- Manitoba is one of two provinces where HIV is mostly linked to drug use or heterosexual sex
- Researchers analyzed the health information of people living with HIV in two Manitoba cities
- HIV suppression was less likely among those who were unhoused or using methamphetamine
In the past decade, the joint United Nations Programme on HIV/AIDS (UNAIDS) set the following goals for cities, regions and countries to achieve with their populations who have HIV by the year 2020:
- 90% of people with HIV know their status
- 90% of people with HIV are taking HIV treatment
- 90% of people on HIV treatment have achieved an undetectable viral load
As many countries have reached or surpassed these goals, UNAIDS and the World Health Organization (WHO) have set new targets for cities, regions and countries to reach by the year 2025:
- 95% of people with HIV know their status
- 95% of people with HIV are taking HIV treatment
- 95% of people on HIV treatment have achieved an undetectable viral load
These goals of testing, treatment access and viral suppression (an undetectable viral load) improve the overall health of people with HIV. Research suggests that many people with HIV who have an undetectable viral load will have near-normal life expectancy. Moreover, well-designed studies have found that people with HIV who have a suppressed viral load (as a result of treatment) do not pass on the virus to their sexual partners.
A history of discrimination and trauma
Indigenous peoples in Canada have suffered centuries of ongoing racism and colonialism. They have been forcibly displaced from their ancestral land, have suffered numerous injustices as the state sought to erase their language and culture and have faced disparities in accessing services. These hurtful and genocidal policies have caused intergenerational trauma among Indigenous peoples, leaving them vulnerable to poor health and addiction. As a result, some Indigenous communities experience high rates of mental health issues today.
Although many Canadian provinces have made overall progress in achieving 90-90-90, some populations, particularly Indigenous people and those who use drugs, are not able to achieve the best health that they otherwise could.
New HIV infections in Manitoba
In Manitoba, leading researchers have found that reports of newly diagnosed cases of HIV increased during the years 2018 through 2021. In the rest of Canada, most cases of HIV are among gay, bisexual and other men who have sex with men (gbMSM). However, researchers found that among the recent increases in HIV cases in Manitoba, 45% of those newly diagnosed were women. Furthermore, 76% of newly diagnosed people self-identified as Indigenous. Most of the newly diagnosed cases (61%) identified as heterosexual and 72% disclosed injecting drugs, most commonly methamphetamine. Many newly diagnosed people lacked stable housing.
Among those diagnosed with HIV, women were more likely than men to inject drugs, use methamphetamine and to lack stable housing. This finding suggests that women represent a particularly vulnerable population in Manitoba.
As reports of methamphetamine use and precarious housing increase across Canada, it is possible that the findings in Manitoba may serve as a precursor to what other provinces, as well as high-income countries, may experience in the coming decade.
The Manitoba study underscores the need for comprehensive interventions done in partnership with Indigenous peoples to address the issues driving the intersection of HIV, housing, mental illness and methamphetamine use.
Study details
Researchers engaged with the local community in Winnipeg and Brandon, Manitoba, to help guide their study. Information was collected from medical charts for review.
A brief average profile of study participants was as follows:
- 47% cisgender men, 40% cisgender women; there were 4 transgender women, 2 transgender men and 3 non-binary people
- age – 35 years
- major ethno-racial groups: Indigenous – 76%; White – 13%; Black – 5%
- 71% of people lived in urban areas and 29% lived in rural areas
- 80% disclosed use of drugs and, in most cases, participants used two or more drugs
- common drugs used: methamphetamine – 62%; alcohol – 61%; tobacco – 55%; cannabis – 33%; cocaine – 21%; opioids – 19%
- common methods of drug use: injection – 56%; smoking – 45%; snorting – 17%
- houseless – 35%
Note that percentages do not always total 100%, as some data were missing.
Results
Sex differences
The figures in the list above are averages. When researchers examined the data by sex, they found that women were more likely to inject drugs (72%) than men (43%). More women were using methamphetamine (76%) than men (51%). Also, women were more likely to experience houselessness (43%) than men (29%).
Co-existing conditions
According to the researchers, common health issues faced by participants were sexually transmitted and blood borne infections (STBBIs) and mental illness. Women were more likely to be diagnosed with common STBBIs (chlamydia, gonorrhea, syphilis) than men.
Focus on HIV and related issues
More women were newly diagnosed with HIV (81%) than men (62%).
AIDS-related conditions were diagnosed in 9% of participants. On average, the CD4+ count at HIV diagnosis was 419 cells/mm3. Initial CD4+ cell counts were greater in women than in men, suggesting that women may have been infected more recently.
About 82% of participants initiated HIV treatment (antiretroviral therapy; ART) at some point in the study. Note that this figure is lower than the initial UNAIDS goal of 90% and the current goal of 95%. The rate of ART initiation did not differ by sex.
However, overall, only 65% of people were able to achieve an undetectable viral load. The proportions of people achieving an undetectable viral load were lower among women (61%) than men (68%).
Rates of viral suppression were lower among people who were houseless (57%).
Among people who injected drugs, the proportion with a suppressed viral load was 60%. This was similar to the proportion of people who used methamphetamine and who achieved a suppressed viral load (61%).
Compare and contrast
New HIV diagnoses increased in Manitoba over the course of the study. Most newly diagnosed people were relatively young adults, many of whom were women who inject drugs, particularly methamphetamine. Most newly diagnosed people identified as heterosexual and Indigenous people were over-represented.
The HIV epidemic in Manitoba is different from most of the rest of Canada, North America and Western Europe. In these places, gbMSM are the predominant population with HIV, and HIV is spread mostly through intercourse.
Many of the newly diagnosed people in this Manitoba study have so far been unable to achieve the initial UNAIDS goal of 90% of people on HIV treatment being virally suppressed.
Meeting people’s needs
The researchers stated that the delivery of health (and other) services needs to be revisited so that they can better meet the needs of newly infected people in Manitoba. The researchers call for enhanced “outreach of in-the-moment care provision, addressing housing, providing harm reduction services and substance use disorder treatment, and including sex- and gender-specific interventions in an integrated approach.”
The average age of study participants was 35. When researchers focused on people who were between 18 and 30 years old, they found that less than 60% who were experiencing houselessness had an undetectable viral load.
This finding is supported by recent research out of Vancouver that found that people without housing were less likely to be on ART and/or achieve viral suppression.
The Manitoba researchers stated that “treating a person’s HIV in isolation [from social determinants of health] does not lead to better health outcomes.”
People who inject drugs
Many people in the Manitoba study injected drugs, particularly methamphetamine. The researchers stated that “hospitalizations related to methamphetamine have increased 600%, while methamphetamine overdose-related deaths have increased 170% from 2015 to 2017. Although methamphetamine use is high in Manitoba, it is increasing across North America and Europe.” The researchers warned that the challenges with drug use faced in Manitoba “may soon be seen in other jurisdictions.”
They called for more research on ways to increase engagement in care among people with HIV who have methamphetamine use disorder.
The researchers also called for evidence-based approaches to reduce the “harms of substance use, particularly injection drug use.” They stated that such approaches should include “needle exchange programs and supervised injection services.” They encouraged the integration of ART provision within harm reduction services.
Indigenous peoples
As mentioned earlier, Indigenous people were over-represented (76%) when it came to newly diagnosed people in the study. The researchers noted that Indigenous people make up about 18% of the population of Manitoba.
The researchers stated that the reason for the over-representation of Indigenous people with HIV “reflects the complex social and structural barriers many Indigenous people face due to systematic oppression by all levels of government over generations.” The researchers referenced Canada’s Truth and Reconciliation Commission (TRC) calls for action to redress the many harms inflicted upon Indigenous peoples. In particular, the researchers paraphrased the TRC calls for “all levels of government to recognize health disparities faced by Indigenous people, and to support and implement Indigenous-led strategies, as well as to collaborate, listen and meaningfully engage with Indigenous peoples to close healthcare gaps.”
Women
The researchers stated that, overall, about one-third of people with HIV in North America are women. However, in the present study, nearly half of the people who were newly diagnosed with HIV in Manitoba were women.
They stated that “women face unique barriers, including disproportionate childcare responsibilities; experiences of intimate partner violence; and decreased access to sexual and mental health support.”
The researchers stated that in the study women experienced “higher rates of houselessness, methamphetamine use, injection drug use, mental health issues and STBBIs, suggesting a particularly vulnerable group.” They added that “services and interventions that specifically address barriers unique to females and women, such as the approach outlined by the Women-Centred HIV Care Model, have the potential to make a great impact in this particularly vulnerable population and are urgently needed.”
Bear in mind
The Manitoba study is important and underscores the challenges that some populations and regions face to meet UNAIDS goals.
What’s more, the issues uncovered by the Manitoba researchers—particularly the intersection of HIV, lack of housing, mental illness and methamphetamine use—may be a harbinger of what other parts of Canada and even other high-income countries face in the coming decade.
—Sean R. Hosein
Resources
Delivering on Truth and Reconciliation Commission Calls to Action – Government of Canada
Women-Centred HIV Care – CHIWOS
People who inject drugs report unique barriers to hepatitis C treatment – CATIE News
Alberta – improvements in survival but changing causes of death – CATIE News
Researchers encourage simultaneous testing for three viruses—HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV) – CATIE News
2025 AIDS Targets – UNAIDS
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