HIV/AIDS in First Nations in Saskatchewan

1. HIV/AIDS in First Nations in Saskatchewan Marlene Larocque BSW, MPH Aboriginal Health Sciences McMaster University February 1, 2013

2. Agenda • Introduction Activity • HIV Basics • Aboriginal People and HIV in Canada • Reflection on the Readings • Treatment, Adherence, Side Affects • Ethics and Disclosure • Overview on Current HIV profile in SK • A closer look at HIV in Saskatchewan • Discussion, Q/A

3. Basic Facts about HIV • Human Immunodeficiency Virus: weakens the immune system • Transmission: blood born virus • HIV can lead to AIDS (Acquired Immunodeficiency Syndrome) if left untreated and can lead to acquiring with an opportunistic infection • The number of people living with HIV in Canada (including AIDS) continues to rise, from an estimated 64,000 in 2008 to 71,300 in 2011 (an 11.4% increase). PHAC 2011.

4. HIV Transmission

5. HIV Transmission • Transmission: shared/dirty IDU, unprotected sexual contact with someone who is HIV positive (heterosexual and MSM) • HIV is present in 5 bodily fluids: semen, vaginal fluids, anal fluids, blood, breast milk • HIV can only be spread when one of these fluids from a person with HIV gets into the bloodstream of another person - through broken skin (SK Provincial Leadership Team)

6. Living well with HIV • There is currently no cure for HIV; but there is treatment, living with HIV requires lifelong clinical management and wellness support • HIV+ women can have healthy, HIV- children providing they are under medical supervision • Improvements to HIV treatment and medications means fewer pills and increased life expectancy (side effects) • Unknown is the impact of years of medication on the body (bone density, cancers, dementia, liver and kidney functions, etc.)

7. HIV/AIDS: Aboriginal Peoples in Canada 2011 • Estimated that 390 new HIV infections occurred in Aboriginal people in 2011 (12.2% of all new infections) vs. approx 420 new infections in 2008 (12.6% of all new infections in 2008). • Infection rate 3.5% higher in First Nations, Inuit and Métis when compared to non-Aboriginal counterparts • Summary: Estimates of HIV Prevalence and Incidence in Canada, 2011 Public Health Agency of Canada

8. Exposure to HIV Comparison between Aboriginal/non-Aboriginal in 2011 • Aboriginal • IDU 58.1% • Heterosexual 30.2% • MSM 8.5% • IDU-MSM 3.1% • Non-Aboriginal • IDU 13.7 • Heterosexual • Endemic 20.3% • Non-Endemic 20.1% • MSM: 46.6% Summary: Estimates of HIV Prevalence and Incidence in Canada, 2011 Public Health Agency of Canada

9. Journal Articles • “AIDS is Something Scary”: Canadian Aboriginal Youth and HIV Testing (Mill, J.E. Wong, T. Archibald, C. Sommerfeldt, S. Worthington, C. Jackson, R. Prentice, T. Myers, T. 2011) Pimatisiwin: A Journal of Aboriginal and Indigenous Community Health 9(2) 2011 • Social Exclusion as an Underlying Determinant of Sexually Transmitted Infections among Canadian Aboriginals (Wynne and Currie, 2011) Pimatisiwin: A Journal of Aboriginal and Indigenous Community Health 9(2) 2011 • Strengthening Community-Based Approaches to HIV/AIDS & STI Screening, Treatment & Prevention among Atlantic First Nations People Steenbeek; Amirault; Saulnier; Morris (2010) Canadian Journal of Aboriginal Community-based HIV/AIDS Research • Addressing HIV/AIDS among Aboriginal People using a Health Status, Health Determinants and Health Care Framework: A Literature Review and Conceptual Analysis Nowgesic (2010) Canadian Journal of Aboriginal Community-based HIV/AIDS Research

10. Themes from the Articles • Disparities in Health Status (elevated STI’s, chronic conditions, injuries, suicide, • Access to Health Services: delayed testing and diagnosis, time from diagnosis to care, treatment in medical facilities • Education Levels and knowledge about health (low screening, wait for signs of illness) • Barriers: Confidentiality, attitudes towards sexual health, transportation, • Mental/emotional wellness: abuse, assault, violence, poverty, isolation • Risk-taking, Social networks • Urbanization, racism

11. Structural Inequities • Colonization (social disruption) • Cultural Continuity (western and traditional conceptualization of health and wellness) • Access to Health Services (holistic, accessible, culturally competent care) • Health Policy for First Nations in particular • Geography (rural/remote location) • Self-Determination / community control • Poverty (depth and scope of material poverty)

12. HIV rates in Saskatchewan 2001-2011

14. HIV by Self-Reported Ethnicity (2001-2010)

15. Selected Risk Factors 2001-2010

16. Overall Objectives: Saskatchewan HIV Strategy 2010 to 2014 • Decrease the number of new HIV infections • Improve the quality of life for infected individuals • Reduce the risk factors for acquisition

17. Saskatchewan HIV Strategy, 2010-2014-Four Pillars • Community Engagement and Education (to reduce risk and reduce stigma) • Prevention and Harm Reduction (to promote safer behaviors) • Clinical Management (patient first approach) • Surveillance and Research (understand disease characteristics to inform treatment plans)

18. Positive Voice Stories Social Determinants of Health Broader Determinants Education Employment Access to health services Housing Culture Gender Early childhood development Coping Skills Poverty Racism Addictions Colonization Social disruption Residential School Geography Inter-generational impacts

19. HIV Testing/ Results Three C’s of HIV testing • Pre/Post Test Counselling (risk factors, window period, when to pick up results, risk reduction, legal and ethical obligations, link into care/community services) • Consent (cannot be coerced) • Confidential (results will not be shared with the public) • HIV is a reportable infection (for surveillance) • Contract tracing (confidential and original case not revealed) • Age, location, gender, risk factors • HIV Testing in Canada is opt-in (must request) • Pregnant women with high-risk behaviour are opt-out • A blood test is the only way to know for sure if an individual has HIV (can live without symptoms for months/years)

20. 2 types of HIV tests in Canada Standard Testing Point of Care (RAPID) Results in 7-10 days Blood Test Detects HIV antibodies No confirmatory test Results Positive Negative Results in minutes Finger prick Detects HIV antibodies Results Preliminary positive Preliminary negative Unknown Must be confirmed though a standard test

21. Additional Tests • A + HIV result only detects HIV antibodies; need the full picture of HIV to determine options and a treatment plan • More blood work: determine cd4 count (strength of immune system) and viral load (amount of HIV virus in your blood), check for STI’s, HCV, TB, etc • Co-Infection and treatment of co-morbid conditions • Infectious Disease Physician recommends a treatment regime with patient participation and monitors the numbers over time

22. Adherence • Adherence is sticking to your drug schedule. It is very important because even missing pills occasionally can sabotage long-term success in using anti-HIV drugs. Managing your health, page 137 • Improved drugs reinforce improved adherence to HIV medications • A good relationship and support from ID physicians, pharmacists, social worker, spiritual care provider, family, partners, Nurses can facilitate adherence

23. Side Effects of antiretroviral therapy • ‘Usually’ last 4-8 weeks • Both long and short term side effects • Nausea, diarrhoea, vomiting, sleeplessness, fatigue, weight loss, fat redistribution, loss of appetite, headaches, decreased bone density • HIV + individuals might throw away meds • Absorption of medication is compromised • Mental wellness: fear, stigma, unknown future, job, financial insecurity, stress • Social support, nutrition, clean water • Keeping a diary/journal to record health (CATIE)

24. Resistance to HIV medications • At the base of drug resistance is the fact that HIV is a little sloppy about making copies of itself. The new copies often contain changes, called mutations. These small changes in the genetic material of the virus result in changes to the way the virus is put together. Some mutations may allow the virus to replicate even when antiretroviral drugs are being used. This ability to replicate in the presence of antiretroviral drugs is called drug resistance. • Resistance to one drug can cause cross-resistance to other drugs in the same class, even if you haven’t taken those drugs before. • A Practical Guide to HIV Drug Treatment, page 91

25. Ethical Disclosure • Ethical considerations of who/when to tell (partner, family, co-workers, employers, etc) • Legal obligations R vs. Cuerier, to inform sexual partners if there is ‘significant risk’ , but a gap remains about the use of condoms during intercourse • Dating and having HIV is sensitive and scary • First Nations: benefit through SA, but must disclose status to the SA worker

26. Emerging Themes/Considerations • On/Off Reserve health care delivery and protocols • Co-Infection (TB, HCV) • chronic conditions • Accurate data/ numbers, age, gender • Point of Care Testing • Case management and advocacy (social determinants of health) • Contact tracing challenges • Disclosure and legal obligations • Education materials to encourage awareness and reduce stigma • Community readiness and capacity • Unique characteristics of each community (leadership, location)

27. National HIV/AIDS Organizations • Canadian Aboriginal AIDS Network • Canadian AIDS Society • Canadian Association of HIV Research • CATIE Canadian AIDS Information Exchange • Social Research Council (University of Toronto) • Nine Circles in Winnipeg • Provincial and Local AIDS Service Organizations across the country (All Nations Hope, AIDS Saskatoon)