD 4.3%). In total, 131 service providers engaged in 22 virtual capacity-building training sessions with 21 clinical cases discussed. Learners self-reported increased confidence in 15/15 abilities, including the ability to provide WCHC. As of December 2023, the toolkits were downloaded 7766 times.

CONCLUSIONS

We successfully developed WCHC toolkits and shared them with diverse clinical and community audiences through various dissemination methods.

A Systematic Review of the Impact of HIV-Related Stigma and Serostatus Disclosure on Retention in Care and Antiretroviral Therapy Adherence Among Women with HIV in the United States/Canada

This systematic review explores the roles of HIV stigma and disclosure of HIV serostatus in antiretroviral therapy (ART) adherence and retention in care (RIC) among women with HIV (WHIV) in the United States and Canada. We conducted a systematic search of electronic databases (PubMed, Embase, CINAHL, PsycINFO, and Google scholar) to identify peer-reviewed articles published between January 1996 and December 2022. The search yielded 1120 articles after duplicates were removed. Of these, 27 articles met the inclusion criteria. The majority (89%) of the studies were conducted in the United States. The studies included WHIV from diverse racial/ethnic groups, residing in both urban and rural areas. Most of the studies suggested that internalized stigma, perceived community stigma, and fear of disclosure were important barriers to ART adherence and RIC among WHIV. HIV-related stigma experienced within the health care setting was also reported as a factor impacting health care utilization. A few studies identified mental health distress as a potential mechanism accounting for the association and suggested that social support and resilience may buffer the negative effects of stigma and disclosure on ART adherence and RIC among WHIV. Our review indicates that stigma and concerns about disclosure continue to significantly affect HIV health outcomes for WHIV in high-income countries. It underscores the importance of integrated HIV care services and interventions targeting mental health, resilience building, and improved patient-provider relationships for WHIV to enhance ART adherence and RIC. Longitudinal studies and investigations into additional mechanisms are needed to advance understanding and inform women-centered interventions.

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.

Challenges and barriers to HIV care engagement and care cascade: viewpoint

Patients with human immunodeficiency virus (HIV) are subject to long-term management and a complex care process. Patients with HIV are clinically, socially, and emotionally vulnerable, face many challenges, and are often stigmatized. Healthcare providers should engage them with diligence in the HIV care cascade process. In this paper, we discuss from our viewpoint certain social and public health barriers and challenges that should be considered by healthcare providers to better engage patients in the HIV care cascade process and maximize its outcomes.

Patient-Provider Relationships and Antiretroviral Therapy Adherence and Durable Viral Suppression Among Women with HIV, Miami-Dade County, Florida, 2021-2022

Women with HIV in the United States are more negatively affected by adverse social determinants such as low education and poverty than men, and thus, especially need a supportive health care system. This cross-sectional study assessed the role of the patient-provider relationship on antiretroviral therapy (ART) adherence and durable viral suppression among women with HIV (WHIV) in Miami-Dade County, Florida. Patient-provider relationship was measured, in part, using the Health Care Relationship Trust Scale and Consumer Assessment of Health Care Providers and Systems. The survey was administered by telephone to women in the Ryan White Program June 2021-March 2022. Adherence was defined as 90% adherent on the average of three self-reported items. Lack of durable viral suppression was defined by at least one viral load ≥200 copies/mL among all tests conducted in a year. Logistic regression models were generated using backward stepwise modeling. Of 560 cis-gender women, 401 (71.6%) were adherent, and 450 (80.4%) had durable viral suppression. In the regression model, adherence was associated with higher patient-provider trust and provider communication as well as excellent perceived health, lack of significant depressive symptoms, no alcohol use within the last 30 days, and lack of transportation problems. In the regression model using provider as a random effect, durable viral suppression was associated with older age, Hispanic ethnicity, and lack of illegal drug use. While the results show that a strong patient-provider relationship facilitates ART adherence in WHIV, there was no association with durable viral suppression.

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.

Markers of ovarian reserve in women living with HIV: A systematic review

BACKGROUND

Anti-Mullerian hormone (AMH) levels indicate ovarian reserve and are predictive of reproductive aging. Studies evaluating AMH levels in women with HIV have produced conflicting results, and reasons for inter-study differences have not been assessed. To understand reproductive aging in HIV, we conducted a systematic review of ovarian reserve among women with HIV.

METHODS

We searched Ovid MEDLINE, Ovid EMBASE, and CAB Direct for studies including AMH in reproductive-aged women with HIV. Two reviewers used the Newcastle-Ottawa scale to assess the quality of extracted data.

RESULTS

Of the 315 reports screened, ten met the inclusion criteria. Studies were conducted across seven countries and included 3673 women with HIV and 2342 HIV-negative women in the comparison group. Ethnic distribution, combination antiretroviral therapy coverage, and viral load suppression varied considerably across studies. Nine of the ten reviewed studies reported lower unadjusted AMH levels in women with HIV than in those without HIV; however, in studies that adjusted for confounders (n = 4), only two showed an association between HIV and AMH. Low CD4 count and high viral load correlated with low AMH in the two largest studies. Other studies found that opioid use and elevated inflammatory markers were associated with low AMH. Study quality varied considerably, and many were of low quality (n = 6).

CONCLUSION

Current evidence is inconclusive about the relationship between HIV and AMH, although studies suggest a trend toward lower AMH among women with HIV. Future studies that adjust for HIV-related factors, inflammatory markers, and substance use are needed in the era of contemporary HIV care to confirm the association between HIV and reduced ovarian reserve and establish its underlying cause.

Pathways From Recent Incarceration to Antiretroviral Therapy Adherence: Opportunities for Interventions to Support Women Living With HIV Post Release From Correctional Facilities

ABSTRACT

Women living with HIV are increasingly incarcerated and experience suboptimal HIV health outcomes post release from incarceration. Drawing on cohort data with cisgender and trans women living with HIV (Sexual Health and HIV/AIDS: Women's Longitudinal Needs Assessment), we used path analysis to investigate pathways from recent incarceration to optimal antiretroviral therapy (ART) adherence. We tested direct effects between recent incarceration, mediating variables, and ART adherence, along with indirect effects between incarceration and ART adherence through each mediator. We assessed model fit using chi-square, root-mean-square error of approximation (RMSEA), and comparative fit index (CFI). Our hypothesized model fit well to the data (χ2(1)=1.100; p=.2943; CFI = 1.000; RMSEA = 0.007). Recent experiences of homelessness, criminalized substance use, and gender-based violence each fully mediated the pathway between recent incarceration and optimal ART adherence. Findings highlight the need for safe and supportive housing, supports for criminalized substance use, and trauma and violence-informed care and practice post release from incarceration.

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

BACKGROUND

While scarce, literature suggests that women at the intersection of HIV status and gender and/or sexual minority identities experience heightened social and health disparities within health care systems.

OBJECTIVES

This study examines the association between sexual and/or gender minority identities and: (1) experiences of poor treatment by health professionals and (2) being unable to access health services among a cohort of women living with HIV in Metro Vancouver, Canada.

DESIGN

Data were drawn from a longitudinal community-based cohort of women living with HIV (Sexual Health and HIV/AIDS Women's Longitudinal Needs Assessment).

METHODS

We examined associations between sexual and/or gender minority identities and the two outcomes. We drew on explanatory variables to measure sexual minority and gender minority identities independently and a combined variable measuring sexual and/or gender minority identities. The associations between each of these three variables and each outcome were analysed using bivariate and multivariable logistic regression models with generalized estimating equations for repeated measures over time. Adjusted odds ratios and 95% confidence intervals are reported.

RESULTS

The study sample included 1460 observations on 315 participants over 4.5 years (September 2014 to February 2019). Overall, 125 (39.7%) reported poor treatment by health professionals and 102 (32.4%) reported being unable to access health care services when needed at least once over the study period. A total of 110 (34.9%) of participants reported sexual and/or gender minority identities, 106 (33.7%) reporting sexual minority identities, with 29 (9.2%) reporting gender minority identities. In multivariable analysis, adjusting for confounders, sexual minority identities, and combined sexual and/or gender minority identities were significantly associated with increased odds of experiencing poor treatment by health professionals (sexual minority adjusted odds ratio = 1.39 (0.94-2.05); sexual and/or gender minority adjusted odds ratio = 1.48 (1.00-2.18)) and being unable to access health services (sexual minority adjusted odds ratio = 1.89 (1.20-2.97); sexual and/or gender minority adjusted odds ratio = 1.91 (1.23-2.98)). In multivariable analysis, gender minority identities were not significantly associated with increased odds of experiencing poor treatment by health professionals (gender minority adjusted odds ratio = 1.38; 95% CI = 0.76-2.52) and being unable to access health services (gender minority adjusted odds ratio = 1.72; 95% CI = 0.89-3.31) possibly due to low sample size among women with gender minority identities.

CONCLUSION

Our findings suggest the need for access to inclusive, affirming, trauma-informed health care services tailored specifically for and by women living with HIV with sexual and/or gender minority identities.

HIV care cascade for women living with HIV in the Greater Toronto Area versus the rest of Ontario and Canada

BACKGROUND

The Greater Toronto Area (GTA) is home to 39% of Canada's population living with HIV. To identify gaps in access and engagement in care and treatment, we assessed the care cascade of women living with HIV (WLWH) in the GTA versus the rest of Ontario and Canada (in this case: Quebec and British Columbia).

METHODS

We analyzed 2013-2015 self-reported baseline data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study for six care cascade stages: linked to care, retained in care, initiated antiretroviral therapy (ART), currently on ART, ART adherence (≥90%), and undetectable (<50 copies/mL). Multivariable logistic regression was used to reveal associations with being undetectable.

RESULTS

Comparing the GTA to the rest of Ontario and Canada, respectively: 96%, 98%, 100% were linked to care; 92%, 94%, 98% retained in care; 72%, 89%, 96% initiated ART; 67%, 81%, 90% were currently using ART; 53%, 66%, 77% were adherent; 59%, 69%, 81% were undetectable. Factors associated with viral suppression in the multivariable model included: living outside of the GTA (Ontario: aOR = 1.72, 95% CI: 1.09-2.72; Canada: aOR = 2.42, 95% CI: 1.62-3.62), non-Canadian citizenship (landed immigrant/permanent resident: aOR = 3.23, 95% CI: 1.66-6.26; refugee/protected person/other status: aOR = 4.77, 95% CI: 1.96-11.64), completed high school (aOR = 1.77, 95% CI: 1.15-2.73), stable housing (aOR = 2.13, 95% CI: 1.33-3.39), income of ≥$20,000 (aOR = 1.52, 95% CI: 1.00-2.31), HIV diagnosis <6 years (6-14 years: aOR = 1.75, 95% CI: 1.16-2.63; >14 years: aOR = 1.87, 95% CI: 1.19-2.96), and higher resilience (aOR = 1.02, 95% CI: 1.00-1.04).

CONCLUSION

WLWH living in the GTA had lower rates of viral suppression compared to the rest of Ontario and Canada even after adjustment of age, ethnicity, and HIV diagnosis duration. High-impact programming for WLWH in the GTA to improve HIV outcomes are greatly needed.

A two-day workshop reviewing Canadian provincial and national HIV care cascade indicators, reporting, challenges, and recommendations

BACKGROUND

The HIV care cascade is an indicators-framework used to assess achievement of HIV clinical targets including HIV diagnosis, HIV care initiation and retention, initiation of antiretroviral therapy, and attainment of viral suppression for people living with HIV.

METHODS

The HIV Care Cascade Research Development Team at the CIHR Canadian HIV Trials Network Clinical Care and Management Core hosted a two-day virtual workshop to present HIV care cascade data collected nationally from local and provincial clinical settings and national cohort studies. The article summarizes the workshop presentations including the indicators used and available findings and presents the discussed challenges and recommendations.

RESULTS

Identified challenges included (1) inconsistent HIV care cascade indicator definitions, (2) variability between the use of nested UNAIDS's targets and HIV care cascade indicators, (3) variable analytic approaches based on differing data sources, (4) reporting difficulties in some regions due to a lack of integration across data platforms, (5) lack of robust data on the first stage of the care cascade at the sub-national level, and (6) inability to integrate key socio-demographic data to estimate population-specific care cascade shortfalls.

CONCLUSION

There were four recommendations: standardization of HIV care cascade indicators and analyses, additional funding for HIV care cascade data collection, database maintenance and analyses at all levels, qualitative interviews and case studies characterizing the stories behind the care cascade findings, and employing targeted positive-action programs to increase engagement of key populations in each HIV care cascade stage.

Factors associated with loss to follow up among HIV-exposed children: a historical cohort study from 2000 to 2017, in Porto Alegre, Brazil

BACKGROUND

There are many inequalities in terms of prevention and treatment for pregnant women with HIV and exposed children in low and middle-income countries. The Brazilian protocol for prenatal care includes rapid diagnostic testing for HIV, compulsory notification, and monitoring by the epidemiological surveillance of children exposed to HIV until 18 months after delivery. The case is closed after HIV serology results are obtained. Lost to follow-up is defined as a child who was not located at the end of the case, and, therefore, did not have a laboratory diagnosis. Lost to follow-up is a current problem and has been documented in other countries. This study analyzed factors associated with loss to follow-up among HIV-exposed children, including sociodemographic, behavioral, and health variables of mothers of children lost to follow-up.

METHODS

This historical cohort study included information on mothers of children exposed to HIV, born in Porto Alegre, from 2000 to 2017. The research outcome was the classification at the end of the child's follow-up (lost to follow-up or not). Factors associated with loss to follow-up were investigated using the Poisson regression model. Relative Risk calculations were performed. The significance level of 5% was adopted for variables in the adjusted model.

RESULTS

Of 6,836 children exposed to HIV, 1,763 (25.8%) were classified as lost to follow-up. The factors associated were: maternal age of up to 22 years (aRR 1.25, 95% CI: 1.09-1.43), the mother's self-declared race/color being black or mixed (aRR 1.13, 95% CI: 1.03-1.25), up to three years of schooling (aRR 1.45, 95% CI: 1.26-1.67), between four and seven years of schooling (aRR 1.14, 95% CI: 1.02-1.28), intravenous drug use (aRR 1.29, 95% CI: 1.12-1.50), and HIV diagnosis during prenatal care or at delivery (aRR 1.37, 95% CI: 1.24-1.52).

CONCLUSION

Variables related to individual vulnerability, such as race, age, schooling, and variables related to social and programmatic vulnerability, remain central to reducing loss to follow-up among HIV-exposed children.

Vaginal microbiota associated with oncogenic HPV in a cohort of HPV-vaccinated women living with HIV

Background

Women living with HIV (WLWH) experience higher rates of human papillomavirus (HPV) infection and cervical cancer than women without HIV. Changes in the vaginal microbiome have been implicated in HPV-related disease processes such as persistence of high-risk HPV infection but this has not been well defined in a population living with HIV.

Methods

Four hundred and 20 girls and WLWH, age ≥9, across 14 clinical sites in Canada were enrolled to receive three doses of quadrivalent HPV vaccine for assessment of vaccine immunogenicity. Blood, cervical cytology, and cervico-vaginal swabs were collected. Cervico-vaginal samples were tested for HPV DNA and underwent microbiota sequencing.

Results

Principal component analysis (PCA) and hierarchical clustering generated community state types (CSTs). Relationships between taxa and CSTs with HPV infection were examined using mixed-effects logistic regressions, Poisson regressions, or generalized linear mixed-effects models, as appropriate. Three hundred and fifty-six cervico-vaginal microbiota samples from 172 women were sequenced. Human papillomavirus DNA was detected in 211 (59%) samples; 110 (31%) contained oncogenic HPV. Sixty-five samples (18%) were taken concurrently with incident oncogenic HPV infection and 56 (16%) were collected from women with concurrent persistent oncogenic HPV infection.

Conclusions

No significant associations between taxa, CST, or microbial diversity and HPV-related outcomes were found. However, we observed weak associations between a dysbiotic microbiome and specific species, including Gardnerella, Porphyromonas, and Prevotella species, with incident HPV infection.

Interpersonal violence and other social-structural barriers associated with needing HIV treatment support for women living with HIV

Women living with HIV (WLWH), experience disproportionate rates of violence, along with suboptimal HIV health outcomes, despite recent advancements in HIV treatment, known as antiretroviral therapy (ART). The objectives of this study were to: (a) describe different types of support needed to take ART and (b) investigate the social and structural correlates associated with needing support for ART adherence among WLWH. Data are drawn from Sexual health and HIV/AIDS: Women's Longitudinal Needs Assessment, a community-based open research cohort with cisgender and transgender WLWH, aged 14+ who live or access HIV services in Metro Vancouver, Canada (2014-present). Baseline and semi-annual questionnaires are administered by community interviewers alongside a clinical visit with a sexual health research nurse. Bivariate and multivariable logistic regression using generalized estimating equations and an exchangeable working correlation matrix was used to model factors associated with needing supports for ART adherence. Among 276 WLWH, 51% (n = 142) reported needing support for ART adherence; 95% of participants reported lifetime gender-based violence and identified many interpersonal, structural, community, and clinical supports that would facilitate and support ART adherence. In multivariable logistic regression, participants who were Indigenous (adjusted odds ratio [AOR]: 1.70, 95% confidence intervals [CI]: 1.07-2.72), or otherwise racialized (AOR: 2.36, 95% CI : 1.09-5.12) versus white, experienced recent gender-based physical violence (AOR : 1.54, 95% CI : 1.03-2.31), lifetime post-traumatic stress disorder (AOR : 1.97, 95% CI : 1.22-3.18), and recent illicit drug use (AOR : 2.15, 95% CI : 1.43-3.22), had increased odds of needing support for ART adherence. This research suggests a need for trauma-informed, culturally safe and culturally responsive practice and services for WLWH along the HIV care continuum to support ART adherence. All services should be developed by, with, and for WLWH and tailored according to gender identity, taking into account history, culture, and trauma, including the negative impacts of settler colonialism for Indigenous people.

Improving Post-Release Care Engagement for People Living with HIV Involved in the Criminal Justice System: A Systematic Review

Given sub-optimal HIV care outcomes for people living with HIV (PLWH) post-release from incarceration, we systematically searched peer-reviewed literature (2010-2021) describing controlled trial interventions aimed at improving Antiretroviral Therapy (ART) adherence and care linkage following release from correctional facilities for PLWH. Of 392 studies, 16 (4%) met the inclusion criteria. All studies were conducted in the United States and involved some form of intensive case management. Trials that scored highest in terms of study quality provided cell phones for engagement, reported sustained viral load suppression as a measurable outcome to infer ART adherence, and measured longitudinal data collected for at least 3-to-6 months following release. The two trials that demonstrated improved HIV viral load suppression involved Peer Navigators, and incentivized undetectable viral load, respectively. Facilitating support for addictions and addressing other social and structural barriers to achieving optimal health is also of vital importance in bridging care gaps for PLWH.

Short report: Characterizing HIV care among a clinical sample of transgender women living with HIV

INTRODUCTION

This study aimed to characterize and identify factors associated with HIV care among transgender (trans) women living with HIV (TWLWH) in two urban centres in Canada.

METHODS

Retrospective data were collected from clinic charts of TWLWH aged 16 years and older across seven family medicine, endocrinology and/or HIV clinics in Montreal and Toronto, Canada, from 2018 to 2019 (n = 86). We assessed the proportion of individuals being ever engaged in HIV care [defined as having any recorded antiretroviral therapy (ART) regimen and/or viral load], current ART use, and most recent viral load (suppressed [<200 copies/ml] vs. unsuppressed) overall and compared across subgroups using χ² tests.

RESULTS

All TWLWH in our sample [100.0%, 95% confidence interval (CI): 95.8-100.0%] were engaged in HIV care; most (93.0%, 95% CI: 85.4-97.4%) were currently using ART and most (93.4%, 95% CI: 85.3-97.8%) with complete data (n = 71/76) were virally suppressed. A higher proportion of trans women of colour (100.0%) reported current ART use compared with white trans women (76.9%, p = 0.017). A higher proportion of those with no documented history of injection drug use (IDU; 96.6%) were virally suppressed compared with those with a history of IDU (66.7%, p = 0.022). Although not statistically significant, 96.2% of those currently reporting feminizing hormone use were virally suppressed, compared with 85.0% of those not reporting use (p = 0.202).

CONCLUSIONS

Once engaged in HIV care, TWLWH in Canada appear to have excellent ART use and viral suppression. Findings can be leveraged to identify target populations to enhance HIV care and to further explore the relationship between gender-affirming medical care and HIV care.

A practical clinical guide to counselling on and managing contraception, pre-conception planning, and menopause for women living with HIV

Background

Women represent one quarter of the population living with HIV in Canada and are an increasingly important sector of the HIV community. While some women's health issues such as cervical cancer screening and management are well addressed in HIV management guidelines, others are not. These include sexual and reproductive health factors such as contraception, pre-conception planning, and menopause. Existing literature has shown that while women living with HIV in Canada receive good HIV care based on HIV care cascade indicators, their women's health and sexual and reproductive health care needs are not being met.

Methods

In this article, we present a clinical guide for clinicians providing care for women living with HIV on three key women's health topics that are under-discussed during HIV care visits: (1) contraception, (2) pre-conception planning, and (3) menopause.

Results

We have summarized the most pertinent clinical factors on each topic to support straightforward counselling and present important considerations in the context of HIV-related diseases and treatment. Finally, when relevant, we have provided practical stepwise approaches for addressing each of these women's health care topics when seeing a patient during a visit.

Conclusions

It is important that HIV specialists stay well-versed in the complex clinical interactions between HIV treatment and management of women's health issues.

HIV treatment outcomes among newcomers living with HIV in Manitoba, Canada

BACKGROUND

Despite the overrepresentation of immigrants and refugees (newcomers) in the HIV epidemic in Canada, research on their HIV treatment outcomes is limited. This study addressed this knowledge gap by describing treatment outcomes of newcomers in comparison with Canadian-born persons living with HIV in Manitoba.

METHODS

Clinical data from 1986 to 2017 were obtained from a cohort of people living with HIV and receiving care from the Manitoba HIV Program. Retrospective cohort analysis of secondary data was completed using univariate and multivariate statistics to compare differences in socio-demographic and clinical characteristics and treatment outcomes among newcomers, Canadian-born Indigenous persons, and Canadian-born non-Indigenous persons on entry into HIV care.

RESULTS

By end of 2017, 86 newcomers, 259 Canadian-born Indigenous persons, and 356 Canadian-born non-Indigenous persons were enrolled in the cohort. Newcomers were more likely than Canadian-born Indigenous and non- Indigenous cohort participants to be younger and female and have self-reported HIV risk exposure as heterosexual contact. Average CD4 counts at entry into care did not differ significantly between groups. A higher proportion of newcomers was also diagnosed with tuberculosis within 6 months of entry into care (21%), compared with 6% and 0.6% of Canadian-born Indigenous non-Indigenous persons, respectively. Newcomers and Canadian-born non-Indigenous persons had achieved viral load suppression (< 200 copies/mL) at a similar proportion (93%), compared with 82% of Canadian-born Indigenous participants (p < 0.05).

CONCLUSIONS

The distinct demographic and clinical characteristics of newcomers living with HIV requires a focused approach to facilitate earlier diagnosis, engagement, and support in care.

The opioid crisis is driving mortality among under-served people living with HIV in British Columbia, Canada

Introduction

Universal provision of effective antiretroviral medication has been essential to reduce mortality, increase longevity, and reduce onward transmission of HIV. This study aims to illuminate persistent threats to the health and longevity of under-served PLWH in British Columbia (BC), Canada.

Methods

Between 2007 and 2010, 1000 PLWH across BC were enrolled in the Longitudinal Investigation into Supportive and Ancillary health services (LISA) study and completed a cross-sectional survey on their HIV-care experiences and healthcare engagement. The sample generally reflects an under-served population of PLWH. A linkage to the provincial Vital Statistics registry is used in this analysis in order to examine overall mortality and cause-specific mortality trends; probability of death was modeled using logistic regression for participants with ongoing clinical monitoring (n = 910).

Results

By June 2017, 208 (20.8%) participants had died. The majority of deaths 57 (27.4%) were attributed to drug-related complications or overdoses, 39 (18.8%) were attributed to HIV-related complications, and 36 (17.3%) to non-AIDS-defining malignancies. We observed elevated odds of death among PLWH who smoked tobacco (aOR: 2.11, 95% CI: 1.38, 3.23), were older (aOR: 1.06 per one-year increase, 95% CI: 1.04, 1.08), indicated heavy alcohol consumption (aOR: 1.57, 95% CI: 1.11, 2.22), and reported unstable housing (aOR: 1.96, 95% CI: 1.37, 2.80); while higher CD4 cell count was protective (aOR: 0.87 per 100-unit increase, 95% CI: 0.79, 0.94) as was male gender), though non-significant (aOR: 0.73, 95% CI: 0.49, 1.07).

Conclusions

Overdose is - the leading cause of mortality among a cohort of under-served PLWH in BC, Canada. Public health efforts to end the HIV epidemic and support the health and well-being of PLWH are being thwarted by persistent health inequities and the enormous and persistent risks facing people who use drugs. Integrated low-barrier primary care is essential for supporting under-served PLWH, and safe drug supply is needed to support PLWH who use drugs.

Leaving no one behind? An equity analysis of the HIV care cascade among a cohort of people living with HIV in Manitoba, Canada

Background

Manitoba is a central Canadian province with annual rates of new HIV infections consistently higher than the Canadian average. National surveillance statistics and data from the provincial HIV care program suggest that epidemiological heterogeneity exists across Manitoba. New HIV cases are disproportionately reported among females, Indigenous-identifying individuals, and those with a history of injection drug use. Given the heterogeneity in acquisition, it is of interest to understand whether this translates into inequalities in HIV care across Manitoba.

Methods

A sample of 703 participants from a clinical cohort of people living with HIV in Manitoba, with data current to the end of 2017, was used to conduct cross-sectional, disaggregated analyses of the HIV care cascade to identify heterogeneity in service coverage and clinical outcomes among different groups receiving HIV care in Manitoba. Equiplots are used to identify and visualize inequalities across the cascade. Exploratory multivariable logistic regression models quantify associations between equity variables (age, sex, geography, ethnicity, immigration status, exposure category) and progression along the cascade. Adjusted odds ratios (AOR) and 95% confidence intervals (95%CI) are reported.

Results

Equity analyses highlight inequalities in engagement in and coverage of HIV-related health services among cohort participants. Equiplots illustrate that the proportion of participants in each cascade step is greater for those who are older, white, non-immigrants, and report no history of injection drug use. Compared to those living in Winnipeg, participants in eastern Manitoba have greater odds of achieving virologic suppression (AOR[95%CI] = 3.8[1.3–11.2]). The odds of Indigenous participants being virologically suppressed is half that of white participants (AOR[95%CI] = 0.5[0.3–0.7]), whereas African/Caribbean/Black participants are significantly less likely than white participants to be in care and retained in care (AOR[95%CI] = 0.3[0.2–0.7] and 0.4[0.2–0.9], respectively).

Conclusions

Inequalities exist across the cascade for different groups of Manitobans living with HIV; equiplots are an innovative method for visualizing these inequalities. Alongside future research aiming to understand why inequalities exist across the cascade in Manitoba, our equity analyses can generate hypotheses and provide evidence to inform patient-centred care plans that meet the needs of diverse client subgroups and advocate for policy changes that facilitate more equitable HIV care across the province.

Examining Correlates of Pre-ART and Early ART Adherence to Identify Key Factors Influencing Adherence Readiness

Although current standard of care for HIV typically involves immediate initiation of antiretroviral therapy (ART), most patients can benefit from first assessing adherence readiness and addressing any barriers to optimal adherence. A sample of 176 HIV patients planning to start ART enrolled in a controlled trial of an adherence intervention that was based on the Information Motivation and Behavioral skills (IMB) model of health behavior. We examined correlates of multiple adherence readiness measures, as well as electronically measured early ART adherence, to identify variables most important for readiness to adhere well at the start of treatment. Education level, recency of HIV diagnosis and knowledge and commitment to adherence were found to be associated with both ART readiness and early ART adherence. These findings suggest that resources to support adherence readiness should target more experienced HIV patients, and strive to bolster knowledge and attitudes that reinforce commitment to adherence.

Development of the Canadian Women-Centred HIV Care Model Using the Knowledge-to-Action Framework

In Canada, women make up 25% of the prevalent HIV cases and represent an important population of those living with HIV, as a high proportion are racialized and systemically marginalized; furthermore, many have unmet healthcare needs. Using the knowledge-to-action framework as an implementation science methodology, we developed the "Women-Centred HIV Care" (WCHC) Model to address the needs of women living with HIV. The WCHC Model is depicted in the shape of a house with trauma- and violence-aware care as the "foundation". Person-centred care with attention with attention to social determinants of health and family make up the "first" floor. Women's health (including sexual and reproductive health and rights) and mental and addiction health care are integrated with HIV care, forming the "second" floor. Peer support, leadership, and capacity building make up the "roof". To address the priorities of women living with HIV in all their diversity and across their life course, the WCHC Model should be flexible in its delivery (e.g., single provider, interdisciplinary clinic or multiple providers) and implementation settings (e.g., urban, rural).

HIV viral load trajectories of women living with HIV in Metro Vancouver, Canada

This study describes long-term viral load (VL) trajectories and their predictors among women living with HIV (WLWH), using data from Sexual Health and HIV/AIDS: Women's Longitudinal Needs Assessment (SHAWNA), an open prospective cohort study with linkages to the HIV/AIDS Drug Treatment Program. Using Latent Class Growth Analysis (LCGA) on a sample of 153 WLWH (1088 observations), three distinct trajectories of detectable VL (≥50 copies/ml) were identified: 'sustained low probability of detectable VL', characterized by high probability of long-term VL undetectability (51% of participants); 'high probability of delayed viral undetectability', characterized by a high probability VL detectability at baseline that decreases over time (43% of participants); and 'high probability of detectable VL', characterized by a high probability of long-term VL detectability (7% of participants). In multivariable analysis, incarceration (adjusted odds ratio (AOR) = 3.24; 95%CI:1.34-7.82), younger age (AOR = 0.96; 95%CI:0.92-1.00), and lower CD4 count (AOR = 0.82; 95%CI:0.72-0.93) were associated with 'high probability of delayed viral undetectability' compared to 'sustained low probability of detectable VL.' This study reveals the dynamic and heterogeneous nature of WLWH's long-term VL patterns, and highlights the need for early engagement in HIV care among young WLWH and programs to mitigate the destabilizing impact of incarceration on WLWH's HIV treatment outcomes.

Sex Differences in the Treatment of HIV

PURPOSE OF REVIEW

Biological and societal influences are different for men and women leading to different HIV outcomes and related infectious and non-infectious complications. This review evaluates sex differences in the epidemiology and immunological response to HIV and looks at major complications and coinfections, as well as care delivery systems focusing on low- and middle-income countries (LMICs) where most people with HIV live.

RECENT FINDINGS

More women than men access testing and treatment services in LMIC; women are more likely to be virologically suppressed in that environment. There is a growing recognition that the enhanced immunological response to several pathogens including HIV may result in improved outcomes for infectious comorbidities but may result in a greater burden of non-communicable diseases. Men and women have different requirements for HIV care. Attention to these differences may improve outcomes for all.

Prolonged Amenorrhea and Low Hip Bone Mineral Density in Women Living With HIV-A Controlled Cross-sectional Study

BACKGROUND

Women living with HIV (WLWH) have higher rates of prolonged secondary amenorrhea (no flow for ≥1 year) than HIV-negative women. Both having amenorrhea and being HIV positive are associated with lower areal bone mineral density (BMD). However, their combined BMD effects remain unclear. Therefore, we investigated prolonged amenorrhea and BMD in WLWH and controls.

METHODS

This cross-sectional study enrolled WLWH and HIV-negative control women aged 19-68 years of similar backgrounds. We assessed BMD (Hologic; as age- and ethnicity-matched Z-scores) in the Children and women: AntiRetrovirals and Markers of Aging cohort. Participants were stratified by amenorrhea history defined as past/present lack of menses for ≥1 year at age 45 and younger and not because of surgery, breastfeeding, pregnancy, or hormonal contraception. Hip and spine Z-scores by amenorrhea/no amenorrhea used linear models with multivariable analysis for relationships within WLWH.

RESULTS

WLWH (N = 129) were similar to controls (N = 129) in age, body mass index, ethnicity, and substance use. Among WLWH, 21% experienced prolonged amenorrhea vs. 9% in controls. WLWH had significantly lower total hip (mean ± SD: -0.4 ± 0.9 vs. 0.3 ± 1.1; P < 0.001) and spine (-0.5 ± 1.3 vs. 0.2 ± 1.3; P = 0.001) Z-scores than controls. Amenorrhea was independently associated with hip (P = 0.01) but not spine (P = 0.94) BMD by multivariable linear regression. WLWH with amenorrhea had lower hip Z-scores (-0.8 ± 0.9) than those without (-0.3 ± 0.8; P = 0.01). They also had higher rates of substance use, smoking, opioid therapy, hepatitis C coinfection, and lower CD4 nadir.

CONCLUSIONS

WLWH had higher rates of prolonged amenorrhea and lower BMD than controls. WLWH with amenorrhea experienced lower hip BMD Z-scores than those without. Prolonged amenorrhea is an added osteoporosis risk in WLWH.

Interrupted Time Series of User-centered Clinical Decision Support Implementation for Emergency Department-initiated Buprenorphine for Opioid Use Disorder

OBJECTIVES

Adoption of emergency department (ED) initiation of buprenorphine (BUP) for opioid use disorder (OUD) into routine emergency care has been slow, partly due to clinicians' unfamiliarity with this practice and perceptions that it is complicated and time-consuming. To address these barriers and guide emergency clinicians through the process of BUP initiation, we implemented a user-centered computerized clinical decision support system (CDS). This study was conducted to assess the feasibility of implementation and to evaluate the preliminary efficacy of the intervention to increase the rate of ED-initiated BUP.

METHODS

An interrupted time series study was conducted in an urban, academic ED from April 2018 to February 2019 (preimplementation phase), March 2019 to August 2019 (implementation phase), and September 2019 to December 2019 (maintenance phase) to study the effect of the intervention on adult ED patients identified by a validated electronic health record (EHR)-based computable phenotype consisting of structured data consistent with potential cases of OUD who would benefit from BUP treatment. The intervention offers flexible CDS for identification of OUD, assessment of opioid withdrawal, and motivation of readiness to start treatment and automates EHR activities related to ED initiation of BUP (including documentation, orders, prescribing, and referral). The primary outcome was the rate of ED-initiated BUP. Secondary outcomes were launch of the intervention, prescription for naloxone at ED discharge, and referral for ongoing addiction treatment.

RESULTS

Of the 141,041 unique patients presenting to the ED over the preimplementation and implementation phases (i.e., the phases used in primary analysis), 906 (574 preimplementation and 332 implementation) met OUD phenotype and inclusion criteria. The rate of BUP initiation increased from 3.5% (20/574) in the preimplementation phase to 6.6% (22/332) in the implementation phase (p = 0.03). After the temporal trend of the number of physician's with X-waiver training and other covariates were adjusted for, the relative risk of BUP initiation rate was 2.73 (95% confidence interval [CI] = 0.62 to 12.0, p = 0.18). Similarly, the number of unique attendings who initiated BUP increased modestly 7/53 (13.0%) to 13/57 (22.8%, p = 0.10) after offering just-in-time training during the implementation period. The rate of naloxone prescribed at discharge also increased (6.5% preimplementation and 11.5% implementation; p < 0.01). The intervention received a system usability scale score of 82.0 (95% CI = 76.7 to 87.2).

CONCLUSION

Implementation of user-centered CDS at a single ED was feasible, acceptable, and associated with increased rates of ED-initiated BUP and naloxone prescribing in patients with OUD and a doubling of the number of unique physicians adopting the practice. We have implemented this intervention across several health systems in an ongoing trial to assess its effectiveness, scalability, and generalizability.

Assessing Gaps in Comprehensive HIV Care Across Settings of Care for Women Living with HIV in Canada

Background: Women living with HIV in Canada experience barriers to comprehensive HIV care. We sought to describe care gaps across a typology of care. Methods: We analyzed baseline data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS). A typology of care was characterized by primary HIV physician and care setting. Quality-of-care indicators included the following: Pap test, Pap test discussions, reproductive goal discussions, breast cancer screening, antiretroviral therapy (ART) use, adherence, HIV viral load, and viral load discussions. We defined comprehensive care with three indicators: Pap test, viral load, and either reproductive goal discussions over last 3 years or breast cancer screening, as indicated. Multivariable logistic regression analyses measured associations between care types and quality-of-care indicators. Results: Among women living with HIV accessing HIV care, 56.4% (657/1,164) experienced at least one gap in comprehensive care, most commonly reproductive goal discussions. Women accessed care from three types of care: (1) physicians (specialist and family physicians) in HIV clinics (71.6%); (2) specialists in non-HIV clinics (17.6%); and (3) family physicians in non-HIV clinics (10.8%), with 55.5%, 63.9%, and 50.8% gaps in comprehensive care, respectively. Type 3 care had double the odds of not being on ART: adjusted odds ratio (AOR 2.09, 95% confidence interval [CI] 1.16-3.75), while Type 2 care had higher odds of not having discussed the importance of Pap tests (AOR 1.48, 95% CI 1.00-2.21). Discussion: Women continue to experience gaps in care, across types of care, indicating the need to evaluate and strengthen women-centered models of care.

A "one stop liver shop" approach improves the cascade-of-care for Aboriginal and Torres Strait Islander Australians living with chronic hepatitis B in the Northern Territory of Australia: results of a novel care delivery model

BACKGROUND

Aboriginal and Torres Strait Islander Australians are disproportionately affected by Chronic Hepatitis B (CHB) with a prevalence of 6.08% in the Northern Territory (NT) and liver cancer rates 6 times higher than non-Indigenous Australians. Without appropriate care, overall 25% of those living with CHB will die from either liver failure or liver cancer, outcomes that can be minimised with regular follow up, antiviral treatment and hepatocellular carcinoma (HCC) screening. This care including antiviral treatment is publicly funded in the Australian setting however the care cascade still shows inequities in access to treatment for Aboriginal Australians. We describe the impact of a mobile care delivery model, "One Stop Liver Shop", on the cascade of care for people living with CHB in a remote Australian setting.

METHODS

A retrospective analysis was performed for CHB care received between 2013 and 2018 in one very remote Northern Territory community, where the "One Stop Liver Shop" was iteratively developed with the community. Patients with positive Hepatitis B virus surface antigen (HBsAg) were identified through electronic medical records. Proportions of patients who are up-to-date with monitoring investigations and HCC screening were evaluated and compared to national guidelines and targets.

RESULTS

Eighty-three HBsAg positive patients were evaluated. Eighty-eight percent were engaged in care, 16% of whom were receiving antiviral treatment. Liver function tests (LFT) were up to date in 71% of patients in 2013 and 88% in 2018. Viral load (VL) monitoring was up to date for 61 (73%) of patients. There were 44 patients in whom HCC screening was indicated. Of these, 38 (86.4%) were up to date with 6 monthly alpha-fetoprotein (AFP), 35 (79.5%) were up to date with 6 monthly liver ultrasound scan (USS), and 34 (77.3%) were up-to-date for both.

CONCLUSIONS

A "One Stop Liver Shop" developed with and including Aboriginal Health Practitioners bridges gaps in the availability of services to those living with CHB in a very remote community and improves the cascade of care.

Social Determinants of Health and Retention in HIV Care Among Recently Incarcerated Women Living with HIV in Canada

Women living with HIV (WLWH) are over-represented in corrections in Canada, yet little is known about women's experiences post-release. We used CHIWOS cross-sectional data from WLWH to estimate associations between social determinants of health and HIV-related care outcomes among WLWH with recent (within past year) or ever (before past year) incarceration experience. Lifetime incarceration prevalence was 36.9% (6.5% recent; 30.4% ever), with significant differences by province of residence (British Columbia: 10% recent; 52% ever; Ontario: 5%; 24%; Quebec: 6%; 22%; p < 0.001). In adjusted multinomial logistic regression analyses, compared with never incarcerated, recent incarceration was associated with Indigenous ancestry, lower annual income (< $20,000 CAD), unstable housing, current sex work, injection drug use (IDU), and sub-optimal antiretroviral therapy (ART) adherence, while ever incarceration was associated with current sex work, IDU, and experiencing adulthood violence. Our findings have implications regarding supports needed by WLWH in the post-release period, including ART adherence and achieving health and social goals.

Codesigning care improvements for women living with HIV: a patient-oriented deliberative dialogue workshop in Montréal, Quebec

BACKGROUND

Care services have not been sufficiently adapted to meet the comprehensive care needs of women living with HIV. Our study objective was to engage patients and providers in codesigning care recommendations to improve care for this population in the province of Quebec.

METHODS

We conducted a 5-hour deliberative dialogue workshop in April 2019 in Montréal as the final phase of a mixed-methods study investigating comprehensive care for women living with HIV. The study drew on data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS). Recruitment was guided by a purposive maximum-variation sampling strategy to ensure an appropriate mix of participants and was facilitated by our existing CHIWOS networks. Participants included patients (women living with HIV) and HIV care providers (doctors, nurses, pharmacists). The workshop was facilitated professionally and included a synthesis of the evidence, small- and large-group deliberations, and voting on care improvements.

RESULTS

Eight patients and 8 HIV care providers participated. Drawing on identified care priorities, the participants identified 4 relatively rapid care improvements and 3 longer-term improvements. The rapid care improvements included delegating medical acts to members of multidisciplinary care teams; greater involvement of HIV community members within care settings and health care decision-making; creating a women's health information booklet; and increasing HIV education among all health care providers and raising awareness of women's care needs beyond HIV-specific care among HIV care providers. The longer-term care improvements included advocating for complete financial coverage of antiretroviral therapy within the government-sponsored Medicare program, facilitating access to allied care providers (e.g., physiotherapists and psychologists) and launching a population-wide campaign to increase awareness about the Undetectable = Untransmittable (U=U) initiative and other HIV advances.

INTERPRETATION

The deliberative dialogue workshop yielded evidence-based, stakeholder-driven recommendations to improve the comprehensive care of women living with HIV in Quebec.

Receipt of opioid agonist treatment halves the risk of HIV-1 RNA viral load rebound through improved ART adherence for HIV-infected women who use illicit drugs

BACKGROUND

Women living with HIV who use illicit drugs may be particularly vulnerable to HIV-1 RNA viral load (VL) rebound.

METHODS

We used longitudinal data from 2006 to 2017 to evaluate the impact of sociodemographic, behavioral, social-structural, and clinical factors on the hazard of viral rebound for women enrolled in the ACCESS study, a prospective cohort with systematic VL monitoring. Women were included if they achieved VL suppression (<50 copies/mL) following antiretroviral therapy (ART) initiation and had more than one study interview. Sociodemographic as well as substance use, social-structural, addiction treatment, and HIV clinical factors were evaluated as predictors of viral rebound (VL > 1000 copies/mL). Cox regressions using a recurrent events framework, time-varying covariates, robust standard errors, and a frailty component were used.

RESULTS

Of the 185 women included, 62 (34%) experienced at least one viral rebound event over an 11-year period, accumulating a total of 87 viral rebound events. In adjusted analysis, stimulant use more than doubled the hazard of viral rebound (adjusted hazard ratio [AHR]: 2.35, 95% confidence interval [CI]: 1.07-5.14) while the only factor protective against viral rebound was receipt of opioid agonist treatment (OAT) in the past six months (AHR: 0.46, 95% CI: 0.26-0.81). After adjusting for ART adherence in the past six months, the effect of OAT was attenuated (AHR: 0.57, 95% CI: 0.32-1.02).

CONCLUSIONS

Efforts to improve access to and retention within OAT programs and decrease stimulant use may improve rates of viral suppression for HIV-positive women who use illicit drugs.

The People Living with HIV (PLHIV) Resilience Scale: Development and Validation in Three Countries in the Context of the PLHIV Stigma Index

Supporting resilience among people living with HIV (PLHIV) is crucial to their sustained uptake of HIV services as well as psychological and social wellbeing. However, no measures exist to assess resilience specifically in relation to living with HIV. We developed the PLHIV Resilience Scale and evaluated its performance in surveys with 1207 PLHIV in Cameroon, Senegal and Uganda as part of the PLHIV Stigma Index-the most widely used tool to track stigma and discrimination among PLHIV worldwide. Factor analyses demonstrated satisfactory psychometric properties and reliability (alphas = 0.81-0.92). Levels of resilience (e.g., whether one's self-respect has been positively, negatively, or not affected by one's HIV status) varied substantially within and across countries. Higher resilience was associated with less depression in each country (all p < 0.001), and, in Cameroon and Uganda, better self-rated health and less experience of stigma/discrimination (all p < 0.001). The final 10-item PLHIV Resilience Scale can help inform interventions and policies.

Hiring, training, and supporting Peer Research Associates: Operationalizing community-based research principles within epidemiological studies by, with, and for women living with HIV

BACKGROUND

A community-based research (CBR) approach is critical to redressing the exclusion of women-particularly, traditionally marginalized women including those who use substances-from HIV research participation and benefit. However, few studies have articulated their process of involving and engaging peers, particularly within large-scale cohort studies of women living with HIV where gender, cultural and linguistic diversity, HIV stigma, substance use experience, and power inequities must be navigated.

METHODS

Through our work on the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS), Canada's largest community-collaborative longitudinal cohort of women living with HIV (n = 1422), we developed a comprehensive, regionally tailored approach for hiring, training, and supporting women living with HIV as Peer Research Associates (PRAs). To reflect the diversity of women with HIV in Canada, we initially hired 37 PRAs from British Columbia, Ontario, and Quebec, prioritizing women historically under-represented in research, including women who use or have used illicit drugs, and women living with HIV of other social identities including Indigenous, racialized, LGBTQ2S, and sex work communities, noting important points of intersection between these groups.

RESULTS

Building on PRAs' lived experience, research capacity was supported through a comprehensive, multi-phase, and evidence-based experiential training curriculum, with mentorship and support opportunities provided at various stages of the study. Challenges included the following: being responsive to PRAs' diversity; ensuring PRAs' health, well-being, safety, and confidentiality; supporting PRAs to navigate shifting roles in their community; and ensuring sufficient time and resources for the translation of materials between English and French. Opportunities included the following: mutual capacity building of PRAs and researchers; community-informed approaches to study the processes and challenges; enhanced recruitment of harder-to-reach populations; and stronger community partnerships facilitating advocacy and action on findings.

CONCLUSIONS

Community-collaborative studies are key to increasing the relevance and impact potential of research. For women living with HIV to participate in and benefit from HIV research, studies must foster inclusive, flexible, safe, and reciprocal approaches to PRA engagement, employment, and training tailored to regional contexts and women's lives. Recommendations for best practice are offered.

A scalable, automated warm handoff from the emergency department to community sites offering continued medication for opioid use disorder: Lessons learned from the EMBED trial stakeholders

BACKGROUND

In order to streamline the emergency department (ED) referral process in a multi-network automated opioid treatment referral program, we performed a needs assessment of community providers for Medication for Opioid Use Disorder (MOUD) in the EMergency department-initiated BuprenorphinE for opioid use Disorder (EMBED) trial network.

METHODS

A needs assessment was conducted in two phases: (1) key stakeholder meetings and (2) a survey of community sites offering MOUD. Stakeholder meetings were conducted with five key stakeholder groups: 1) ED clinicians and staff, 2) community sites offering MOUD, 3) the investigative team, 4) health system IT staff, and 5) medical ethics experts. Meetings continued until each stakeholder group stated that their priorities and needs were understood. Major categories of needs were extracted pragmatically based on recurrence across stakeholder groups. Informed by needs expressed by IT and MOUD site stakeholders, nineteen MOUD sites were surveyed to better characterize information needs of community sites offering MOUD when receiving an ED referral.

RESULTS

Three major categories of needs for referral system were identified: 1) The system to be automated, flexible and allow multiple channels of referral, 2) Referral metrics are retrievable in a HIPAA compliant manner, 3) Patients are scheduled into community sites offering MOUD as urgently as possible. Of the MOUD sites surveyed, 68.4% (13/19) responded. Based on the responses, specific patient identifiers were required for most MOUD site referrals, and encrypted emails and EHR were the preferred methods of communication for the handoff. 53.8% (7/13) of the sites were able to accept patients within 3 days with only 1 site requiring >7 days.

CONCLUSION

These findings can inform IT solutions to address the discordant priorities of the ED (rapid and flexible referral process) and the community sites offering (referrals minimize variability and overbooking). To prevent drop-out in the referral cascade, our findings emphasize the need for increased availability and accessibility to MOUD on demand and protected communication channels between EDs and community providers of MOUD.

Patterns of social determinants of health associated with drug use among women living with HIV in Canada: a latent class analysis

BACKGROUND AND AIMS

Identifying typologies of social determinants of health (SDoH) vulnerability influencing drug use practices among women living with HIV (WLWH) can help to address associated harms. This research aimed to explore the association of SDoH clusters with drug use among WLWH.

DESIGN

Latent class analysis (LCA) was used to identify the distinct clusters of SDoH. Inverse probability weighting (IPW) was employed to account for confounding and potential selection bias. Associations were analyzed using generalized linear model with log link and Poisson distribution, and then weighted risk ratio (RR) and 95% confidence intervals (CI) were reported.

SETTING AND PARTICIPANTS

Data from 1422 WLWH recruited at time-point 1 of the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS, 2013-15), with 1252 participants at 18 months follow-up (time-point 2).

MEASUREMENTS

Drug use was defined as use of illicit/non-prescribed opioids/stimulants in the past 6 months. SDoH indicators included: race discrimination, gender discrimination, HIV stigma, social support, access to care, food security, income level, employment status, education, housing status and histories of recent sex work and incarceration.

FINDINGS

LCA identified four SDoH classes: no/least SDoH adversities (6.6%), discrimination/stigma (17.7%), economic hardship (30.8%) and most SDoH adversities (45.0%). Drug use was reported by 17.5% and 17.2% at time-points 1 and 2, respectively. WLWH with no/least SDoH adversities were less likely to report drug use than those in economic hardship class (weighted RR = 0.13; 95% CIs = 0.03, 0.63), discrimination/stigma class (weighted RR = 0.15; 95% CIs = 0.03, 0.78), and most SDoH adversities class (weighted RR = 0.13; 95% CIs = 0.03, 0.58).

CONCLUSIONS

Social determinants of health vulnerabilities are associated with greater likelihood of drug use, underscoring the significance of addressing interlinked social determinants and drug use through the course of HIV care and treatment.

Social determinants of health and self-rated health status: A comparison between women with HIV and women without HIV from the general population in Canada

BACKGROUND

Women living with HIV (WLWH) continue to experience poorer outcomes across the HIV care cascade and overall health, an appreciable proportion of which may not be disease-related but due to socio-structural barriers that impact health. We compared socio-structural determinants of health and self-rated health between WLWH and expected general population values.

METHODS

Prevalences of socio-structural determinants and self-rated health were estimated from 1,422 WLWH aged 16+ in the 2013-2015 Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS). Prevalences were also estimated from 46,831 general population women (assumed HIV-negative) in the 2013-2014 Canadian Community Health Survey (CCHS), standardized to the age/ethnoracial group distribution of WLWH. Standardized prevalence differences (SPDs) and 95% confidence intervals (CI) were reported.

RESULTS

Compared to general population women, a higher proportion of WLWH reported annual personal income <$20,000 (SPD 42.2%; 95% CI: 39.1, 45.2), indicating that 42.2% of WLWH experienced this low income, in excess of what would be expected of Canadian women of similar ages/ethnoracial backgrounds. A higher proportion of WLWH reported severe food insecurity (SPD 43.9%; 40.2, 47.5), poor perceived social support (SPD 27.4%; 22.2, 33.0), frequent racial (SPD 36.8%; 31.9, 41.8) and gender (SPD 46.0%; 42.6, 51.6) discrimination, and poor/fair self-rated health (SPD 12.2%; 9.4, 15.0).

CONCLUSIONS

Significant socio-structural inequalities and lower self-rated health were found among WLWH compared to general population women. Such inequities support the integration of a social-determinants approach, social service delivery, and programming into HIV care, with additional resource allocation tailored to the particular needs of WLWH.