Saskatchewan currently has the highest rates of HIV in Canada, about two and a half time times the national average. There have been 1,000 new positive diagnoses in the last five years.
The rate has been climbing steadily since about 2007 while other similar populations, such as Manitoba, have not seen that kind of escalation. The spike is partly attributed to the fact that cocaine users in Saskatchewan prefer injection over snorting or smoking, although it's not clear why.
According to infectious disease specialist Dr. Stuart Skinner, with today's treatments, people with HIV can live as long as people who don't have HIV. Every death should be considered preventable, he said at an HIV workshop held in North Battleford Friday of last week.
But people are still dying.
Skinner, a clinical assistant professor at the University of Saskatchewan and one of the four clinical directors of the Saskatchewan HIV Provincial Leadership Team, told the 120 people at the workshop the reasons people are dying now is because they are diagnosed too late, or because of barriers to effective treatment.
Supporting people who take treatment is a significant challenge, he said, especially when related to addiction, mental health and social determinants of health.
"It's a matter of, if you don't have a house over your head, why would you care about taking a pill."
HIV is treatable, he said. There is no cure, but we have the next best thing - effective medication. But to get treatment to people is a challenge.
"We really need to support people living with HIV," he said. "There's a lot of stigma, especially in Saskatchewan, in urban and rural centres."
He added, "There are a lot of pockets of stigma in smaller rural communities. We have to help [HIV positive patients] feel they are not isolated, help them stay in their home community with family and friends."
In the initial years of the spike, many of the new cases were in Saskatoon or Regina, but that has shifted, he said. Cases in urban centres are dropping, but being picked up by smaller and rural cases, especially in First Nations and other aboriginal communities.
Skinner said about 80 per cent of new cases are self-reported First Nations and Métis individuals, and 70 to 80 per cent are related to injection drug use.
Along with injection related HIV infections, there is the added challenge of co-infection, especially Hepatitis C.
There have been 7,000 new cases of Hep C provincially in the last 10 years, said Skinner.
"We are starting to see the consequences of that in terms of liver disease and cancer," he said, however he added that treatments are getting better and Hep C is something that can be cured. That will be a positive impact for the HIV population, he said.
Skinner also addressed the importance of testing. People are dying because they are getting tested too late. There is "incredibly strong evidence" that treating HIV before end stage complications set in is of significant benefit, individually and in the realm of public health, especially since counselling around risk indicators can prevent further transmission.
At a governmental level, early diagnosis can result in huge cost savings, because the costs of treatment are higher in the later stages.
"It's a no brainer," said Skinner.
Skinner is a member of the Saskatchewan HIV Provincial Leadership Team, which was created to implement the Saskatchewan HIV Strategy 2010-14. The team has recommended voluntary confidential HIV testing and counselling be conducted, as close to the individuals' home community as possible, for: all pregnant women; all tuberculosis/Hep C patients; all clients assessed in a sexually transmitted infection clinic or seen in any health care setting for an STI; all patients showing signs/symptoms that may be consistent with HIV-related disease; all clients who have requested an HIV test; all patients aged 13 to 64 receiving primary or emergency health care who do not know their HIV status or who are sexually active and have not had an HIV test in the last 12 months.
The stigma surrounding HIV and AIDS, plus social determinants such as geography, poverty and racism, affect access to testing, Skinner said.
At issue, also, is the criminalization of HIV, the only infection that has criminal issues. (In Canada, people living with HIV can be charged with a criminal offence for not disclosing their HIV to sexual partners.)
"Until we can treat it consistent with everything else, it will still have this stigma related," he said.
There are so many issues around HIV, said Skinner, that it's necessary to develop unique, innovative team models around care that are comprehensive and address all those issues.
In this province, access to testing and treatment can be eight hours away, and the stigma is "huge" in Saskatchewan.
"I can't say enough about that." said Skinner. "So many people living with HIV feel so isolated, because sometimes they get kicked out of their communities, their families won't talk to them, their friends won't talk to them, there is a fear of disclosure we really need to try to rally around to reduce stigma."
HIV treatment is also affected by limited resources and lack of funding. In a province with the highest rates of HIV, TB and Hep C in the country, there are only eight infectious disease specialists. Manitoba has 15, Alberta has 52. In Northern Saskatchewan, family physicians number three for 10,000. That's "ridiculously low," said Skinner.
"Care providers are trying to do more complex care with less numbers and it's incredibly difficult. We really need to think outside the box and come up with different models."
They have to be community-based models tailored to the needs and resources of those communities, and flexible enough to be tailored to the individual needs of the patients. They need to be multidisciplinary and collaborate with specialist care, he said.
It all boils down to the social determinants of health, such as poverty, abuse, housing issues, unemployment and mental health, he said. It is also related to the legacy of residential schools, he added, and to the racism that occurs in this province, all issues that lead to addiction and to HIV and Hep C.
"All programming and support needs to include managing the social determinants, or the treatment is not effective."
Excerpted from Saskatchewan Ministry of Health HIV Strategy 2010-2014
The pattern of HIV in Saskatchewan is different from any other province or territory in that the new cases are predominantly injection drug users (60 per cent) and /or aboriginal, (72 per cent). Forty-four per cent of new cases are young women. There is repeated and strong anecdotal evidence of encouraged sharing of needles for 'loyalty' reasons and shared family habits. ITrack study findings show that 38 per cent of injection drug users in Regina inject with families compared to an average of 12.7 per cent across seven Canadian cities. Approximately 50 per cent inject with sex partners compared to less than 30 per cent for other Canadian cities.
