Background: There are over 7.5 million older (age 50+) people living with HIV (PLWH) around the world, and in resource-rich settings, close to 40% of PLWH will be at least 60 years old within the decade. Although this population is strong - both in numbers and experience - older PLWH face challenges having their living expertise acknowledged and their unmet needs (physical, mental, social, financial) addressed by peers, community-based organizations, healthcare providers, policy makers, and global leaders in the HIV response due to persistent ageism.

Actions: To harness the momentum of the first-ever face-to-face networking zone for ageing and older PLWH held at AIDS 2022, representatives from four civil society organizations established a grassroots network called the International Coalition of Older People with HIV (iCOPe HIV). The founding organizational members are leaders in their own jurisdictions when it comes to improving care, optimizing quality of life and fostering empowerment among ageing and older PLWH. Their first collaborative undertaking was to pen and gather support for the Glasgow Manifesto.

Outcome: The Glasgow Manifesto, launched in October 2022, is a call to action by ageing and older PLWH and their allies. The preamble of this living document describes the pressing need to adapt current HIV responses to better address the challenges facing a growing number of older PLWH worldwide. Diverse stakeholders are called upon to implement 10 actions across three domains – care, quality of life, and empowerment. By December 2022, 123 organizations representing every continent had endorsed the Manifesto, committing to advocate for change in their own settings.

Next Steps: iCOPe HIV’s founding members continue to rally and engage stakeholders with a mutual interest in equitable health outcomes for ageing and older PLWH in the process of identifying strategic priorities, establishing an inclusive governance and membership model, and planning for sustainability.

HIV stigma negatively affects the health and wellbeing of people living with HIV, with certain populations continuing to be disproportionately affected and often facing intersecting stigmas. While studies have examined the impacts of ethnicity, gender, and sexual orientation on HIV stigma separately, less is known about how these factors may intersect, and potentially exacerbate levels of HIV stigma. To fill this gap, this study aims to examine how these intersecting identities may impact levels of internalized, enacted, and anticipated stigma among people living with HIV in Canada.

Participants were recruited in Ontario, Alberta, and Québec (n=1064) as part of the People Living with HIV Stigma Index study in Canada. This global survey tool was created by and for people living with HIV and contains quantitative scales to measure different types of stigma. Three-way analyses were conducted to examine the effect of intersecting identities on types of stigma. Interaction terms were created by taking the product of the main effects of ethnicity, gender, and sexual orientation with a model being created for enacted, internalized, and anticipated stigma as outcomes.

Levels of internalized, enacted, and anticipated stigma were consistent across most intersecting groups within the sample; however, people occupying certain intersections had significantly higher levels of stigma. For internalized stigma, African, Caribbean, and Black lesbian females had the highest scores (b = 0.80, p=0.09), while Indigenous lesbian females had elevated scores for enacted (b = 1.24, p=0.01) and anticipated stigma (b = 0.71, p=0.09).

Overall, we saw consistent levels of HIV stigma across many key populations, with people in a few specific intersections displaying increased levels. These findings indicate that HIV interventions and programs tailored to specific population at the intersections of ethnicity, gender, and sexual orientation may be effective at reducing HIV stigma and optimizing individual and population health outcomes.

Contexte :
Le dévoilement du statut sérologique est un défi pour les personnes vivant avec le VIH (PVVIH). Dans certaines circonstances, les PVVIH doivent dévoiler leur statut sérologique sans pouvoir choisir la manière appropriée pour le faire. Nous nous sommes intéressé·es à l’impact de la crise sanitaire de la COVID-19 sur le dévoilement non volontaire du statut sérologique.

Méthodes :
Dans le cadre du programme multi-pays EPIC, un questionnaire personnalisé a été diffusé au Québec pour évaluer l'impact de la crise sanitaire auprès des PVVIH entre juillet et novembre 2021. Les personnes ayant eu l'expérience d'un dévoilement non volontaire du statut sérologique ont été comparées aux personnes qui n'ont pas dévoilé sur différents facteurs socio-économiques à l'aide de tests Mann-Whitney ou Chi-2.

Résultats :
Au total, 173 PVVIH (âge médian, IQR : 47 ans [38-59]) ont répondu au questionnaire. Parmi elles, 30% (n=52) ont indiqué que la crise sanitaire les a obligées à dévoiler leur séropositivité. Les personnes ayant dévoilé leur statut sérologique étaient plus jeunes que celles qui ne l'ont pas fait (41ans [33-56] vs 51ans [41-61], p<0,001). Elles avaient plus souvent besoin d'une aide financière (73% vs 47%, p=0,003) ou alimentaire (65% vs 44%, p=0,015). Elles ont aussi plus souvent ressenti un impact négatif de la crise sanitaire sur leur vie personnelle (64% vs 46%, p=0,034). Enfin, Elles étaient plus susceptibles d’avoir interrompu leurs traitements (22% vs 6,1%, p=0,006) ou d’avoir une charge virale détectable (40% vs 8,2%, p<0,001).

Conclusions :
Le jeune âge, le faible revenu, le besoin d'un soutien alimentaire, le bien-être réduit et la non-adhérence aux traitements étaient des facteurs socio-économiques associés au dévoilement non volontaire du statut VIH pendant la crise COVID-19. D'autres études sont maintenant nécessaires pour comprendre l'impact du dévoilement non volontaire pendant la crise sanitaire sur le bien-être des PVVIH.

Background: Sexual relationship power (SRP) inequities, including dominance in condom use decision-making, have been associated with increased HIV incidence among heterosexual women. However, studies and measures of SRP are limited among queer, trans, and non-monogamous young women and non-binary youth (YWNB). The aim of this analysis is to understand how YWNB in diverse relationships perceive condom use decision-making within their intimate relationships.

Methods: Between August-November 2022, cognitive interviews were conducted with gender-inclusive YWNB aged 17-29 living in British Columbia with recent experience (within 12 months) in non-heterosexual and/or non-monogamous relationships. Participants were asked to think aloud about their response and reflect on the relevance of one item of the SRP decision-making dominance sub-scale: “Who usually has more say [you, your partner, both equally] about whether you use condoms/protection.” Interviews were conducted virtually, audio-recorded, transcribed and analyzed using thematic analysis.

Results: Of 30 YWNB (median age=23.5), 46.7% identified as women, 46.7% as non-binary, and 6.7% were unsure/questioning. Most youth identified as pansexual/bisexual/queer (76.7%) or gay/lesbian (20%), with half reporting being in non-monogamous relationships. The relevance of condom use decision-making in youth’s relationships varied, with many YWNB, especially those not having sex with penises, stating the question was not applicable. Those who felt the question was important and applicable discussed condom use as a mutual decision made with partners, either as contraception or one of the multiple and more relevant ways (e.g., testing, open communication, and PreP) they navigated safer sex practices with sexual partners.

Discussion: Our findings reveal that current measurement of SRP dynamics and HIV/STI prevention strategies, particularly pertaining to condom use, may misrepresent diverse youths’ experiences and agency in their sexual decision-making. Additional measures, research, and sexual health promotion that are relevant and reflective of the diverse needs and experiences of queer, trans, and non-monogamous YWNB are required.

Background:
Newcomer immigrants are less likely to have a primary healthcare provider.
Among GBM immigrants, the lack of primary healthcare may lead to lower PrEP uptake.

Methods:
We examined data from Engage, a cohort study of GBM aged ≥16 years, recruited through respondent-driven sampling (RDS) (02/2017-08/2019) in Montreal, Toronto, and Vancouver, focusing on sexually active PrEP-eligible GBM (HIV Risk Index Score ≥10). We used RDS-II-adjusted structural equation modelling to investigate how primary healthcare provider and sexual health clinic utilization reported at enrolment accounted for differences in PrEP uptake between non-immigrants, newcomer (≤5 years in Canada), recent (6 – 10 years), and established (>10 years) immigrants, controlling for various socio-demographic variables (e.g., age, education, etc.).

Results:
A total of 1351 participants (17.9% newcomer, 6.0% recent, and 12.3% established immigrants) were considered PrEP-eligible ––24.4% reported PrEP use in the past 6 months, 65.5% having a primary healthcare provider, and 54.9% utilizing other clinics for STI testing.

Primary healthcare provider (not sexual health clinic) utilization was associated with PrEP uptake (see Figure). There was an indirect effect of immigration such that newcomer immigrants
were less likely to be on PrEP because they were less likely to have a primary healthcare provider.

Conclusion:
These findings suggest that primary healthcare providers may be important for PrEP access among GBM. Given unequal access to primary healthcare providers among newcomer immigrants versus non-immigrants, it is important to minimize barriers to newcomer healthcare access in order to improve PrEP uptake.

The Peer Navigator Project (PNP) is a collaborative research project that brings together researchers and community partners in Canada (Toronto, Vancouver, London) and Kenya (Eldoret, Huruma, Kitale) to explore and evaluate the use of peer supports for street-connected youths’ (SCY) access to HIV and AIDS prevention, testing, and treatment. SCY can cross several key populations, including but not limited to people who use drugs, sex workers, sexual and gender minorities, and African and Black populations. Six peer navigators (PNs) are currently working in five of the study sites, and the project is using quantitative and qualitative data to monitor the PNs interactions with SCY, with a focus on the increased uptake of HIV testing and access to treatment for youth living with or at risk of HIV. Overall, the PN model has been an adaptable and well-received addition to all of the project sites. SCY have improved access to HIV care and have been offered a range of HIV and social service referrals. PNs are positive role models who encourage and support the well-being of youth. However, the PNs must also navigate several structural and systemic challenges based on intersecting stigma of HIV and housing insecurity for SCY to receive ongoing healthcare access. A sustainable PN program needs to advocate for greater recognition of SCYs access to healthcare as a human right.

HIV stigma negatively impacts the health of people living with HIV; however, less is known about the determinants of stigma and how these may affect an individual’s health. We examined the impact of different types of stigma on self-rated overall health and the health risks and protective factors that may contribute to or buffer (lessen) the experiences of stigma in a sample of people living with HIV from Atlantic Canada.

There were 81 people living with HIV recruited from provinces across Atlantic Canada to complete the People Living with HIV Stigma Index, a global survey tool developed by people with HIV to measure nuanced changes in stigma. Health risks (alcohol and drug misuse, depression, low income, lack of basic needs, and unemployment) and protective factors (social support, self-efficacy, and resiliency) were assessed, and health risk and protective factor scores were established for each person. Chi-squared tests were used to examine how scores impact rates of internalized, enacted, and anticipated stigma.

Rates of internalized stigma were high (58%) but not significantly associated with self-rated health, while enacted and anticipated stigma were higher (84% and 85%, respectively) and both were associated with lower self-rated health (p<0.01). For those with more than two health risks, rates increased significantly for internalized (33% to 65%, p=0.02), enacted (61% to 90%, p<0.01), and anticipated stigma (67% to 90%, p<0.01). Protective factors had the opposite effect, with increased scores seeing decrease in internalized stigma scores (90% to 46%, p<0.01), but not for enacted or anticipated stigma.

Increasing health risks can have a significant and added impact on experiences of stigma and downstream negative impact on self-rated overall health. Interventions aimed at bolstering internal (e.g., self-efficacy) and external (e.g., social support) resources may help to reduce rates of internalized stigma and associated negative effects on health and wellbeing.

Background: In 2021, global experts published the "Consensus statement on the role of health systems in advancing the long-term well-being of people living with HIV" (PLWH) which culminates in five recommendations. To catalyze policy changes that optimize the well-being of PLWH in Canada, these recommendations need interpreting through the lens of our national HIV response and systems of care. A Canadian companion document is being co-created to guide future action.

Methods: With support from the National Community Advisory Committee on Optimal Health and Well-being in HIV (NCAG), Realize is holding six deliberative dialogues (DDs) to engage diverse stakeholders in Canada’s HIV response (PLWH, HIV organizations, clinicians). The voices of Indigenous and Francophone communities and PLWH are amplified. DD co-facilitators familiarize participants with the global statement and facilitate identification of priority areas for systems change in the Canadian context using interactive dialogue and activities. Notes and recordings enable thematic analysis.

Results: The first two DDs engaged 6 PLWH and 3 community stakeholders involved in policy, clinical, and community work. In partial alignment with two global recommendations, participants described the need for integrated approaches to primary, HIV-, and other specialist care, tailored to specific sub-population needs (e.g., women). They indicated such a model would decrease reliance on individual providers to address complex issues, and the burden of asynchronous medical visits on PLWH (e.g., travel, time away from caregiving). As in the global statement, drawing attention to and reducing the pervasiveness and harm of intersecting forms of stigma were identified as critical to improving quality of life for PLWH in Canada. Recommendations for monitoring and research tended not to be prioritized.

Conclusions: These DDs are identifying global recommendations for health systems change that most resonate with stakeholders in Canada and facilitating engagement by PLWH whose voices were underrepresented on the global expert panel.