Background: GBM who use amphetamines experience increased likelihood of HIV transmission and poor adherence to antiretroviral therapy. We explored attitudes of GBM toward their amphetamine use and associations with reduced amphetamine use over time.

Methods: We recruited sexually-active GBM aged ≥16 years in Montreal, Toronto, and Vancouver using respondent-driven sampling (RDS) from from 02-2017 to 08-2019, with follow-up visits every 6–12 months. Among participants who reported past-six-month (P6M) amphetamine use at baseline, we used RDS-weighted logistic regression to identify associations with reporting needing help reducing their substance use. Comparing follow-up visits with the prior visit, we used mixed-effects logistic regression to model associations of reduced P6M amphetamine use.

Results: Of 2449 GBM enrolled, 423 self-reported as living with HIV (RDS-adjusted proportions: Montreal 12.7%, Toronto 18.4%, Vancouver 19.4%). At baseline, 727 (29.7%) reported P6M amphetamine use. Of these, 608 (83.6%) reported not needing help reducing their substance use. Reporting needing help reducing substance use was associated with group sex participation (adjusted odds ratio [AOR]=2.35, 95%CI: 1.25–4.44), HADS anxiety subscale scores ≥11 (AOR=2.11, 95%CI: 1.16–3.83), greater financial strain (AOR=1.35, 95%CI: 1.21–1.50), and greater Escape Motive Scale scores (AOR=1.07, 95%CI: 1.03–1.10). Self-reported HIV-positive status was associated with reporting needing help reducing substance use in univariable analyses (OR=2.90, 95%CI: 1.87–4.47), but was not selected for inclusion in the final multivariable model. Among 4441 follow-up visits, 534 (12.0%) were visits where participants reported decreased amphetamine use. Reduced P6M amphetamine-use was less likely among GBM who identified as African, Caribbean, or Black (AOR=0.40, 95%CI: 0.17–0.95), reported P6M ecstasy use (AOR=0.06, 95%CI: 0.04–0.09), or perceived their amphetamine use as problematic (AOR=0.12, 95%CI: 0.06–0.22).

Conclusions: Targeted interventions should focus on reaching the concentrated minority of GBM who need help reducing their substance use and view their amphetamine use as problematic but do not experience reduced use over time.

Previous Cedar Project research identified recently experiencing a non-fatal drug overdose was associated with increased risk of all-cause mortality. In the ongoing toxic drug crisis, closer examination of predictors of non-fatal overdose are important to address the disproportionate burden of overdose death among Indigenous peoples in BC.

This longitudinal study (2011-2016) comes from the Indigenous-governed Cedar Project cohort and examines factors associated with non-fatal overdose among young Indigenous peoples who use drugs in Vancouver and Prince George, BC. The primary outcome was a self-reported non-fatal overdose measured at semi-annual follow-ups. Prentice-Williams-Peterson models were used to examine factors associated with non-fatal overdose in men and women, separately. Results were adjusted for location, age, and calendar year.

Overall, 105 non-fatal overdoses were reported by 471 participants over 1032 person-years. The incidence rate was 9.53 per 100 person-years (95%CI:7.79-11.53), with no statistically significant difference between men and women. Living with HIV was not significantly associated with non-fatal overdose for men (aHR:2.00;95%CI:0.83-4.82) or women (aHR:0.68;95%CI:0.25-1.80).

Among men, homelessness (aHR:3.42;95%CI:1.76-6.64), thoughts of suicide (aHR:2.79;95%CI:1.29-6.02), injection drug use (aHR:21.99;95%CI:7.75-62.38), needing help to inject (aHR:5.00;95%CI:2.58-9.67), psychological distress (aHR:1.74;95%CI:1.24-2.44), and living with HCV (aHR:3.92;95%CI:1.85-8.31) were risk factors for non-fatal overdose. While speaking traditional language at home when growing up (aHR:0.42;95%CI:0.18-1.00) was protective against non-fatal overdose.

Among women, homelessness (aHR:3.10;95%CI:1.70-5.64), experiencing violence (aHR:2.82;95%CI:1.61-4.94), sex work (aHR:1.98;95%CI:1.12-3.49), sexual assault (aHR:2.95;95%CI:1.29-6.77), thoughts of suicide (aHR:3.35;95%CI:2.05-5.46), psychological distress (aHR:1.74;95%CI:1.32-2.30), injection drug use (aHR:7.43;95%CI:3.98-13.85), alcohol bingeing (aHR:1.90;95%CI:1.01-3.59), trying unsuccessfully to access treatment (aHR:2.03;95%CI:1.03-4.02), needing help to inject (aHR:4.35;95%CI:2.49-7.59), and having been admitted to hospital (aHR:2.42;95%CI:1.30-4.50) were associated with non-fatal overdose.

These findings highlight the adverse role of structural violence and protective role of Indigenous language on non-fatal overdose among young Indigenous peoples in BC. There is an urgent need for safe supply and Indigenous-led policies to curtail trauma and deaths from drug overdoses.

Background: Use of illicit fentanyl and related analogues may lead to more frequent injections and risky injection-related practices. We investigated the association between injection fentanyl use and sharing of injection equipment among who people who inject drugs.

Methods: In a cross-sectional study in Toronto, we surveyed 249 people who inject drugs in 2019 whom we recruited in supervised consumptions services. We estimated the average marginal effect of fentanyl injection frequency (daily, less than daily, none) on the probability of sharing injection equipment, adjusting for age, gender, incarceration, homelessness, and frequencies of other drugs injected.

Results: In the last 6 months, 117 (47.0%) of participants injected fentanyl daily, 49 (19.7%) less-than-daily, and 78 (31.3%) did not inject fentanyl. Multivariable models showed that participants injecting fentanyl daily had probabilities of 23.9% (95% confidence level [CI] 14.0%, 32.7.%) of sharing a syringe, 41.2% (95% CI 30.9%, 51.5%) of sharing a cooker, and 29.1% (95% CI 19.3, 38.9) of sharing a filter. Participants injecting fentanyl less-than-daily had probabilities of 20.9% (95% CI 4.2%, 37.6%) of sharing a syringe, 36.3% (95% CI 17.5, 55.1)of sharing a cooker, and 29.4% (95% CI 11.2%, 47.7%) of sharing a filter. Participants who did not inject fentanyl had probabilities of 5.5% (95% CI 0.0%, 11.7%) of sharing a syringe, 12.4% (95% CI 3.0%, 21.8%) of sharing a cooker, and 11.3% (95% CI 2.6%, 20.1%) of sharing a filter.

Conclusions: People who regularly used fentanyl reported injection practices that increased risk for infectious disease transmission. Innovative approaches to reduce these risks are needed.

Background: If HIV self-testing is to function as one of the prevention tools in our toolbox, then its implementation needs to adapt to external factors, including regional and population specific contexts. GetaKit – a research study to observe the outcomes of mailout HIV self-testing in the real-world – started as a pilot in the Ottawa region in July 2020 and expanded to 18 sites across Ontario since April 2021. This rapid scale-up across multiple diverse regions was informed by a complex adaptive system theory approach and was built on the premise that HIV testing – and self-testing – will not have uptake among diverse persons at-risk for HIV using a one-size-fits-all approach.

Methods: The implementation strategy for GetaKit includes: a division of labour between the core research team and ASO partner sites across Ontario; the identification of patterns of self-organization that permit flexibility and adaptability; and partnership with ASOs to implement local status-neutral linkage to prevention and care pathways.

Results: Using complex adaptive system theory to expand the GetaKit study reduced implementation timelines from 5 months to 4 weeks. ASO partners provided timely feedback and information that shaped training and resources, informed new registration pathways for participants with access barriers, and developed strategic promotional approaches to raise awareness of HIV self-testing among diverse people at high-risk for HIV.

Conclusions: Public health interventions are implemented in complex systems, requiring timely response to feedback and flexibility to adjust to local contexts. Moreover, self-testing requires a robust resource landscape to ensure that positive results are confirmed, people newly diagnosed are linked to HIV care, and people who test negative are linked to prevention services. GetaKit is an example of using a complexity lens to ensure that HIV self-testing is an effective conduit into the status-neutral care cascade across a varied landscape.

Sexual health reports continue to show increasing trends of sexually transmitted infections (STIs) in Canada. Even though the evidence on racial STIs disparities is limited, the few non-representational studies suggest some racial groups are disproportionately impacted. Effective use of appropriate health services could enhance timely diagnosis and subsequent treatment especially among racialized populations who often have limited access to resources. That notwithstanding, there is a dearth of research on how racialized groups access and use STI health services in Canada. We contribute to this gap by examining heterosexual African, Caribbean, and Black (ACB) men’s STI status and their access to health services in Toronto, Canada. We used complementary log-log regression to analyze survey data (n=240) that was collected between March 2018 and February 2019 from heterosexual ACB men in Toronto. The findings show that 18.3% of heterosexual ACB men have a history of one or more STIs diagnoses either in the past six months or over six months ago. The most common STIs were HIV (6.6%) and Chlamydia (7.7%). Multivariate results revealed that ACB men with a history of STI diagnosis (OR=1.99, CI=1.14, 3.49) encountered challenges accessing healthcare in the 12 months prior the survey. Other factors such as having no family doctor (OR=1.88, CI=1.20, 2.95), being immigrant (OR=1.93, CI=1.19, 3.15), having language difficulty (OR=1.85, CI=1.01, 3.41), and experiencing housing instability (OR=1.56, CI=1.05,2.32) were associated with higher odds of experiencing difficulty accessing healthcare. These findings are discussed within the broader concept of marginalization and the burden of STIs among heterosexual ACB men. We also recommend the need to pay attention to structural factors and social determinants of health that increase ACB and other marginalized populations’ susceptibility to STIs as well as inhibit their access to STI health services.

Background: Women living with HIV are at higher risk for cervical and other HPV-related cancers due to biological synergies between HIV and HPV. National immunization guidelines recommend HPV vaccine for people living with HIV up to 27 years of age. We measured HPV vaccine coverage among women attending HIV care in Ontario and identified socio-demographic, behavioural, and clinical characteristics associated with HPV vaccination.

Methods: The Ontario HIV Treatment Network Cohort Study is a multi-site clinical cohort. Participants who self-identified as a cis- or trans-woman completed a one-time questionnaire on HPV vaccine knowledge and receipt during annual interviews (2017-2020). We used logistic regression to derive age-adjusted odds ratios (aOR) and 95% confidence intervals (CI) to identify factors associated with self-reported vaccine uptake (≥1 dose).

Results: Among 592 women (median age=48 years; 58.3% immigrants from countries with generalized HIV epidemics), 13.2% had received ≥1 dose. Of those vaccinated, 64.6% had received the full 3-dose series. Among unvaccinated women, just over half (56.3%) had heard of HPV vaccine (vs. 100% of vaccinated women). Vaccine coverage was significantly higher among women aged 20-29 years at 31.0% but fell to 13.9% in those aged 30-49 years and <10% in those aged ≥50 years. The median age at first dose was 40 years. After adjusting for age, vaccine uptake was significantly associated with being employed (aOR=3.44, 95%CI=1.29-9.19), higher income ($40,000-$59,999 vs. <$20,000; aOR=3.08, 95%CI=1.41-6.73), being married/common-law (aOR=1.96, 95%CI=1.09-3.52), living with children (aOR=2.39, 95%CI=1.37-4.16), immigrating to Canada >5 years ago (aOR=3.13, 95%CI=1.35-7.25), never smoking (aOR=2.10, 95%CI=1.02-4.35), and being in HIV care longer (per 10 years; aOR=1.86, 95%CI=1.27-2.71).

Conclusions: HPV vaccine knowledge and coverage remains low among women engaged in HIV care in Ontario, even among younger women most likely to benefit from vaccination. Socioeconomic factors and healthcare access facilitators were identified as key variables influencing uptake.

“Undetectable=Untransmittable”, or U=U, is a powerful public health message designed to reduce HIV stigma and help communicate the scientific consensus that HIV cannot be sexually transmitted when a person living with HIV has an undetectable viral load. Between October 2020-February 2021 we conducted 11 in-depth interviews and 3 focus groups with diverse HIV/STI service providers (nurses, public health workers, physicians, sexual health educators) in Ontario, Canada (n=18). Our objective was to understand how the U=U message was communicated to sexual health service users. Interview questions were embedded in a larger study focused on improving access to HIV/STI testing. Transcripts were transcribed verbatim and analysed following grounded theory. Most providers emphasized the significance of this biomedical advancement in HIV prevention but had some challenges effectively communicating U=U in everyday practice. We discovered four interrelated barriers related to consistently communicating the U=U message: (1) provider-perceived limitations of the framing (e.g., a few participants wanted to “leave a margin” of risk and were not comfortable with “zero HIV risk” messages); (2) service users not interested in receiving sexual health information (e.g., in order to provide “client centered care” some providers did not share U=U messages if service users were only interested in HIV/STI testing or if other discussions needed prioritization); (3) skepticism and HIV stigma from service users (e.g., providers explained how the hesitancy of some service users accepting the U=U message was shaped by a legacy of HIV prevention messages and persistent HIV stigma); and (4) need for more culturally competent resources (e.g., U=U resources needed for communities other than sexual and gender minority men; non-English speakers). We discuss ways to overcome barriers to communicating the U=U message as well as the limitations and potential unintended consequences of U=U framings in the context of persistent unequal access to HIV prevention and treatment.

Background:
Kotawe (start a fire): Igniting cultural responsiveness through community-determined intervention research has created an opportunity for Indigenous women to reflect on and explore their relationships to their health and well-being and integrate traditional teachings of women’s and girls’ roles, responsibilities, ceremonies, songs, medicines and rites through ongoing, seasonally-driven, cultural intervention practices at All Nations Hope Network (ANHN). Indigenous people are over-represented in HIV/AIDS statistics, and the literature indicates that Indigenous women, in particular, are the most marginalized population in Canada. Yet there is a startling lack of gender-specific, Indigenous-specific, HIV/AIDS resources, programs and services.

Method:
The Kotawe project has provided an opportunity for seven Indigenous women (Willow Warriors) to participate in Cultural Intervention Practices (CIP's) for a duration of 36 months in Saskatchewan. The goal of the study is to develop, implement, and assess the impact of land- and gender-based cultural interventions, addressing risk behaviours and contexts, mental health and trauma, and foster wellness among Indigenous women.
We have achieved this goal by exploring the women’s experiences of the Cultural Intervention Practices in social, environmental, physical, spiritual, emotional, intellectual ways.

Results:
The Kotawe project initiatives have come to encompass a range of culturally safe practices and programs proven to reduce the harms of colonial violence against Indigenous women. The focus has been on decreasing individual harm from problematic substance use through the provision of specific Indigenous knowledges, practices, and services has demonstrated an Indigenous woman’s cultural safe harm reduction approach. The seasonal CIP's provide a gender-based analysis, including a determinants of health lens, to explore reducing harms associated with Indigenous women’s experience from colonial violence. Through this work, the Willow Warriors have expressed that their high-risk behaviours have decreased, and they have begun their healing journey towards wellness.