A Manifesto for transformative action on HIV among Black communities in Canada.

Black communities bear a hugely disproportionate share of Canada's HIV epidemic. Black persons annually represent up to one quarter of new diagnoses, while in contrast, diagnoses have been falling among white Canadians for the past two decades. There has been a notable lack of urgency and serious debate about why the trend persists and what to do about it. For too long, public institutions have reproduced hegemonic white supremacy and profoundly mischaracterized Black life. Consequently, Black communities suffer policies and programs that buttress systemic anti-Black racism, socio-economically disenfranchise Black communities, and in the process marginalize knowledgeable, experienced, and creative Black stakeholders. The Interim Committee on HIV among Black Canadian Communities (ICHBCC) is a group of Black researchers, service providers, and community advocates who came together in early 2022 to interject urgency to the HIV crisis facing Black communities. Specifically, the ICHBCC advocates for self-determined community leadership of research, policies, and programs, backed by access to appropriate resources, to change the trajectory of HIV among Black Canadian communities. In this article, we introduce the wider community to the Black HIV Manifesto that we developed in 2022.

RéSUMé: Les communautés noires constituent une part très disproportionnée de l'épidémie de VIH du Canada. Les personnes noires représentent annuellement jusqu'au quart des nouveaux diagnostics, tandis que les diagnostics diminuent chez les Canadiennes et les Canadiens de race blanche depuis 20 ans. Il y a une absence notable d'urgence et de débat sérieux sur la raison de la persistance de ces tendances et sur ce qu'il faudrait y faire. Pendant trop longtemps, les institutions publiques ont reproduit l'hégémonie de la suprématie blanche et extrêmement mal caractérisé les vies noires. Par conséquent, les communautés noires souffrent de politiques et de programmes qui soutiennent le racisme anti-Noirs systémique, privent les communautés noires de leurs droits socioéconomiques et marginalisent ainsi les connaissances, l'expérience et la créativité des parties prenantes noires. Le comité intérimaire sur le VIH dans les communautés noires du Canada (ICHBCC) est un groupe de chercheurs et de chercheuses, de prestataires de services et de porte-parole communautaires de race noire qui se sont regroupés au début de 2022 pour mettre l'accent sur le caractère urgent de la crise du VIH dans les communautés noires. Plus précisément, l'ICHBCC plaide en faveur d'un leadership communautaire autodéterminé de la recherche, des politiques et des programmes, appuyé par un accès aux ressources nécessaires, pour changer la trajectoire du VIH dans les communautés noires du Canada. Dans cet article, nous présentons à l'ensemble de la communauté le « manifeste noir sur le VIH ¼ que nous avons élaboré en 2022.

Black heterosexual men's resilience in times of HIV adversity: findings from the "weSpeak" study.

BACKGROUND: In Canada, heterosexual African, Caribbean and Black (ACB) men tend to suffer a disproportionate burden of HIV. Consequently, studies have examined the underlying contributors to this disparity through the nexus of behavioral and structural factors. While findings from these studies have been helpful, their use of deficit and risk models only furthers our knowledge of why ACB men are more vulnerable to HIV infection. Thus far, there is a dearth of knowledge on how heterosexual ACB men mobilize protective assets to promote their resilience against HIV infection. METHODS: As part of a larger Ontario-based project called weSpeak, this study examined how ACB men acquire protective assets to build their resilience to reduce their HIV vulnerability. We analyzed three focus group discussions (n = 17) and 13 in-depth interviews conducted with ACB men using NVivo and a mixed inductive-deductive thematic analyses approach. RESULTS: The findings show that ACB men mostly relied on personal coping strategies, including sexual abstinence, to build resilience against HIV. Interpersonal resources such as family, friends, and religious communities also played an important role in constructing ACB men's resilience. ACB men bemoaned their lack of access to essential institutional resources, such as health services, that are important in managing HIV adversity. CONCLUSION: Based on these findings, there is an urgent need for HIV policy stakeholders, including service providers, to engage the ACB community in the design of intervention programs. Additionally, addressing the socioeconomic disadvantages faced by ACB communities will increase the capacity of ACB men to develop resilience against HIV.

"You have to make it cool": How heterosexual Black men in Toronto, Canada, conceptualize policy and programs to address HIV and promote health.

BACKGROUND: Black Canadian communities are disproportionately impacted by HIV. To help address this challenge, we undertook research to engage heterosexual Black men in critical dialogue about resilience and vulnerability. They articulated the necessity of making health services 'cool'. METHODS: We draw on the analyses of focus groups and in-depth interviews with 69 self-identified heterosexual Black men and 12 service providers who took part in the 2016 Toronto arm of the weSpeak study to explore what it means to make health and HIV services 'cool' for heterosexual Black Canadian men. RESULTS: Our findings revealed four themes on making health services cool: (1) health promotion as a function of Black family systems; (2) opportunities for healthy dialogue among peers through non-judgmental interactions; (3) partnering Black men in intervention design; and (4) strengthening institutional health literacy on Black men's health. CONCLUSIONS: We discuss the implications of these findings for improving the health of Black Canadians.

Black Canadians' Exposure to Everyday Racism: Implications for Health System Access and Health Promotion among Urban Black Communities.

This study explores the social determinants of Black Canadians' exposure to everyday racism, its relationship to health system access, and implications for health promotion. We used data from the A/C Study survey on HIV transmission and prevention among Black Canadians. We implemented the survey (N = 1360) in 2018-2019 in Toronto and Ottawa-two large cities that together account for 42% of Canada's Black population-among self-identified Black residents aged 15-64 years, who were born in sub-Sahara Africa or the Caribbean or had a parent who was born in those regions. Participants reported racist encounters in the preceding 12 months using the Everyday Discrimination Scale. We assessed the socio-demographic correlates of racist experiences and the impact of racism on health system access using multivariable generalised linear models. Sixty percent of participants reported experiencing racism in the preceding 12 months. Based on the adjusted odds ratios, participants were more likely to experience racism if they were older, employed, Canadian-born, had higher levels of education, self-identified as LGBTQ + and reported generally moderate access to basic needs and adequate housing; and less likely to experience racism if they lived in Ottawa, self-identified as female or reported higher levels of social capital. Visiting a healthcare provider or facility, and difficulty accessing healthcare were associated with racist experiences. Racist experiences diminished the likelihood of being tested for HIV. Racist experiences were widespread, especially among those with higher levels of social wellbeing or greater exposure to Canadian institutions. Study participants also associated racist experiences with the healthcare system.

Immigrant generational status and the uptake of HIV screening services among heterosexual men of African descent in Canada: Evidence from the weSpeak study.

Objective: Canada became a preferred destination for many non-European and non-American migrants since the introduction of favorable immigration policies in the late 1960 s. Blackimmigrants from the African and Caribbean regions however are a known vulnerable population to HIV infection in Canada. Even though first-generation immigrants might differ from subsequent generations in terms of culture and beliefs which are important for health outcomes and behaviors, research examining disparities in their use of preventative healthcare is limited. This study aimed to examine generational disparities in the uptake of HIV screening services among a sample of heterosexual Black men in Ontario, Canada. Methods: We used data from a cross-sectional survey sample (n = 829) that was collected from heterosexual Black men in four Ontarian cities (Toronto, Ottawa, London and Windsor) between March 2018 and February 2019. We used the negative log-log link function of the binomial family to examine the independent relationship between immigration status and the uptake of HIV testing and the cumulative effect of other predictor variables on HIV testing in nested models. Results: Findings from multivariate analysis show second-generation immigrants were significantly less likely to test for HIV compared with their first-generation immigrant counterparts. After controlling for theoretically relevant variables, the second-generation immigrants were 53% less likely to test for HIV. We further observed that participants with good knowledge of HIV transmission (OR=1.05; p > 0.05) and those who were older were more likely to test for HIV. Those with masculine tendencies (OR=0.98; p > 0.05) and those who reported not having sexual partner were less likely to test (OR=0.57; p > 0.01). Religion emerged as a significant predictor of HIV testing as Christians (OR=1.62; p > 0.05) and other believers (OR=1.59; p > 0.05) were more likely to test for HIV when compared to their Muslim counterparts. Conclusion: HIV prevention policies may need not only prioritize first-generation immigrants, but the wellbeing of their descendants as well. This could be achieved by implementing programs that will enhance second-generation immigrants' use of HIV screening services. Additionally, HIV educational programs would be of relevance and especially so as respondents with good knowledge of HIV transmission consistently demonstrated higher likelihood of testing for their HIV status.

Community perspectives on addressing and responding to HIV-testing, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) among African, Caribbean and Black (ACB) people in Ontario, Canada.

BACKGROUND: The African, Caribbean, and Black (ACB) population of Ontario, Canada is comprised of individuals with diverse ethnic, cultural and linguistic backgrounds and experiences; some of whom have resided in Canada for many generations, and others who have migrated in recent decades. Even though the ACB population represents less than 3.5% of the Canadian population, this group accounts for 21.7% of all new HIV infections. It is well-documented that ACB populations, compared to the general population, experience multi-level barriers to accessing appropriate and responsive HIV services. In this paper, we present qualitative findings on the ACB population's experiences with HIV-testing, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) and obtain their perspectives on how to improve access. METHODS: We conducted twelve Focus Group Discussions (FGDs), within a two-day World Café event and used socio-ecological framework and community-based participatory research (CBPR) approaches to guide this work. We meaningfully engaged ACB community members in discussions to identify barriers and facilitators to HIV testing, PEP and PrEP and how these may be addressed. The FGDs were transcribed verbatim and thematic analysis guided data interpretation. Credibility of data was established through data validation strategies such as external audit and peer-debriefing. RESULTS: Our analyses revealed multi-level barriers that explain why ACB community members do not access HIV testing, PEP and PrEP. Fear, health beliefs, stigma and lack of information, were among the most frequently cited individual- and community-level barriers to care. Health system barriers included lack of provider awareness, issues related to cultural sensitivity and confidentiality, cost, and racism in the health care system. Participants identified multi-level strategies to address the HIV needs including community-based educational, health system and innovative inter-sectoral strategies. CONCLUSION: CBPR, co-led by community members, is an important strategy for identifying the multi-level individual, interpersonal, community, institutional and structural factors that increase HIV vulnerability in ACB communities, notably anti-Black systemic racism. Study findings suggest the need for targeted community-based strategies and strategies aimed at reducing health system barriers to testing and care.

Knowledge of sexual partner's HIV serostatus and the practice of safer sex among heterosexual men of African descent in London, Ontario.

Objective: Poor knowledge of sexual partners' HIV status is a major contributing factor in the heterosexual spread of HIV in Canada. This study examined knowledge of sexual partner's HIV serostatus and the practice of safer sex among self-identified heterosexual African, Caribbean and Black (ACB) men in London, Ontario.Design: A cross-sectional data was collected from 156 heterosexual ACB men in London. The negative log-log link function was fitted to estimate the relationship between knowledge of sexual partner's HIV status and condom use among ACB men.Results: Findings show that ACB men who know their sexual partner's HIV status are less likely to use condoms compared to men who do not know the serostatus of their sexual partner, controlling for other theoretically relevant covariates. In addition, the findings show that sexually active, single ACB men are less likely to use condoms. On the other hand, ACB men with higher education, employed and with income over 60 thousand dollars a year have a higher likelihood of using condoms.Conclusions: Heterosexual ACB men who used condoms even when they did not know their sexual partners' HIV status could be explained as a resilience-building strategy in response to their increasing HIV vulnerabilities. Heterosexual ACB men's use of condoms is further associated with socioeconomic factors including income, employment and education that need to be addressed for an improved safer sex.

Black Resilience: A Strategic Asset for Engaging Heterosexual Black Canadian Men in Community Responses to HIV.

Black people's disproportionate burden of HIV in Canada has raised questions about whether they are sufficiently resilient to HIV, and how to promote resilience. In this paper, we critically examine the issue of resilience among heterosexual Black men in four large Canadian cities (Ottawa, Toronto, London, and Windsor). In 2016, a team of researchers engaged self-identified heterosexual Black men in critical reflection on HIV-related resilience and vulnerability, with the goal of identifying pathways to strengthen their involvement in community responses to HIV. In total, 56 men participated in in-depth interviews and 154 participated in 21 focus groups. The team also organized six focus groups (N = 41) with policymakers, service providers, and community leaders. All four cities participated in a multi-stage iterative process to identify the thematic content of the data. Three overarching sources of resilience emerged from our critical interpretive analysis: (1) bonding with other men, (2) strong commitment to family and community, and (3) demonstrating self-confidence and self-determination. These sources of resilience illustrate the value of love as a driving force for collective action on social justice, support for family and community, and self-determination. These expressions of love support heterosexual Black men to resist or negotiate the structural challenges and gendered ideologies that make them vulnerable to HIV. Based on our analysis, we propose the concept of Black resilience that transcends merely bouncing back from or accommodating to adversity; instead, we understand Black resilience as a predisposition that motivates strategic resistance to systemic disadvantage that undermines Black people's health and wellbeing.

Concurrent sexual partnerships and HIV testing among heterosexual Black men in Ontario, Canada: findings from the weSpeak study.

BACKGROUND: African, Caribbean, and Black men constitute the second-highest category of males living with HIV in Ontario, which increased from 15.4% to 17% between 2011 and 2016. Previous studies have attributed this disproportionately higher rate to multiple concurrent sexual partnerships and low rates of HIV testing. Drawing on theoretical constructs of the health belief model (HBM), this study examined the relationship between multiple concurrent sexual partnerships and the uptake of HIV testing services among heterosexual Black men in Ontario. METHODS: Using a cross-sectional sample data of 829 individuals from four cities in Ontario, we employed the multinomial logit analysis to examine the relationship between multiple sexual partnerships and the uptake of HIV testing services among heterosexual Black men. RESULTS: The findings show that heterosexual Black men with multiple concurrent sexual partners were more than twice (RRR = 2.306, P < 0.01) as likely to test for HIV within the past 12 months when compared to those with one partner. Furthermore, being an immigrant, having good knowledge of HIV transmission, and earning lower annual income predicted higher odds of testing while sexual debut between the ages of 16 and 20 years, no visit to a healthcare provider in the past year and difficulty accessing healthcare significantly predicted lower likelihood of testing for HIV. CONCLUSIONS: These findings align with the theoretical constructs of the health belief model but more importantly, they suggest heterosexual Black men with concurrent sexual partners may be aware of their HIV risk and are taking measures to know their serostatus. Hence, making HIV screening services accessible and at safer spaces could increase their use of HIV screening services.

A cross-sectional investigation of HIV prevalence and risk factors among African, Caribbean and Black people in Ontario: The A/C Study.

Background: The human immunodeficiency virus (HIV) epidemic has disproportionately affected African, Caribbean and Black (ACB) communities in Canada. We investigated the prevalence and factors associated with HIV infection among ACB people in Ontario. Methods: A cross-sectional survey of first- and second-generation ACB people aged 15-64 years in Toronto and Ottawa (Ontario, Canada). We collected sociodemographic information, self-reported HIV status and offered dried blood spot (DBS) testing to determine the prevalence of HIV infection. Factors associated with HIV infection were investigated using regression models. Results: A total of 1,380 people were interviewed and 834 (60.4%) tested for HIV. The HIV prevalence was 7.5% overall (95% confidence interval [CI] 7.1-8.0) and 6.6% (95% CI 6.1-7.1) in the adult population (15-49 years). Higher age (adjusted odds ratio [aOR] 2.8; 95% CI 2.77-2.82), birth outside of Canada (aOR 4.7; 95% CI 1.50-14.71), French language (aOR 9.83; 95% CI 5.19-18.61), unemployment (aOR 1.85; 95% CI 1.62-2.11), part-time employment (aOR 4.64; 95% CI 4.32-4.99), substance use during sex (aOR 1.66; 95% CI 1.47-1.88) and homosexual (aOR 19.68; 95% CI 7.64-50.71) and bisexual orientation (aOR 2.82; 95% CI 1.19-6.65) were associated with a positive HIV test. Those with a high school (aOR 0.01; 95% CI 0.01-0.02), college (aOR 0.00; 95% CI 0.00-0.01) or university education (aOR 0.00; 95% CI 0.00-0.01), more adequate housing (aOR 0.85; 95% CI 0.82-0.88), a higher social capital score (aOR 0.61; 95% CI 0.49-0.74) and a history of sexually transmitted infections (aOR 0.40; 95% CI 0.18-0.91) were less likely to have a positive HIV test. Conclusion: Human immunodeficiency virus infection is linked to sociodemographic, socioeconomic, and behavioural factors among ACB people in Ontario.

Factors Associated with Condom Knowledge, Attitude, and Use among Black Heterosexual Men in Ontario, Canada.

African, Caribbean, and Black (ACB) men living in Canada share a heightened risk of HIV infection and the associated risk factors such as suboptimal use of family planning services such as condom use. In this study, we assessed the factors associated with knowledge, attitude, and condom use among ACB men in Ontario. Methods. This was a cross-sectional study that surveyed heterosexual ACB men regardless of their residency status living in Ontario (n = 430). This is a part of a larger mixed methods study informed by critical race theory, intersectionality, and community-based participatory research (CBPR). Outcome variables were knowledge of condom use, attitude towards condom use, and actual use of condom during the last 12 months. Results. Of 430 participants, 77.70% has good knowledge of condom use as a protection against HIV transmission, 31.77% had positive attitude towards condom use, and 62.43% reported using condom regularly with casual partners during the last 12 months. Men who were currently married had more positive attitude towards condom use compared with their unmarried counterparts (odds ratio = 1.46, 95% CI = 1.20, 1.78). Canadian residents were found to have higher odds of having correct knowledge of condom (odds ratio = 1.31, 95% CI = 1.11, 1.55), and positive attitude towards condom use (odds ratio = 1.44, 95%CI = 1.09, 1.92). Men who visited sexual health clinics showed a positive association with having correct knowledge of condom (odds ratio = 1.78, 95% CI = 1.30, 2.44) and reported experiences of difficulty in accessing sexual health. This showed a negative association towards condom use (odds ratio = 0.45, 95% CI = 0.21, 0.97]. Conclusion. A considerable percentage of heterosexual ACB men did not have correct knowledge regarding the protective effect of condom use against HIV and positive attitude towards the use of condom. Several sociodemographic and healthcare-related factors were significantly associated with knowledge, attitude, and use of condom.

Sexual Debut Among Heterosexual Men of African and Caribbean Descent: Are the Youth Initiating Sex Earlier than the Older Generation?

Although age at first sex is considered a measure of sexual risk and vulnerability for HIV infection, there is a dearth of literature on age at sexual debut in the Canadian context. This study examined time variations to first sex among heterosexual African, Caribbean, and Black (ACB) men in four Ontarian cities. A population-based retrospective survey (n = 879) on timing to first sexual intercourse was conducted between 2018 and 2019 among self-identified heterosexual ACB men 16 years or older and residing in London, Ottawa, Toronto or Windsor. We used the lognormal survival analysis technique to examine variations in time to first sexual intercourse among age cohorts and between cities. The findings showed a generational shift in the pattern of sexual initiation, with younger heterosexual ACB men initiating sexual intercourse earlier compared with those currently older than 50 years. We observed those between 16 and 19 years, 20 and 29 years, and 30 and 39 years of age to have significantly higher risk ratios of TR = 0.852, TR = 0.869, and TR = 0.855, respectively. At city level, the results show marked spatial variations, with youth in cities of Toronto, Ottawa, and London at the highest risk of early sexual debut relative to those in Windsor. Early initiation of first sexual intercourse among heterosexual ACB youth was observed with those in the larger cities being at a relatively higher risk. There is the need for programs aimed at delaying sexual debut among youth in general. It is, however, important to recognize the relative risk of those in the larger cities.

"I went in there, had a bit of an issue with those folks": everyday challenges of heterosexual African, Caribbean and black (ACB) men in accessing HIV/AIDS services in London, Ontario.

BACKGROUND: In Canada, heterosexual African, Caribbean, and Black (ACB) men's heightened risk of HIV infection has been linked to behavioral characteristics, including practices of hegemonic masculinity that discourage the use of HIV preventive services. However, this framing is bereft of the role of structural factors that may be contributing to new HIV infections. This paper examined the underlying factors limiting access to health services among heterosexual ACB men in London, Ontario Canada. METHODS: A convenient sampling technique was used to recruit thirty-seven (n = 37) self-identified heterosexual ACB men and service providers. Four focus groups (FG) were conducted; three with ACB participants of similar age category (i.e., 16-24; 25-38; 39+), and one with service providers. The FGs focused on the barriers to using health services and interrogated the ease of access to HIV intervention programs by ACB men respectively. Recurring themes from the FGs were probed further using in-depth interviews (n = 13). FGs and in-depth interviews complemented each other in reducing uneven power dynamics, fact checking, and allowing for detail discussion of the topic under study. Data analyses were done in NVivo using a mixed inductive-deductive thematic analyses approach. RESULTS: Most ACB men lacked information on HIV and were unaware of their increased risk of infection. Contrary to the notion that behavioral characteristics keep ACB men away from health services, we found that most ACB men were unaware of the availability of these services. Those that had some knowledge about the services reported that they were not appropriately tailored to their needs. In addition, stereotypes and stigma about the etiology of HIV among Blacks, and systemic neglect served as significant barriers to ACB men's use of services. CONCLUSION: The findings suggest that, to enhance preventive health service use among heterosexual ACB men, there is the need to remove structural barriers. Engaging ACB men in the design and implementation of policies may be useful at improving access to HIV information, testing, and treatment services. Increased information dissemination to ACB men would create awareness of the availability of HIV services. Finally, service providers should be conscious of ACB men's concern about experiences of discrimination and racism at service centers.

Examining HIV-related stigma among African, Caribbean, and Black church congregants from the Black PRAISE study in Ontario, Canada.

HIV-related stigma impedes adoption and implementation of effective HIV prevention and treatment strategies. It may also exacerbate racial/ethnic HIV disparities. Given high levels of religious observance within African, Caribbean, and Black (ACB) communities and the social capital that faith-based organizations hold, these entities may be promising venues for stigma-remediation and effective partners in community-based, HIV-focused programing. However, more research is needed to understand HIV-related stigma in these institutions. This study examines HIV-related stigma among six ACB churches in Ontario, Canada. Surveys were distributed to ACB attendees (N = 316) and linear regressions determined relationships between HIV-related stigma and stigma subdomains with demographics, greater disagreement with same-sex relationships, HIV knowledge, and religiosity. Greater disagreement with same-sex relationships was the only variable associated with the HIV-related stigma scale and all of its subscales. Age, gender, HIV knowledge, religiosity, contact with persons living with HIV, and length of time in Canada were associated with varying aspects of HIV-related stigma. Findings can inform the development of HIV-related stigma interventions and the characteristics of individuals these efforts should target to achieve maximum impact.

Love, Judgement and HIV: Congregants' Perspectives on an Intervention for Black Churches to Promote Critical Awareness of HIV Affecting Black Canadians.

We assess participants' experience of Black Pastors Raising Awareness and Insight of Stigma through Engagement (Black PRAISE), an intervention for Black churches to promote critical awareness of HIV affecting Black Canadian communities. We used a community-based participatory approach to implement Black PRAISE among six churches in the Greater Toronto Area and Ottawa, in October-November 2016. For the intervention, congregants received a booklet with validated HIV-related information, attended a sermon on compassion and justice, viewed a short film on HIV-related stigma, and completed baseline and follow-up surveys to evaluate the effectiveness of the intervention. We then conducted in-depth interviews with 18 pastors and congregants from the six churches to explore how they experienced the intervention. Three major themes emerged from an iterative exploration of the thematic content of the interviews: the beneficial impact of the intervention; reconciling the moral and theological issues of their faith with the social reality of HIV and stigma; and perspectives on future stigma reduction efforts. Participants spoke approvingly about Black PRAISE and supported stigma reduction but acknowledged uncertainties about their capacity to actualise their commitment. The main overarching lessons from Black PRAISE are as follows: first, our results support a community-based participatory approach to productively engaging Black congregations in stigma reduction and health promotion; second, promising or successful interventions incorporate multiple components to promote critical awareness about the specific health issue for Black life and wellbeing; and third, interventions are more likely to succeed if they support critical reflection on the underlying conceptual issues, implicit assumptions and belief systems among the professional and lay stakeholders.

Black PRAISE: engaging Black congregations to strengthen critical awareness of HIV affecting Black Canadian communities.

In Canada, HIV disproportionately affects Black communities. Though Black faith leaders play an influential role engaging Black communities around social care and social justice, their response to HIV has been somewhat muted. Black PRAISE is a novel intervention for Black churches to strengthen congregants' critical awareness of HIV affecting Black communities. A multi-stakeholder team developed and tested the intervention in 2016 - 17 among six churches in the province of Ontario, where more than half of Black Canadians reside, using a community-based participatory approach. Specifically, the intervention aimed to strengthen how congregants understand HIV among Black communities and reduce their level of stigma toward people living with HIV. We addressed critical awareness among the participating congregations through (i) disseminating a booklet with validated information that promoted critical health literacy related to HIV; (ii) enabling pastors to deliver a sermon on love, compassion and social justice; and (iii) developing and screening a short film that featured Black Canadians discussing their experiences of HIV-related stigma. We assessed changes in knowledge and stigma by surveying congregants (N = 173) at baseline and two follow-ups using validated instruments and other measures. Through Black PRAISE, congregants significantly increased their HIV-related knowledge; moreover, exposure to all the intervention components was associated with a significantly reduced level of stigma. A likely strategic outcome of Black PRAISE is that churches are empowered to help strengthen Black people's community-based response to HIV and join efforts to eliminate the structural conditions that increase Black people's vulnerability to HIV.

Overview of systematic reviews on strategies to improve treatment initiation, adherence to antiretroviral therapy and retention in care for people living with HIV: part 1.

OBJECTIVES: We sought to map the evidence and identify interventions that increase initiation of antiretroviral therapy, adherence to antiretroviral therapy and retention in care for people living with HIV at high risk for poor engagement in care. METHODS: We conducted an overview of systematic reviews and sought for evidence on vulnerable populations (men who have sex with men (MSM), African, Caribbean and Black (ACB) people, sex workers (SWs), people who inject drugs (PWID) and indigenous people). We searched PubMed, Excerpta Medica dataBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Web of Science and the Cochrane Library in November 2018. We screened, extracted data and assessed methodological quality in duplicate and present a narrative synthesis. RESULTS: We identified 2420 records of which only 98 systematic reviews were eligible. Overall, 65/98 (66.3%) were at low risk of bias. Systematic reviews focused on ACB (66/98; 67.3%), MSM (32/98; 32.7%), PWID (6/98; 6.1%), SWs and prisoners (both 4/98; 4.1%). Interventions were: mixed (37/98; 37.8%), digital (22/98; 22.4%), behavioural or educational (9/98; 9.2%), peer or community based (8/98; 8.2%), health system (7/98; 7.1%), medication modification (6/98; 6.1%), economic (4/98; 4.1%), pharmacy based (3/98; 3.1%) or task-shifting (2/98; 2.0%). Most of the reviews concluded that the interventions effective (69/98; 70.4%), 17.3% (17/98) were neutral or were indeterminate 12.2% (12/98). Knowledge gaps were the types of participants included in primary studies (vulnerable populations not included), poor research quality of primary studies and poorly tailored interventions (not designed for vulnerable populations). Digital, mixed and peer/community-based interventions were reported to be effective across the continuum of care. CONCLUSIONS: Interventions along the care cascade are mostly focused on adherence and do not sufficiently address all vulnerable populations.

Social, Clinical, and Behavioral Determinants of HIV Infection and HIV Testing among Black Men in Toronto, Ontario: A Classification and Regression Tree Analysis.

Black men bear a disproportionate burden of HIV infection. These HIV inequities are influenced by intersecting social, clinical, and behavioral factors. The purpose of this analysis was to determine the combinations of factors that were most predictive of HIV infection and HIV testing among black men in Toronto. Classification and regression tree analysis was applied to secondary data collected from black men (N = 460) in Toronto, 82% of whom only had sex with women and 18% whom had sex with men at least once. For HIV infection, 10 subgroups were identified and characterized by number of lifetime male partners, age, syphilis history, and perceived stigma. Number of lifetime male partners was the best single predictor of HIV infection. For HIV testing, the analysis identified 8 subgroups characterized by age, condom use, number of sex partners and Chlamydia history. Age (>24 years old) was the best single predictor of HIV testing.

A/C study protocol: a cross-sectional study of HIV epidemiology among African, Caribbean and Black people in Ontario.

INTRODUCTION: African, Caribbean and Black (ACB) communities are disproportionately infected by HIV in Ontario, Canada. They constitute only 5% of the population of Ontario yet account for 25% of new diagnoses of HIV. The aim of this study is to understand underlying factors that augment the HIV risk in ACB communities and to inform policy and practice in Ontario. METHODS AND ANALYSIS: We will conduct a cross-sectional study of first-generation and second-generation ACB adults aged 15-64 in Toronto (n=1000) and Ottawa (n=500) and collect data on sociodemographic information, sexual behaviours, substance use, blood donation, access and use of health services and HIV-related care. We will use dried blood spot testing to determine the incidence and prevalence of HIV infection among ACB people, and link participant data to administrative databases to investigate health service access and use. Factors associated with key outcomes (HIV infection, testing behaviours, knowledge about HIV transmission and acquisition, HIV vulnerability, access and use of health services) will be evaluated using generalised linear mixed models, adjusted for relevant covariates. ETHICS AND DISSEMINATION: This study has been reviewed and approved by the following Research Ethics Boards: Toronto Public Health, Ottawa Public Health, Laurentian University; the University of Ottawa and the University of Toronto. Our findings will be disseminated as community reports, fact sheets, digital stories, oral and poster presentations, peer-reviewed manuscripts and social media.