"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 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.

Progress toward closing gaps in the hepatitis C virus cascade of care for people who inject drugs in San Francisco.

BACKGROUND: People who inject drugs (PWID) are disproportionately affected by hepatitis C virus (HCV). Data tracking the engagement of PWID in the continuum of HCV care are needed to assess the reach, target the response, and gauge impact of HCV elimination efforts. METHODS: We analyzed data from the National HIV Behavioral Surveillance (NHBS) surveys of PWID recruited via respondent driven sampling (RDS) in San Francisco in 2018. We calculated the number and proportion who self-reported ever: (1) tested for HCV, (2) tested positive for HCV antibody, (3) diagnosed with HCV, (4) received HCV treatment, (5) and attained sustained viral response (SVR). To assess temporal changes, we compared 2018 estimates to those from the 2015 NHBS sample. RESULTS: Of 456 PWID interviewed in 2018, 88% had previously been tested for HCV, 63% tested antibody positive, and 50% were diagnosed with HCV infection. Of those diagnosed, 42% received treatment. Eighty-one percent of those who received treatment attained SVR. In 2015 a similar proportion of PWID were tested and received an HCV diagnosis, compared to 2018. However, HCV treatment was more prevalent in the 2018 sample (19% vs. 42%, P-value 0.01). Adjusted analysis of 2018 survey data showed having no health insurance (APR 1.6, P-value 0.01) and having no usual source of health care (APR 1.5, P-value 0.01) were significantly associated with untreated HCV prevalence. CONCLUSION: While findings indicate an improvement in HCV treatment uptake among PWID in San Francisco, more than half of PWID diagnosed with HCV infection had not received HCV treatment in 2018. Policies and interventions to increase coverage are necessary, particularly among PWID who are uninsured and outside of regular care.

Unmet Health and Social Welfare Needs of Women Who Inject Drugs in San Francisco.

We characterize social welfare and health care needs of women who inject drugs in a community-based survey in San Francisco. A total of 139 women were enrolled; 74.8% were homeless, and 67.6% earned below poverty level. Indicators of health care and prevention program access included: 95.7% with health insurance, 90.6% used a needle exchange program, and 58.2% tested for HIV two or more times. However, only 8.6% received HPV vaccination and there was unmet contraception need for 79.0% of women. Only 28.7% of those testing positive for HCV infection had received treatment. Physical and sexual violence in the last year were common (41.0% and 18.0%, respectively). Women who inject drugs would benefit from integrated health and social services including addressing interpersonal violence, sexual and reproductive health, and HIV and HCV prevention needs. Women-only needle exchange programs and safe injection sites may be effective delivery points for these services.

Awareness and uptake of pre-exposure prophylaxis for HIV among low-income, HIV-negative heterosexuals in San Francisco.

We examined pre-exposure prophylaxis (PrEP) awareness and uptake among low-income heterosexual men and women in San Francisco in 2019. Of 294 HIV-negative survey participants, 42.5% were aware of PrEP. Few women (12.5%) and men (8.9%) had discussed PrEP with a healthcare provider; 3.8% of women and 0% of men had used PrEP in the last year. White participants (adjusted odds ratio (aOR) 5.39, 95% CI 1.02, 28.56), women (aOR 2.19, 95% CI 1.30, 3.70), and age 60 years or above (aOR 4.00, 95% CI 1.12, 14.34) had greater odds of being aware of PrEP. Testing for HIV or sexually transmitted infection in the past year was marginally associated with a greater PrEP awareness. Our findings reveal gaps in PrEP implementation associated with social disparities among low-income heterosexuals. Testing services and targeted promotional and educational materials are needed lest high-risk, low-income populations are left behind in San Francisco's aggressive "Getting to Zero" efforts.

Homelessness, HIV testing, and the reach of public health efforts for people who inject drugs, San Francisco, California.

BACKGROUND: There is a dearth of literature that explicitly examines associations between housing and HIV testing among people who inject drugs (PWID). Thus, the present study investigated the links between housing status and HIV testing for PWID. METHODS: Respondent-driven sampling recruited 382 HIV-negative PWID, who completed structured interviews in San Francisco. Logistic regression determined whether housing statuses in the past 12 months ([1] owned/rented, [2] single-room occupancy hotels [SROs], [3] living with friends/family/partners, [4] shelters, [5] outdoors) were associated with getting HIV tested in the past 12 months while adjusting for sociodemographics and receptive sharing of injection paraphernalia in the past 12 months. RESULTS: PWID who lived in SROs had greater odds of being tested for HIV than PWID who did not live in SROs (aOR = 1.95, CI.95: 1.06-3.60) while adjusting for covariates. Although bivariable analyses indicated that receptively sharing syringes was more common for PWID who lived with others (χ2[3] = 7.94, p = 0.047) or lived outdoors (χ2[3] = 9.50, p = 0.023) than those who did not, respectively, PWID who lived with others (aOR = 1.72, CI.95 = 0.95-3.14) or lived outdoors (aOR = 1.37, CI.95 = 0.74-2.53) did not show greater odds of HIV testing in multivariable analyses. CONCLUSIONS: PWID who lived in SROs had greater odds of HIV testing than PWID who did not live in SROs. Although PWID who lived with others or outdoors showed greater HIV risk, they did not show greater odds of HIV testing. Public health efforts may be reaching PWID in SROs, but more work is needed to reach PWID who live with other people or outdoors.

Prevalence and disparities in opioid overdose response training among people who inject drugs, San Francisco: Naloxone training among injectors in San Francisco.

BACKGROUND: Expanding naloxone training stands to reduce opioid-related overdose deaths. The current study assessed the prevalence of overdose response training and use of naloxone among people who inject drugs (PWID). METHODS: Data were from a survey of PWID in San Francisco in 2018, recruited by respondent-driven sampling (RDS). Eligibility criteria were age over 18 years, injected non-prescribed drugs in the last year, San Francisco residence, and referral by another participant. Interviews collected demographic characteristics and injection-related behavior. RESULTS: The sample (N=458) was majority male (67.5%) and over 45.5 years. Over three-fourths (76.0%) injected primarily opioids. Overall, 62.9% received overdose response training and 68.8% owned a naloxone kit. A majority (77.9%) had witnessed an overdose in the past year, of whom 55.8% used naloxone the last time they witnessed an overdose. Receiving overdose response training was significantly lower among persons of non-white race/ethnicity compared to whites (adjusted odds ratio [AOR] 0.43, 95% CI 0.27, 0.69) and higher among those who owned naloxone (AOR 6.29, 95% confidence interval [CI] 3.95, 10.02) and used syringe exchange programs (AOR 3.51, 95% CI 1.41, 8.79). CONCLUSION: While the majority of PWID have had overdose response training, gaps and disparities persist in promotion of naloxone use.

Fentanyl self-testing in a community-based sample of people who inject drugs, San Francisco.

BACKGROUND: Fentanyl test strips (FTS) can prevent overdose by identifying unknown fentanyl-laced drugs. We measured FTS use amongst people who inject drugs (PWID) in San Francisco. METHODS: Data were from a cross-sectional survey of PWID in 2018, recruited by respondent-driven sampling. Participants were asked about FTS use in the last 12 months. RESULTS: Of 458 PWID surveyed, 45.4% had used an FTS in the last 12 months. FTS use was higher among PWID younger in age (adjusted odds ratio [AOR] 0.97 per year, 95% confidence interval [CI] 0.95-0.98), witnessing overdose (AOR 2.40, 95% CI 1.36-4.23), currently owning naloxone (AOR 2.92, 95% CI 1.76-4.87), and receiving overdose training (AOR 1.62, 95% CI 1.04-2.51). FTS use was lower among Black/African Americans (AOR 0.56, 95% CI 0.34-0.93). Amongst FTS users, 80.2% had a positive result, of whom 43.4% did not change their use of the drug, 26.5% abstained from using it, and 30.1% used a lower dose. CONCLUSION: Efforts to promote the use of FTS may have reached under half of PWID in San Francisco. Avenues need to be found to increase the role of FTS as a harm reduction approach to prevent overdose, particularly for older and Black/African American PWID.

Will We Get to Zero HIV Stigma in San Francisco?

Cities worldwide are striving to get to zero HIV stigma as a condition to get to zero new infections. We tracked an indicator of perceived HIV stigma across surveys of men who have sex with men (MSM) in San Francisco from 2011 to 2017. Little improvement in perceived HIV stigma was observed, from 22.3% (95% CI 18.7-26.3) of MSM agreeing with the statement "Most people would discriminate against someone with HIV" in 2011 to 21.0% (95% CI 17.5-24.9) in 2017 (χ2 test for trend 0.252, p = 0.616). Success in ending the epidemic may flag without addressing the causes of HIV stigma.

Substance use disorders among African, Caribbean and Black (ACB) people in Canada: a scoping review protocol.

INTRODUCTION: Previous research demonstrated that substance use continues to be one of the most complex and prevalent problems among African, Caribbean and Black (ACB) people. A number of studies were conducted to characterise substance use patterns in this population. To our knowledge, this is the first known review in Canada characterising substance use disorders on ACB people.This scoping review seeks to answer the following research questions: What characterises substance use disorders among ACB people in Canada? What are the different types and prevalence of substance use among ACB people in Canada? Do ACB people in Canada use more than one substance? What factors are associated with substance use among ACB people in Canada? What are the health and social impacts of substance use in ACB people in Canada? METHODS AND ANALYSES: This study will use the methodological framework for scoping reviews developed by Arksey and O'Malley. We will search electronic bibliographic databases including Ovid MEDLINE, PsycINFO and CINAHL. We will limit our search to English articles published between 2000and2019. In addition, we will conduct a grey literature search. Two investigators will independently screen citations and full-text articles. Our findings will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis for scoping reviews guidelines. We will provide a descriptive summary of the studies and summarise the findings with respect to the outcomes and report any gaps that might require further investigation. ETHICS AND DISSEMINATION: Our proposed study does not involve human participants; therefore, research ethics approval is not required. This study will provide evidence that will inform the development of strategies for appropriate interventions, as well as policy and further research. The results will be disseminated through publications in open access peer-reviewed journals, presentations at scientific meetings and to the lay public.