Background: There has been growing interest in the use of incentives to increase the uptake of health-related behaviours and achieve desired health outcomes at the individual and population level. However, the use of incentives remains controversial for ethical reasons. An area in which incentives have been not only proposed but used is HIV prevention, testing, treatment and care.
Methods: The main objective of this qualitative case study was to document the experiences of health care and service providers tasked with administrating incentivized HIV testing, treatment, and care in British Columbia, Canada. A second objective was to explore the ethical and professional tensions that arise as well as strategies used to mitigate them. We conducted interviews with 25 providers and 6 key informants.
Results: Our findings suggest that incentives target populations believed to pose the most risk to public health. As such, incentives are primarily used to close the gaps in the HIV Cascade by getting the "right populations" to test, start treatment, stay on treatment, and, most importantly, achieve (and sustain) viral suppression. Participants considered that incentives work because they "bring people through the door." However, they believed the effectiveness of incentives to be superficial, short-lived and one-dimensional – thus, failing to address underlying structural barriers to care and structural determinants of health. They also raised concerns about the unintended consequences of incentives and the strains they may put on the therapeutic relationship. They had developed strategies to mitigate the ensuing ethical and professional tensions and to make their work feel relational rather than transactional.
Conclusions: We identify an urgent need to problematize the use of incentives as a part of the HIV Cascade agenda and interrogate the ethics of engaging in this practice from the perspective of health care and service providers.

Background: Annual rates of new HIV infections in Manitoba are consistently higher than the Canadian average and disproportionately reported among females, Indigenous-identifying individuals, and people who inject(ed) drugs. Given this heterogeneity in acquisition, it is of interest to understand whether inequities in HIV care and treatment outcomes exist across Manitoba.

Methods: Using a sample of 703 cohort participants of Manitobans living with HIV (data current to the end of 2017), we conducted cross-sectional, disaggregated analyses of the HIV care cascade. We used equiplots to identify and visualize disparities across the cascade, and multivariable logistic regression to quantify associations between equity variables (age, sex, geography, ethnicity, immigration status, HIV exposure category) and progression along the cascade (in care, retained in care, on treatment, virologically suppressed). Adjusted odds ratios (AOR) and 95% confidence intervals (95%CI) are reported.

Results: The proportion of participants in each cascade step is greatest for those who are older, white, non-immigrant, living in eastern Manitoba or have never injected drugs (Figure). Compared to Winnipeggers, eastern Manitobans have greater odds of virologic suppression (AOR[95%CI]=3.8[1.3-11.2]). Indigenous participants are half as likely to be virologically suppressed than white participants (AOR[95%CI]=0.5[0.3-0.7]); African/Caribbean/Black participants are less likely to be in care (AOR[95%CI]=0.3[0.2-0.7]) and retained in care (0.4[0.2-0.9]).

Conclusions: Inequities exist across the Manitoban cascade. Our analyses generate hypotheses for future research into why inequities exist and contribute to evidence that can inform care plans that meet the needs of diverse client subgroups and advocate for policy changes supporting equitable HIV care across Manitoba.

Background: One third of Canadians diagnosed with HIV are youth (ages 16 to 29). Among young people in Canada at greatest risk of HIV infection are lesbian, gay, bisexual, transgender, queer, questioning, and Two-Spirit (LGBTQ2S) youth. Youth also have among the lowest uptake of HIV services. The Peer Navigator Project is studying the adaptability and scalability of Peer Navigation (PN) as an innovative model to increase access and uptake of HIV prevention, testing, and treatment by street-involved youth (SIY) in Canada (London, Toronto & Montreal) and Kenya (Kitale & Eldoret). The objectives of this analysis are a) to describe barriers to and facilitators of accessing HIV services among SIY populations in the Canadian sites; and b) identify the appropriateness and acceptability of the PN model.

Methods: Key informant interviews, focus groups and theatre testing were conducted from September 2018 – September 2020 with SIY, healthcare providers, and community stakeholders in the three sites. We utilized a thematic approach and the socio-ecological theoretical framework to guide and interpret qualitative findings.

Results: Fifty-four interviews, 9 focus groups, and 7 theatre-testing presentations were conducted. Barriers to and facilitators of accessing HIV services were described across societal, public policy, institutional, inter-personal, and individual levels. Primary barriers identified were intersectional stigma and discrimination, issues related to official identification of SIY, lack of knowledge, training, and LGBTQ2S inclusivity among healthcare providers, ineffective and sometimes harmful communication among healthcare providers, lack of social support, lack of basic needs, lack of self-esteem, fear, lack of trust, and competing priorities. Facilitators included free and anti-discriminatory healthcare services, patient-centered care models, system navigation and peer support, and individual self-efficacy.

Conclusion: Multiple modifiable barriers and facilitators were identified by stakeholders across all levels of the socioecological model. The PN model was found to be highly acceptable and appropriate for this population.

Background. HIV prevention is increasingly targeting key populations at risk of HIV even within generalized epidemic settings. Both paid and unpaid sex with women is commonly reported among African MSM and anecdotal reports suggest that MSM sex workers and female sex workers (FSW) share clients at common hotspots. Therefore, overlapping sexual networks could play an important role in shaping the wider HIV epidemic, but transmission dynamics remain poorly understood. Here we utilize phylogenetic analysis to better understand HIV transmission among MSM and FSW accessing the Sex Worker Outreach Program in the central business district of Nairobi, Kenya.

Methods. Blood was collected in consecutively sampled MSM (n= 165) and FSW (n= 746) living with HIV as part of routine treatment provided by SWOP between 2017-2019. HIV pol gene was sequenced using an in-house HIV drug resistance mutation genotyping assay. Phylogenetic clusters were inferred using patristic distance between sequences measured on phylogenetic trees. Effective population size estimates were inferred using an MCMC analysis as implemented in BEAST v1.10.4.

Results. We amplified 511 HIV pol sequences of the 911 (56.1%) available specimens. A majority of MSM sequences (65.2%) were part of a cluster while only 22.0% of FSW sequences clustered. A total of 58 clusters were inferred ranging from 2-9 individuals in size. Most clusters were exclusively FSW (n=29) or a mixture of FSW and MSM (n=25). Only four clusters were exclusively MSM. Effective population size estimates suggest that HIV among MSM grew exponentially around 2006, peaked in 2008, and remained stable until 2019. A similar trend was observed among FSW except the initial phase of growth occurred around 2009.

Conclusion. Clustering between MSM and FSW sequences suggests a significant overlap between key population transmission networks. HIV transmission within MSW and FSW follow similar trajectories suggesting transmission occurred mainly before SWOP's existence.

“Excellence is the best deterrent to racism” and addressing racism will ease access to health care by everyone and reduce HIV epidemic. We identified associated factors of increased counts on types of everyday racism experienced by ACB men in Ottawa and Windsor, Ontario. We also determined the health-related outcomes of the racism experienced. Data (Ottawa, n= 210 and Windsor, n=156) were drawn from a broader weSpeak program. Counts of everyday discrimination self-reported as due to racism were five types: i) being treated with less courtesy, ii) receiving poorer services, iii) people acting as if you are not smart, iv) people acting as if they are afraid of you, and v) being threatened or harassed. Because no city-level effect was found, we employed Poisson regression analysis to determine predictors of everyday racism, and a bivariate spearman’s rank correlation to estimate the health-related outcomes the everyday racism. Over 50% of the men in Ottawa (n = 114, 54.3%) and Windsor (n=100, 64.1%) experienced 1 to 5 types of everyday racism. An ACB man in full-time employment experienced 1.56 times (p< .001, 95% CI = 1.27/1.93) more of types of everyday racism than those not in full-time employment. Being a Muslim relative to non-Muslim increased the types of racism by 1.48 times (p <.01, 95 CI = 1.15/1.91). For a unit increase in traditional masculinity score, 1.03 times (p <.01, 95 CI = 1.01/1.05) more types of everyday discrimination were experienced. Results of bivariate correlation analysis show that everyday racism increased difficulty accessing health care (ρ = .21, p < .01, 95% CI = .07/.37) and reduced self-rated health score (ρ = -.19, p < .01, 95% CI = -.30/-.08). We recommend holistic approaches to addressing racism from places of employment to health care systems through targeted antiracism workshops and community-driven antiracism campaigns.

Background: The impacts of low sexual relationship power (SRP), including the consequences of having a controlling partner, has not been widely explored among women living with HIV (WLHIV). We measured the psychometric properties, prevalence, and key outcomes (condom use and violence) of the relationship control (RC) SRP sub-scale among Canadian WLWH.


Methods: We used baseline data from WLWH (≥16 years) reporting consensual sex in the last 6 months enrolled in the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study. Relationship control was measured using original scoring from Pulerwitz’s (2000) 16-item RC sub-scale and dichotomized into low/medium [score=1-2.82] vs. high RC [score=2.82-4], with higher scores reflecting less controlling behaviour from partner. Exploratory factor analysis and Cronbach’s alpha assessed scale reliability. Crude and adjusted logistic regression examined associations between RC and condom use (inconsistent and never vs. consistent) and experiencing recent (last 3 months) and previous but not current vs. never violence (sexual, physical and/or emotional), controlling for potential confounders.

Results: Overall, 473 WLWH (33% of cohort) were included in this analysis. Median age=39 (IQR=33-46), 81% were on antiretroviral therapy, and 78% reported an undetectable viral load. The RC sub-scale demonstrated good reliability (Cronbach’s alpha=0.92) with items loading onto one factor. 80% had high RC. WLWH with high (vs. low/medium) RC were more likely (p<0.05) to have higher education, less difficulty meeting monthly expenses, and no children. In multivariate models, higher RC was associated with less inconsistent (aOR:0.34(95%CI:0.15-0.76)) and never (0.27(0.10-0.71)) vs. consistent condom use; and reduced experiences of current (aOR=0.09(0.03-0.28)) (vs. never), but not previous violence.

Conclusions: Findings highlight that the relationship control sub-scale is a valid and reliable measure for examining relationship power equity among sexually active Canadian WLWH. Programs that prioritize building safety and support for women are critical to addressing violence and promoting positive sexual health outcomes.