Background:

In 2021, Manitoba (MB) reported the highest numbers of new HIV infections ever, while simultaneously experiencing a decreasing linkage to care and decreasing viral suppression. Our study aimed to identify barriers and facilitators to HIV care and the impacts of the COVID-19 pandemic from the perspectives of front-line service providers who work with People Living with HIV (PLHIV) in MB.

Methods:

We conducted in-depth semi-structured virtual interviews with service providers between October 2022 and January 2023. Purposive sampling was used to include a cross-section of service providers including clinicians, pharmacists, nurses, social workers, harm reduction workers and program managers.

Results:

Service providers (n=26) reported experiences of burnout, increased stress, increased workloads, and a failure of the health care system to adequately fund positions that are needed to tackle the syndemic of high rates of HIV and other sexually transmitted and blood borne infections, and increased methamphetamine use in Manitoba. They noted that the barriers to HIV care that existed for PLHIV prior to the COVID-19 pandemic such as inadequate support for PLHIV using substances (harm reduction or treatment options), housing instability and low income, and inaccessible health care services were exacerbated due to the COVID-19 pandemic and resulted in further socioeconomic disparities among PLHIV, increased substance use, and diversion of health care staff and resources away from HIV care to COVID-19 care. 

Conclusion:

Our results indicate that investments in HIV health care and social support systems are needed from all levels of governments in Manitoba to improve linkage to care for PLHIV and to prevent front line service provider burnout.

Objective: Health and social inequities worsened during the COVID-19 pandemic, yet little research explores how women living with HIV (WLWH) were impacted. This study investigated relationships between social-structural factors, including physical/sexual gender-based violence (GBV) and (1) not completing a follow-up survey during the pandemic, and (2) increased difficulty accessing HIV care during this time.
Methods: Data were drawn from the Sexual Health and HIV/AIDS: Women’s Longitudinal Needs Assessment (SHAWNA) Project, an open longitudinal community-based research project with WLWH in Metro Vancouver (2014-present). (1) We compared social-structural factors (measured at most recent follow-up in the 18 months prior to the pandemic) of women we saw during the pandemic (March 15/2020-August 31/2021 based on data available for this analysis) to those we did not, using bivariate analysis. (2) The impact of GBV on HIV care access during the pandemic was assessed using multivariable logistic regression; adjusted odds ratios (AOR) and 95% confidence intervals (CI) are reported.
Results: Among women in this study (n=245), 59.2% were Indigenous, 31.4% were White, and 9.4% were African, Black, South Asian, or other racialized/women of colour, with 11.4% reporting trans gender identity. Compared to women seen during the pandemic, women not seen (n=82; 33.5%) were more likely to report GBV (14.7% vs. 26.8%, p=.011), injection (32.5% vs. 51.2%, p=.004) or non-injection drug use (41.1% vs. 59.8%, p=.007), and less likely to report >=95% ART use (73.0% vs. 58.5%, p=.065) at their most recent follow-up. In multivariable analysis, GBV was significantly associated with increased difficulty accessing HIV care during the pandemic (AOR:3.65; 95%CI:1.21-11.05).
Conclusion: Findings highlight the impact of GBV during the pandemic and the importance of reaching out to women less engaged in care; care should be low-barrier and trauma-informed. Programs/policies should be aware and responsive to GBV impacts on HIV care access in pandemics and generally.

Background: HIV treatment interruptions (TIs) are common and can limit the effectiveness of antiretroviral therapy (ART). While often viewed as patient non-compliance, TIs may alternatively, signal structural disparities in healthcare access. We conducted a qualitative study to elucidate the pathways and obstacles to treatment re-engagement among people living with HIV (PLWH) with a recent TI in British Columbia.

Methods: Interviewer- and peer-led semi-structured interviews were conducted with 15 PLWH between November 2020 to March 2022. Participants were recruited through the STOP HIV/AIDS Program Evaluation (SHAPE) Study and regional HIV program coordinators and experienced a TI within the past 3-years. The interviews centered on experiences with TIs and various factors that facilitated treatment re-engagement. Participatory analysis involving Peer Research Associates and emergent coding, guided by interpretive description, were used to uncover themes around HIV care and treatment re-engagement.

Results:
Participant experiences centered around re-framing TIs as unintended consequences of de-stabilizing events, rather than intentional non-compliance: “I don’t think it was deliberate, but then again, I don’t know”. De-stabilizing events leading to treatment breaks, such as depression, relapsing, or the illness or death of a loved one, were overwhelmingly associated with shame, fear, and/or despair for participants, which may be reinforced inadvertently by healthcare providers. Supportive pathways to HIV care and treatment focused on fostering trusting relationships, both with providers and with a social support network. A common thread of what facilitated treatment re-engagement was client autonomy, self-determination, and shared power in decision-making with their healthcare provider. In contrast, participants identified that perceptions of punitive measures from providers to encourage compliance were seen as a barrier to re-engaging with care and treatment, ultimately eroding trust.

Conclusions: Strategies which focus on facilitating trusting relationships and fostering shared decision-making with PLWH who have interrupted treatment may be more successful in re-engaging them in care.

Methodological innovations in public health research are required to significantly reduce new HIV infections in Canada. New HIV infections in Saskatchewan–predominantly through injection drug use–are particularly pronounced, at twice the national average for the past 5 years. A community-based HIV organization has created reportneedles.ca, a real time geographic information system (GIS) to map community needle incidence in Regina, Saskatchewan, and have partnered with researchers to evaluate a rapid assessment and response methodology. Informed by principles of harm reduction and implementation science, this community-based, innovative method will generate geo maps of Regina hotspots where community needle incidence in public spaces is the highest to deploy and evaluate HIV prevention of rapid and self-test kits and harm reduction interventions of Naloxone training and support groups. From April 2021 to November 2022, 32,976 discarded needles have been retrieved from 320 public reports on the reportneedles.ca app. Our community-academic partnership permits a pragmatic trial design whereby community needle incidence, HIV epidemiology, and overdose death rates can be compared between a 1.5-year period of the needle incidence app and a 1.5-year period of the app alongside targeted HIV prevention and harm reduction interventions. Additional data from mixed-method research on the harm reduction interventions comprised of analyses of variance on mean differences pre- and post-intervention using the Opioid Overdose Knowledge Scale and Substance Use Recovery Evaluator alongside open-ended questions on changes in knowledge and behaviour, will further determine whether this methodology is effective. These metrics could indicate safer drug use, reduced rates of HIV infection, and reduced overdose death. This presentation will detail this novel rapid assessment and response methodology, which could be a cost-effective, pragmatic approach to target public health interventions to local areas of highest need.

HIV stigma remains high in Canada, negatively affecting the health and wellbeing of people living with HIV. However, there is a limited understanding about how the social determinants of health impact the relationship between stigma and health. This study examines how enacted, internalized, and anticipated stigma impacts physical, mental, and overall health and how social determinants of health moderate these relationships.

Participants (n=339) were recruited in Ontario from September 2018 – August 2019 to complete the People Living with HIV Stigma Index at baseline (t1) and at follow up (t2) approximately two years later. Moderation models were created with each type of stigma at t1 as the antecedents and physical, mental, and overall health at t2 as the outcomes. Social determinants of health included age, years since HIV diagnosis, gender, sexual orientation, ethnicity, geographic region, education, employment, and basic needs were entered as moderators.

Moderation models were significant only for the mental health outcomes. For internalized stigma and mental health, age was a significant moderator (b = -0.17, 95% CI = -0.32, -0.01). For enacted stigma and mental health, age (b = -0.16, 95% CI = -0.31, -0.01), region (b = 5.13, 95% CI = 1.41, 8.84), and basic needs (b = 5.28, 95% CI = 1.50, 9.05) were significant moderators. Lastly, for anticipated stigma and mental health, region (b = 7.16, 95% CI = 2.60, 11.72), sexual orientation (b = -6.57, 95% CI = -11.51, -1.63), and basic needs (b = 5.51, 95% CI = 0.99, 10.03) were significant moderators.

The relationships between experiences (and different forms) of stigma and how these may affect health outcomes in people living with HIV are complex and multi-factorial. Consideration for how some determinants of health may moderate these relationships may be helpful to consider when developing stigma interventions to be more effective.

Background:
Heterosexual-identifying men who have sex with both men and women (H-MSMW) are an under-researched population who may facilitate HIV/STI transmission between MSM and heterosexual sexual networks. Using a mixed-methods approach, we investigated perceptions and management of HIV/STI transmission risk among H-MSMW, and how their relationship status with women affected their sexual behaviour.

Methodology:
We used an exploratory sequential mixed-methods design, comprising semi-structured qualitative interviews (SSIs) with 14 H-MSMW in England, and secondary quantitative analysis of data from 486 H-MSMW participants of the 2010 European Men-Who-Have-Sex-With-Men Internet Survey (EMIS-2010) from 17 Western European countries, including 315 (64.8%) H-MSMW in steady relationships with women. We analysed SSIs thematically to develop initial hypotheses, which we tested quantitatively, estimating prevalence ratios (PR) to measure associations between relationship status and sexual behaviour with male sexual partners.

Results:
H-MSMW interview participants expressed concern about potential HIV/STI acquisition through sex with men, and the consequences of this for the health of, and relationships with, steady female partners. This encouraged the use of risk mitigation strategies, including sexual exclusivity with female partners, condom use, and avoiding sex (with male or female partners) they considered “high” risk of transmission. Quantitative analyses of EMIS-2010 data corroborate these findings; among H-MSMW, having a steady female partner was associated with a reduced likelihood of reporting anal intercourse (AI) with recent male partners (PR=0.81; 95%CI:0.72–0.92) and inconsistent condom use with male AI partners (PR=0.74; 95%CI:0.56–0.97). HIV testing in the previous year was low (24.7%) and not associated with relationship status.

Conclusion:
This innovative mixed-methods study showed that some H-MSMW recognise the need for, and actively employ, strategies to reduce HIV/STI transmission risk, especially where this may affect their relationships with female partners. The limited effectiveness of some strategies and limited reporting of testing suggest the need for targeted sexual health messaging.

Background:
Sex and sexual health practices of Middle Eastern and North African (MENA) youth in Canada are under-researched, even as the community grows rapidly due to high immigration rates. YSMENA community-based research study identified key determinants driving how MENA diaspora youth living in Ontario access sexual health and HIV prevention interventions.

Methods:
Using a mixed-methods design, data were gathered through quantitative socio-demographic surveys and qualitative focus groups involving 56 MENA youth, ages 16-29 years in Ontario, of which 24 were female-identified. Six (6) sequential critical dialogical focus groups were held with subgroups: cis heterosexual women (n=14), cis lesbian and bisexual women (n=3), and trans women (n=7), where members in each sub-group participated in two sessions. Sessions were transcribed and coded using NVIVO for thematic analysis.

Results:
Findings offer a rich and nuanced picture of how young MENA women in Ontario navigate sexual relationships, healthcare and demonstrate resiliencies. Average age of the women was 25.7 years (SD=3.92). About 70% were born outside Canada and half (50%) lived less than nine years in Canada. Most (72%) reported having an undergraduate or post-graduate education, yet almost one third of the sample earned <$10,000/year. Themes common to all subgroups included: (1) pressures to conform to immigrant familial expectations; and (2) barriers when accessing healthcare, sexual health and HIV prevention services. Sub-group specific themes included: societal and cultural expectations to maintain virginity and sexual innocence among cis women; and compounded levels of exclusion due to homophobia and transphobia among trans women. Although challenges faced were deeply entrenched in patriarchy, heteronormativity and internalized shame, many women demonstrated resilience and self-acceptance.

Conclusion:
Study findings have important implications that can support sexual health programming in Ontario to be more inclusive and culturally relevant for young MENA women. Results also offer youth-identified recommendations for healthcare practitioners and service providers.

Background: According to the Loneliness and Sexual Risk Model, higher levels of loneliness are associated with increased sexual risk-taking among GBM. Given that COVID-19 protection measures in Canada (e.g., social distancing and isolation) led to increases in loneliness, this time period may also have elevated sexual risk-taking among GBM.

Methods: Participants (n=1,134) were recruited from Engage, an ongoing cohort study of GBM in Montreal, Toronto, and Vancouver, to take part in the Engage COVID-19 sub-study. Using linear regression, we examined the association between age, loneliness and social support during COVID-19, testing whether age moderated the association between loneliness and sexual risk-taking (e.g., engaging in group, transactional, or anonymous sex; chemsex; or sex with new casual partners). We also explored whether loneliness in the first year of the COVID-19 pandemic (03/2020-02/2021) predicted sexual risk-taking in the same time period as well as one year later (03/2021-02/2022), controlling for education, income, city, living alone, and HIV status.

Results: There was a significant association of age with loneliness (beta=-.144, p<.001) and social support (beta=-.170, p<.001). Age moderated the association between loneliness and sexual risk-taking (p=.003); younger participants experiencing more loneliness were more likely to report engaging in sexual risk-taking. Across age groups, we found that GBM who reported more loneliness in the first year of COVID-19 were less likely to report sexual risk-taking in the second year (OR= 0.75, p = .006).

Conclusion: Loneliness may not have led to increased sexual risk-taking a year later perhaps due to greater isolation (and loneliness) among those who were more concerned about COVID-19. However, it seems that the sexual risk-taking of younger GBM in the first year was particularly impacted by loneliness. Additional support to improve their ability to adaptively cope with feelings of loneliness may help, particularly in contexts where social isolation may be necessary.