Introduction
COVID-19 brought renewed attention to public health issues, such as sexually transmitted and bloodborne infections (STBBIs), which were markedly underreported during the pandemic. This underreporting is partly associated with a reduction in both demand and provision of services related to STBBIs, including the Human Immunodeficiency Virus (HIV).
HIV can affect anyone, regardless of age, sex, gender, sexual orientation, race or ethnic origin. However, certain populations carry a disproportionate burden of HIV in Canada. The HIV epidemic is concentrated in marginalized communities, notably amongst 2SLGBTQQIA+, Indigenous, and other racialized groups due to structural and social factors that create health inequities. Indigenous peoples represent approximately 5% of the total Canadian population as of 2021, while the HIV infection rate among Indigenous peoples accounts for approximately 5-10% of all new HIV cases reported in Canada. This blog highlights the overburden of HIV among Indigenous peoples in Canada.
What is HIV and How is it Treated?
HIV is a virus that attacks the body’s immune system, targeting white blood cells. HIV is a manageable, lifelong chronic condition with proper treatment and care. HIV can be spread from the body fluids of an infected individual, including via mother to child. Sexual transmission and transmission by injection and other drugs remain a great concern.
Despite rigorous research, HIV remains an incurable condition. Antiretroviral therapies (ART) are, however, at the forefront of HIV treatment, which stop the virus from replicating in the body. ART drugs keep the infection under control, stopping symptoms, complications, and reducing the risk of HIV transmission. HIV infection suppressed under ART is increasingly being considered a chronic condition, particularly in developed countries with ready access to ART. However, huge disparities remain, particularly amongst Indigenous populations in the context of intergenerational trauma and systemic racism.
In 2022, HIV self-test kits were introduced to the public with $17.9 million in federal funding support. Eight million specifically went to supporting community-based organizations, including Indigenous organizations, to make testing more available among the marginalized populations they serve. Self-test kits were praised as playing an important role in identifying folks unknowingly living with HIV. However, the program was not extended beyond March 2024, prompting advocates to voice concerns over the elimination of a critical resource for testing and treatment.
HIV in Canada: Disparity Across Jurisdictions
In December 2023, the Public Health Agency of Canada (PHAC) reported a surge of almost 25% in new HIV cases (1,833 people) from 2021 to 2022 with a 2022 diagnoses rate of 4.7/100,000 population (Figure 1).
However, the national rate can be misleading. The provincial distribution of numbers tells a different story of disparity. Both Saskatchewan (19 per 100,000 population) and Manitoba (13.9 per 100,000 population) are the only two provinces with diagnoses rates several times the national average and account for most of the national rate of HIV diagnoses.
Amongst the provinces, Saskatchewan and Manitoba have the highest proportion of their populations who identify as Indigenous, at 16% and 18%, respectively. A correlation analysis of the provincial data of the percentage of Indigenous population (2021 Census) versus the 2021-22 HIV diagnosis rate (PHAC 2023) shows a strong and significant positive correlation between the diagnoses rate of HIV and the percentage of Indigenous population in Saskatchewan and Manitoba (Figure 2). In its 2018-2021 Report, the Manitoba HIV Program reported a growth in proportion of self-identified Indigenous people referred to the program over time. A vast majority (73.4%) of the people referred to the program in 2021 self-identified as Indigenous, which in the year 2018 was 51.4%.
In Ontario with the largest absolute number of Indigenous population, in 2022 compared to 2019, a significant dip in HIV diagnoses among Indigenous males was observed in contrast to no difference in numbers among Indigenous females. Such trends were not seen in provinces such as Manitoba and Saskatchewan with highest per capita Indigenous population.
HIV in Manitoba and Recent Initiatives
Manitoba has one of the highest HIV diagnoses rates at several times the national average. From 2018 to 2022, the provincial data show a doubling of HIV diagnosis rate. In 2022, the province saw 196 new cases, representing an increase of 36.1% in the number of new cases compared to 2021 (Table 1). New cases further jumped to 388 in 2023. Such trends indicate an increasing demand for healthcare and relevant services in the context of a shortage of professionals, which has created a ‘health crisis’ for First Nations in Manitoba, particularly in remote communities.
The increase in the HIV incidence over the past decade has led public health professionals to identify HIV and other STBBIs a provincial priority as of December 2023. The province announced new initiatives and funding supports, including $271,000 for a mobile care service run by the Aboriginal Health and Wellness Centre (AHWC). Support for Mino Pimatisiwin Sexual Wellness Lodge operated by Ka Ni Kanichihk was also included.
In May 2024, Manitoba further announced free PrEP (pre-exposure prophylaxis, a daily antiretroviral medication that reduce the risk of HIV infection), PEP (post-exposure prophylaxis, antiretroviral medicine taken after being potentially exposed to HIV), and ART (antiretroviral therapy to treat HIV), stating “these medications will be available at no cost to individuals who do not currently have 100 per cent coverage under another federal or provincial plan, including removing the pharmacare deductible for these medications.”
“We must work together to eliminate the barriers and support Manitobans living with HIV/AIDS.”
-Minister Uzoma Asagwara, Manitoba Health, Seniors and Long-Term Care (2024)
Conclusion
Indigenous populations across Canada are disproportionately impacted by the HIV epidemic, with trends worsening in several jurisdictions. Manitoba and Saskatchewan, with the highest per capita Indigenous populations, are facing higher incidence rates than elsewhere in Canada. Concrete solutions rest in political will to address the crisis with the application of culturally safe care, without stigma and discrimination, respecting the right to Indigenous self-determination, and seeking guidance from Indigenous models of well-being based on a balance between physical, mental, spiritual and emotional health.
“It is heartbreaking to hear about so many of our relatives living with [HIV]. We must look beyond calculated statistics; these are real people, being affected in real life-altering ways. These are the same First Nations citizens who are also victims of systemic racism and generations of colonial impositions that continue to predispose First Nations women, girls, and 2SLGBTQQIA to poverty, shelter insecurity, food insecurity, sexual violence, and addictions… We need to prioritize education to decrease [stigma] and provide accessibility to testing, treatment, and the tools and resources to prevent further infection.”
-Grand Chief Cathy Merrick, Assembly of Manitoba Chiefs (2022)
Approaches such as harm reduction, HIV-self testing, and removal of barriers to healthcare access must be prioritized. While new federal and provincial initiatives may provide a beacon of hope, engagement with Indigenous stakeholders at all levels remains a priority given the impact of HIV amongst Indigenous peoples in Canada.