HIV decriminalization, phylogenetics and Indigenous health headline Fall ARV update

posted on December 23, 2019

The fall HIV/ARV Update brought expert presentations about scientific findings on HIV decriminalization, phylogenetics, Indigenous health and more.

Strategies to improve HIV care for Indigenous people living with HIV

Coast Salish matriarch and Elder Roberta Price, greeted the hundreds of researchers, clinicians and community members gathered at the Fall 2019 HIV/ARV Update with a warm welcome.

Dr. David Tu spoke about a pilot project in collaboration with Elder Roberta for HIV care of Indigenous clients. His presentation focused on examining the “Kilala Lelum” (Butterfly House) model of service - based on respect, humility, kindness and strategies of laughter to promote cultural safety. Dr. Tu emphasized the need to promote heath equity and wellness through partners.

“Recognizing my own training as a non-Indigenous physician working in this community, I had no capacity to address in a meaningful way my clients’ cultural identity,” admitted Dr. Tu. He connected with a group of patient-dedicated elders to develop a model for shared understanding, communication, respect and goals.

Results showed a reduction in depressive symptoms and a 46% decline in total emergency room visits. There is an increase in ‘hopefulness’ in the future Dr. Tu said, sharing the story of one of his clients who benefited from the guidance and support of elders.

Elder Price and Dr. Tu recommended further meaningful interventions to address HIV rates among Indigenous people in Canada and evolving the “Kilala Lalem” model to address the needs of Indigenous clients.

HIV status disclosure

Dr. Kate Salters discussed the impact disclosure has on those living with HIV. Describing it as a deeply personal decision made within social contexts, Dr. Salters pointed to varying degrees of personal risk, including rejection, violence, judgement and betrayal of confidentiality. Often, disclosure is emphasized as a necessity with new sexual partners.

Findings in BC show despite the risks associated with disclosure, 73.4 per cent of 657 participants in the LISA (Longitudinal Investigation into Supportive & Ancillary Health Services) study disclosed their HIV status to their sexual partners. “Individuals who were less likely to disclose to their partners were women and gay or bi men, suggesting there may be a barrier that is gender and sexuality-specific, said Dr. Salters.”

There is no law surrounding HIV disclosure, says Dr. Salters, essentially non-disclosure invalidates one’s consent, leading to a charge of sexual assault.

Dr. Salters argued the criminalization of HIV non-disclosure leads to increased stigma against people living with HIV, does not help people overcome barriers to HIV disclosure, reduces HIV testing and does not reflect the science of U=U (undetectable=untransmittable).

Phylogenetics insights into HIV and HCV

Dr. Jeffrey Joy began his presentation with a look at the United States’ plan to end HIV, which includes a national plan for “rapid and overwhelming response to emerging HIV clusters and to monitor for new clusters.” He highlighted this is something we have been doing in Canada, especially in BC, for the past seven years. HIV transmission is being monitored in BC and across provincial boundaries through collaboration with various agencies.

HIV phylogenetics can help contain HIV transmission and allow public health resources to be deployed proactively and efficiently. A surprising amount of information of public health value is in phylogenetic data and can pinpoint groups of people most in need of health services.

HCV evolves as rapidly as HIV, and this similarity allows phylogenetic testing to be applied to HCV. Some key differences include: the HCV resistance test is not currently the standard of care and approximately 20% of people naturally clear HCV. However, HCV clusters can still represent localized outbreaks and as the HCV database grows, there will be an opportunity to monitor HCV hotspots for their public health risk and to deploy resources accordingly.

PrEP

Dr. Junine Toy provided a comprehensive PrEP (pre-exposure prophylaxis) program overview showing steady uptake since its launch by the provincial government in 2018, particularly among high-risk men who have sex with men.

Program data shows that most PrEP users are located in Vancouver (3,055), followed by the Fraser Health region (813), while 442 participants reside on Vancouver Island. The majority of clients are accessing PrEP through sexual health clinics in Vancouver and greater Vancouver, while outside of these areas, program participants are turning to general medical clinics.

There are high retention rates at the 18-month mark among people enrolled in the program. There have been eight new cases of HIV among the cohort, but Dr. Toy clarified these individuals were not using PrEP at the time of their infection.

Opioid use disorder

Dr. Annabel Mead discussed the significant overall reduction in overdose deaths in BC for the first time since 2016. Urban centres are still the hardest hit, and nearly 80% of overdose deaths are among men. However, in contrast to the positive news regarding an overall reduction in deaths, there was an increase in the number of Indigenous people who succumbed to overdose. Indigenous people are dying at four times the rate of the general population and almost half of overdose deaths in Indigenous people are women.

Canadian guidelines for opioid use disorder state withdrawal management alone should be avoided and opioid agonist therapy options may include buprenorphine/naloxone as first line, followed by methadone, slow release oral morphine and injectable iOAT (opioid agonist therapy).

Dr. Mead emphasized the need for a range of pharmacotherapies for OUD particularly to maximize engagement of patients in treatment.