Photo by Joshua Mcknight.
Over the past 40 years, communities have mobilized to make progress in terms of supporting people living with HIV/AIDS (PHA) and reducing the spread of the Human Immunodeficiency Virus. Despite advancements in medication and addressing social stigma, sexuality-based disparities in HIV/AIDS prevention and care program design remain high. This is an area that intrigues me as a community health promoter. I conducted a review of the literature (academic and grey literature) to identify sexuality-based disparities in this area of program design. For the purposes of this paper’s inquiry, I explored “sexuality” as sexual orientation or patterns of emotional, romantic, or sexual attraction (HealthLinkBC, n.d.). My findings in relation to sexuality and HIV include the following:
- Firstly, syndemics were identified in multiple contexts. Syndemic theory explores how the interactions of multiple, simultaneous epidemics (systemic racism, unemployment, lack of universal healthcare, substance use and COVID-19) synergistically contribute to health inequities and a disproportionate representation of HIV among racialized communities specifically Black men who have sex with other men (Poteat, 2020). These co-occurring factors were represented in the HIV in Canada—surveillance report, 2019 where gay, bisexual, and other men who have sex with men (gbMSM, 39.7%) and people who inject drugs (PWID, 21.5%) represented a high proportion of all reported adult cases with known exposure (Haddad, 2019). Similar statistics were reported the previous year. New infections among gbMSM represented half of all new HIV infections in 2018, despite making up only 3-4% of the Canadian adult male population (Public Health Agency of Canada, 2020).
- Secondly, I decided to look at sexuality and related access to HIV prevention and care programs. Exploring the Sex Now survey dashboard developed by the Community-Based Research Center (CBRC), interesting relationships between variables were identified. Among online Canadian survey participants that identified as gay (n=4708), 70% reported being out to their health provider, however for those who identified as bi (n=1176) or queer (n=1231), the percentage dropped to 40.6% and 61.6% respectively (CBRC, 2019). Not being out to your health care provider means that a health care provider would not have sufficient context about an individual’s social determinants of health and what potential structural vulnerabilities may be disproportionately impacting them.
- Thirdly, I reviewed how race, gender, and ethnicity was reported among sexuality-based disparities in HIV prevention and care in Ontario. The Ontario HIV Epidemiology and Surveillance Initiative reported 687 first-time HIV diagnoses in Ontario in 2019 and breaking the percent of diagnoses by key populations and sex revealed; 53.6% were gbMSM, 15.1% ACB (African, Caribbean and Black) males, 11.9% ACB females, 2.9% Indigenous males and 2.0% Indigenous females (OHESI, 2020). The same report found 12.2% representation among folks who inject drugs. HIV is also disproportionately represented among ACB women (25% of all new HIV diagnoses in 2015), despite accounting for only 5% of Ontario’s population (OHTN, 2019). The worldwide burden of HIV on trans women is very high as well (Baral, 2012).
- One cannot forget the effect of COVID-19 on queer and trans communities and the fact that more members of the BIPOC (Black, Indigenous, People of Color) LGBTQI2S community live with physical and mental health disabilities as well as other health conditions compared to the LGBTQI2S community at large and the national population (Egale, 2020).
These findings portray the harsh reality of sexual health inequities, specifically the disproportionate representation of HIV/AIDS among various key populations. These same populations are structurally vulnerable when you consider the other social determinants of health and syndemic factors that amplify HIV risk. Research demonstrates that economic (financial crisis), legal (past incarceration), and social (housing instability) hardships are important factors that will contribute to the increased likelihood of HIV infection among Black MSM populations (Nelson, 2016). Syndemic factors will also result in increasing viral HIV loads and reducing medication adherence among PHAs (Friedman, 2015). This same study suggested the integration of mental health care, substance use interventions, and sexual risk prevention into HIV care. A standard program design that is operationalized in various ways. When the Government of Canada looked at their 90-90-90 HIV targets in 2018, they found only an estimated 87% were diagnosed, 85% of those diagnosed on antiretroviral treatment (ART) and 94% of people on treatment with a suppressed viral load by the end of 2018 (Public Health Agency of Canada, 2020). These trends are a product of current HIV prevention and care programs that are delivered federally and provincially in Canada and remain under target. A strategy that is outlined by the Pan-Canadian Framework for Action: Reducing the health impact of sexually transmitted and blood-borne infections in Canada by 2030, all levels of government are tasked to take a syndemics approach to dealing with STBBIs (Public Health Agency of Canada, 2019).
Social and Environmental Impact of projects, products, programs, and policies
When I consider the various social and environmental interventions that take the shape of projects, products, programs, and policies, one must consider the multiple social determinants of health that influence the ability of an individual to access and uptake potential HIV/AIDS prevention strategies.
1) Programs: I was able to identify two tiers of HIV prevention and care programs in Ontario, Canada that support projects at local, regional, and national levels. The Community Action Fund, administered by the Public Health of Agency of Canada (federally), invests over 26 million in funds annually to support stakeholders address HIV, Hepatitis C and other sexually transmitted blood borne infections (Government of Canada, 2021). The AIDS and Hepatitis C Programs unit lead and support AIDS Service organizations (ASO) across Ontario provide HIV/AIDS care (Government of Ontario, n.d.). Similarly, each province and territory will have a unit within its Ministry of Health and Long Term Care. Sexually Transmitted Blood Borne Infections or STBBIs are tested for, traced, and treated through regional branches of Public Health. Access to testing and treatment can also be achieved through an individual’s primary care provider, however significant structural barriers exist when it comes to 2SLGBTQ+ folks accessing STBBI testing, treatment, and counselling. Despite dominantly discussed themes of “mistrust” between 2SLGBTQ+ folks and primary care providers, we must disrupt this theme to consider the turbulent relationship between clinical care and trans folks given the only recent de-pathologizing of gender incongruence (World Health Organization, 2018). Access to timely Antiretroviral Therapy (ART) treatment and wrap around care also remains somewhat difficult with the patchwork of treatment options available through the Trillium Drug Plan (ODP), Ontario Disability Support Program (ODSP), Ontario Works (OW), and one’s availability to private insurance (ACT, 2017).
2) Projects: A combination of community-based interventions, clinical care programs, social support programs and community based participatory research contribute to the growing array of project designs currently delivered in Ontario. Guided by the Ontario Accord, peer-based projects allow for meaningful engagement and greater involvement of people living with HIV (OAN, n.d.). However, a significant amount of social stigma and discrimination reduce access to available resources.
3) Products: Antiretroviral therapy (for folks living with HIV), PrEP (Pre-Exposure Prophylaxis for folks who are HIV negative with seropositive sexual partners) and PEP (Post-Exposure Prophylaxis for folks who are HIV negative who may have been exposed to HIV) are current HIV prevention strategies available for communities (CATIE, 2017). With new HIV testing innovations approved by Health Canada, the access to self testing technologies means that there are a lot more variables to consider when creating community HIV testing opportunities (CATIE, 2020).
4) Policies: HIV decriminalization has not yet caught-up to the science and several gaps in policy result in criminalization of communities while placing folks living with HIV at risk of ongoing structural violence (HALCO, 2019). Organizational spaces (physical and virtual), policies (hours of operation, training for staff) and templates (intake forms) have also found to create barriers to accessing care among femme identifying folks affected or effected by HIV/AIDS (WHAI, n.d.)
Key Debates and Discourses
Language amongst sexually and gender diverse communities continue to evolve and change over time, this requires public service organizations to adapt in a timely fashion and create opportunities for communities to meaningfully engage. Gaps that contribute to delays in cultural humility and awareness of structural vulnerabilities result in degradation of service pathways and reduced uptake of care. Independent, routine community-led monitoring of programs and services would support quality improvement, client satisfaction and care accessibility (MPact Global Action, 2020).
Despite interests in leading decentralized pre-existing, community centered, and peer-led HIV prevention and care services, the majority of programs and services deliver specific stand-alone treatments representing current states of evidence-based practice. Unfortunately, single interventions that reduce depression, anxiety, substance use, and HIV risk in siloed and sequential approach to prevention and treatment ignore intersectionality and client centered care (Pachankis, 2019).
Queer communities are often regarded as a monolith. Service providers and decision makers must recognize that sometimes even the most effective HIV prevention strategies like PrEP will not be accessible, acceptable, and sustainable for all 2SLGBTQ+ folks and that factors such as socio-economic status, geographic location and literacy will affect intervention uptake (Morgan, 2018). The most important piece of context is the historical trauma that the state perpetuated against queer and trans folks. From the Toronto Bathhouse raids to the lack of a systemic response during the Bruce McArthur murders in the Gay Village, examples of state violence and lack of civil protections are disproportionately numerous among BIPOC 2SLGBTQ+ folks. In order for community programs to develop authentically and meaningfully with colonial systems there must first be reparations and restitutions for the harmful impacts. In order to move forward, there must be multisectoral, indigenized and anti-oppressive ways of co-designing, implementing and evaluating programs.
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