Research and local public health surveillance data have shown that Black communities are disproportionately impacted by HIV in Canada. However, national HIV surveillance data do not contain sufficient race and/or ethnicity information to adequately describe the magnitude of the problem. Systemic racism and discrimination contribute to vulnerability, exposure to HIV, and health system barriers to accessing prevention technologies, testing and care and have also contributed to the data gaps that limit our ability to describe, address, and monitor these inequities. The low quality and completeness of race and/or ethnicity information in the national HIV surveillance data limits the ability to use this data to inform prevention and care programming, funding decisions, and the monitoring of outcomes.

A group of Black researchers and practitioners came together in 2022 to advocate for new approaches to research and policy to address Black people's continued disproportionate exposure to HIV. During engagements with the Public Health Agency of Canada (PHAC)’s National HIV/AIDS Surveillance Program (HASS), data quality concerns and opportunities for improvement were discussed. As a result of this engagement, the Black Expert Working Group (BEWG) was launched in Summer 2023. The BEWG will provide advice to HASS and contribute to the co-development and implementation of strategies to improve the completeness of the race and/or ethnicity data. This work will include reviewing the language in national HIV surveillance reports, critically reviewing race and/or ethnicity categories currently in use in Canada, developing data collection scripts and training tools, and building capacity among Black stakeholders for evidence-informed responses to HIV.

The BEWG has the potential to support a robust response to HIV among Black communities through community leadership in optimizing the quality, completeness and use of data on HIV.

Background: Existing research on ethical issues in HIV testing, such as perceptions of consent, privacy, and management of HIV-related data and biosamples among African, Caribbean, and Black (ACB) populations in Canada, is scarce. This qualitative study aimed to explore these ethical complexities in community-based HIV testing within the ACB communities in Canada.

Methodology: In-depth, semi-structured interviews were conducted with 33 ACB community members in Manitoba, Canada. A diverse sample was recruited through community agencies, social media, and flyers, considering variations in age, gender, sexual orientation, and geographical location. Data were analyzed using iterative, inductive thematic analysis.

Results: Participants expressed significant concerns about the collection, sharing, and use of HIV data from healthcare encounters, revealing mistrust towards institutions like police, child welfare, and immigration accessing their health information. Participants expressed concerns about several issues, including the management of biological samples, the possibility of data misuse, the risk of human rights violations, anti-Black racism, and the difficulties in upholding principles of consent, privacy, and bodily autonomy. While open to contributing to medical research, they unanimously demanded greater transparency, informed consent, and control over the secondary use of their health data. Participants emphasized informed consent, the need for clear communication on sample use, and ethical considerations like compensation for the use of HIV bio-samples in future research.

Conclusions: The study underscores the need for culturally sensitive approaches in HIV testing and ethical governance in healthcare for ACB communities. It highlights the importance of prioritizing participant empowerment, ensuring transparency, practicing informed consent, and implementing robust data security measures to balance effective HIV information management with the protection of individual rights. A comprehensive, decolonizing, and anti-racist strategy is crucial for transforming HIV testing and healthcare into an equitable and just system.

The persistence of latently infected cells during antiretroviral therapy (ART) remains a barrier to a cure for HIV-1. The HIV-1 accessory protein Nef downregulates MHC-I from the surface of infected cells, preventing the presentation of HIV-1 antigens, which can impede cytotoxic T lymphocyte clearance of latently infected cells. For a group of ART-suppressed Ugandans with HIV-1 (n=14), we identified and sequenced primary nef genes from outgrowth viruses derived from the quantitative viral outgrowth assay (QVOA; (n=49 total nefs). These unique nefs were cloned or synthesized into proviral vectors, used to generate pseudoviruses, and utilized to measure cell surface CD4 and MHC-I downregulation within infected CD4+ Sup-T1 cells via flow cytometry. In these same individuals, the size and rate of change of the replication-competent latent reservoir (RC-LVR) was estimated using previous QVOA results and a Bayesian model over a 5-year study period. We observed substantial variability in participant-derived Nef-mediated MHC-I downregulation (median 114.5% of NL4-3 downregulation, IQR 104.6-121.4%), and CD4 downregulation (median 94.1% of NL4-3 downregulation, IQR 83.9-100.0%) within this cohort. Importantly, we found a significant relationship between Nef-mediated MHC-I downregulation and the rate of change of the RC-LVR (rho=0.61, p=0.023), where less efficient MHC-I downregulation correlated with a faster rate of RC-LVR decay during long-term ART. In contrast, Nef-mediated CD4 downregulation was not associated with changes in the RC-LVR (rho=-0.16, p=0.58). Nef-mediated MHC-I downregulation may contribute to HIV-1 persistence during long-term ART. Strategies to inhibit Nef-mediated MHC-I downregulation could represent a viable therapeutic avenue to reduce the size of the latent reservoir in vivo.

Background: Canada’s immigration system restricts access to those living with certain health conditions, including HIV. Specifically, the Immigration and Refugee Protection Act bars access to anyone who may pose an “excessive demand” on Canada’s public healthcare system or who poses a danger to public health or safety. The system also bars access to individuals who are unable or unwilling to undergo an HIV test, mandatory for many immigration applications.
Description: As part of our advocacy to defend the human rights of people living with HIV, the HIV Legal Network sought to examine the structure and impact of Canada’s immigration system on people living with HIV through legal research, desk-based research, documents obtained through Access to Information Requests, and dialogues with community organizations and people with lived experience.
Lessons Learned: Canada’s immigration system perpetuates harms against people living with HIV and interferes with global efforts to end HIV. People living with HIV are exposed to anti-HIV stigma throughout the immigration process – be it through an application for asylum, for a work or study permit, or for permanent residence. The measures that create that stigma introduce significant inefficiency to Canada’s immigration system, without evidence that they achieve their purported goals. They also limit access to a country in which HIV testing, treatment, and counselling is available, instead reaffirming the false notion that HIV is a condition one must hide to be accorded the same rights as others.
Next Steps: In 2018, the Minister of Immigration, Refugees, and Citizenship promised to repeal the “excessive demand” regime, in light of its recognized harms. Instead of repealing the regime, the government implemented half measures. Our research confirms the ongoing harm of the “excessive demand” regime, as well as the other identified immigration policies and practices, and confirms the ongoing need for a fulsome reform.

Interleukin-17 producing (Th17) CD4+ T cells are more susceptible to HIV infection and depleted early in people living with HIV. Here, we explored whether the frequency of circulating Th17 cells pre-HIV infection were associated with HIV disease progression. We used archived cryopreserved blood cells collected <1 year prior to HIV infection from participants enrolled in HIV Vaccine Trials Network (HVTN) 503 (n=35) and the Partners Pre-Exposure Prophylaxis (PrEP) Study (n=32) cohorts. We applied flow cytometry to quantify Th17 cell frequency. In HVTN 503, participants had a median age of 23 years (IQR: 22-27), while in Partners PrEP, the median age was 30 years (IQR: 25-40). We included 17 female and 18 male participants in HVTN 503, and 19 female and 13 male participants in Partners PrEP. In HVTN 503, IL17+CD4+ T cell frequency correlated inversely with CD4/CD8 ratio measured <180 days (Spearman rank r =-0.42, p=0.012) and >180 days (r = -0.55, p=0.001) post-HIV infection and was associated with a faster decline in CD4+ T cells below 500 copies/mm3 (Cox regression HR = 2.9, 95% CI = 1.2 – 6.9, p=0.015), including after adjusting for viral load (aHR = 2.5, 95% CI = 1.0 – 6.1, p=0.038). However, in Partners PrEP, the correlation with CD4 decline was not significant (HR = 1.2 , 95% CI = 0.4 – 3.4, p=0.795). In an analysis that combined both cohorts, IL17+CD4+ T cells remained a significant predictor of CD4+ T cell decline in the unadjusted (HR = 2.2, 95% CI = 1.1 – 4.3, p=0.023) and viral load adjusted models (aHR = 2.1, 95% CI = 1.0 – 4.1, p=0.038). IL17+ T cell frequency was not associated with peak or set-point viral loads in either cohort. Our study highlights the potential importance of pre-HIV infection Th17 cell levels in shaping HIV disease progression.

Introduction: African, Caribbean, and Canadian Black (ACB) communities in Canada experience multiple barriers to HIV testing and linkage to care. The 'I’m Ready' Program is an HIV self-testing implementation strategy which utilizes a mobile app through which participants can order free HIV self-test kits for delivery or pick-up at any participating locations across Canada. This study examines the effectiveness of the I’m Ready program in reaching ACB communities across Canada.

Methods: Between June 2021 and November 2023, 2,458 participants who identified as ACB accessed the mobile app and completed the pre-test survey. We analyzed the pre-test survey to identify participants’ demographics and recency of their HIV testing. We then performed binary logistic regression to examine the correlates of first-time testers across ACB communities.

Results: Participants were mostly under the age of 24 years old (51%), had greater than a high school education (55%), were employed full time (28%) and lived in rural areas (41%). Most of the participants were first-time testers (42%) or have not been tested in more than a year ago (37%). The program reached first-time testers across Canada, most notably in British Columbia (42%), Alberta (40%), and Ontario (25%). First-time testers are more likely to be under 24 years old (OR=3.06, p<0.01), live in small cities and rural areas (OR=1.45, p<0.01), and more likely to be cis-men in comparison to cis-women (OR=0.80, p=0.01).

Conclusion: The app is a convenient way to increase access to HIV self-testing and is effective in reaching first-time testers in the ACB community, in particular those who are younger or live in rural communities that may not be covered by available services or where services are not tailored to the needs of ACB people.