Building Bridges: Describing a Process for Indigenous Engagement in Epidemiology.

BACKGROUND: Processes for epidemiology embedded with Indigenous methodology are needed. Building Bridges was developed to engage Indigenous peoples in epidemiology to address health issues relevant to them. OBJECTIVES: We describe our process for meaningfully engaging Indigenous leaders and peoples living with human immunodeficiency virus (HIV) in epidemiology research. METHODS: As a community-based research (CBR) project, Indigenous methodologies and leadership ensured the quality and relevance of findings. Study phases included 1) advisory board formation, 2) recruitment, 3) research question identification, 4) data analysis from the Canadian HIV Observational Cohort (CANOC) collaboration, 5) data interpretation and contextualization, and 6) knowledge translation and exchange. LESSONS LEARNED: Support and guidance from Indigenous team members, Spiritual Leaders and Elders along with meaningful relationships with allied academic researchers were pivotal. Expertise and lived experiences in Indigenous culture, HIV, epidemiology and services enabled multidirectional learning. CONCLUSIONS: Building Bridges' success hinged on ongoing co-learning and engagement of Indigenous peoples, service providers and researchers.

Increased mortality among Indigenous persons in a multisite cohort of people living with HIV in Canada.

OBJECTIVE: Compare all-cause mortality between Indigenous participants and participants of other ethnicities living with HIV initiating combination antiretroviral therapy (cART) in an interprovincial multi-site cohort. METHODS: The Canadian Observational Cohort is a collaboration of 8 cohorts of treatment-naïve persons with HIV initiating cART after January 1, 2000. Participants were followed from the cART initiation date until death or last viral load (VL) test date on or before December 31, 2012. Cox proportional hazard models were used to estimate the effect of ethnicity on time until death after adjusting for age, gender, injection drug use, being a man who has sex with men, hepatitis C, province of origin, baseline VL and CD4 count, year of cART initiation and class of antiretroviral medication. RESULTS: The study sample consisted of 7080 participants (497 Indigenous, 2471 Caucasian, 787 African/Caribbean/Black (ACB), 629 other, and 2696 unknown ethnicity). Most Indigenous persons were from British Columbia (BC) (83%), with smaller numbers from Ontario (13%) and Québec (4%). During the study period, 714 (10%) participants died. The five-year survival probability was lower for Indigenous persons (0.77) than for Caucasian (0.94), ACB (0.98), other ethnicities (0.96) and unknown ethnicities (0.85) (p < 0.0001). In an adjusted proportional hazard model for which missing data were imputed, Indigenous persons were more likely to die than Caucasian participants (hazard ratio = 2.69, p < 0.0001). CONCLUSION: The mortality rate for Indigenous persons was higher than for other ethnicities and is largely reflective of the BC population. Addressing treatment challenges and identifying HIV- and non-HIV-related causes for mortality among Indigenous persons is required to optimize their clinical management.

A comparison of virological suppression and rebound between Indigenous and non-Indigenous persons initiating combination antiretroviral therapy in a multisite cohort of individuals living with HIV in Canada.

BACKGROUND: This study compared time to virological suppression and rebound between Indigenous and non-Indigenous individuals living with HIV in Canada initiating combination antiretroviral therapy (cART). METHODS: Data were from the Canadian Observational Cohort collaboration; eight studies of treatment-naive persons with HIV initiating cART after 1/1/2000. Fine and Gray models were used to estimate the effect of ethnicity on time to virological suppression (two consecutive viral loads [VLs] <50 copies/ml at least 3 months apart) after adjusting for the competing risk of death and time until virological rebound (two consecutive VLs >200 copies/ml at least 3 months apart) following suppression. RESULTS: Among 7,080 participants were 497 Indigenous persons of whom 413 (83%) were from British Columbia. The cumulative incidence of suppression 1 year after cART initiation was 54% for Indigenous persons, 77% for Caucasian and 80% for African, Caribbean or Black (ACB) persons. The cumulative incidence of rebound 1 year after suppression was 13% for Indigenous persons, 6% for Caucasian and 7% for ACB persons. Indigenous persons were less likely to achieve suppression than Caucasian participants (aHR=0.58, 95% CI 0.50, 0.68), but not more likely to experience rebound (aHR=1.03, 95% CI 0.84, 1.27) after adjusting for age, gender, injection drug use, men having sex with men status, province of residence, baseline VL and CD4+ T-cell count, antiretroviral class and year of cART initiation. CONCLUSIONS: Lower suppression rates among Indigenous persons suggest a need for targeted interventions to improve HIV health outcomes during the first year of treatment when suppression is usually achieved.

Experiences of chronic stress and mental health concerns among urban Indigenous women.

We measured stress, depression and post-traumatic stress disorder (PTSD) levels of urban Indigenous women living with and without HIV in Ontario, Canada, and identified correlates of depression. We recruited 30 Indigenous women living with HIV and 60 without HIV aged 18 years or older who completed socio-demographic and health questionnaires and validated scales assessing stress, depression and PTSD. Descriptive statistics were conducted to summarize variables and linear regression to identify correlates of depression. 85.6 % of Indigenous women self-identified as First Nation. Co-morbidities other than HIV were self-reported by 82.2 % (n = 74) of the sample. High levels of perceived stress were reported by 57.8 % (n = 52) of the sample and 84.2 % (n = 75) had moderate to high levels of urban stress. High median levels of race-related (51/88, IQR 42-68.5) and parental-related stress (40.5/90, IQR 35-49) scores were reported. 82.2 % (n = 74) reported severe depressive symptoms and 83.2 % (n = 74) severe PTSD. High levels of perceived stress was correlated with high depressive symptoms (estimate 1.28 (95 % CI 0.97-1.58), p < 0.001). Indigenous women living with and without HIV reported elevated levels of stress and physical and mental health concerns. Interventions cutting across diverse health care settings are required for improving and preventing adverse health outcomes.

Comparison of coping strategies and supports between aboriginal and non-aboriginal people living with HIV in Ontario.

Complex historical and cultural factors have contributed to the HIV epidemic among Aboriginal populations in Canada. This study assesses social supports, adaptive and maladaptive coping mechanisms, stress, and mastery of Canadian-born Aboriginal and Canadian-born Caucasian people living with HIV in Ontario and posits that coping and social support are important micro- and meso-level factors associated with the epidemic. This cross-sectional analysis included questionnaire data collected from 2007 to 2011 at HIV clinics in Toronto. Categorical and continuous variables were compared using chi-square and Wilcoxon rank sum tests, respectively. Correlates of social support and coping were determined using univariate and multivariable linear regression. The analysis included 70 Aboriginal and 665 Caucasian participants. Aboriginal participants had lower levels of employment, education, and annual household income. Aboriginal participants reported more overall (7 vs. 4, p = 0.0003), ongoing (4 vs. 2, p = 0.0004), and early childhood (2 vs. 1, p = 0.02) stressors. Maladaptive coping, adaptive coping, and mastery scores were similar between Aboriginal and Caucasian participants. In multivariable analysis, injection drug use and lower education levels were significant correlates of higher maladaptive coping and lower overall support scores. Despite numerous socioeconomic challenges and personal stressors, Aboriginal people living with HIV who are accessing care exhibited comparable coping and mastery scores to Canadian-born Caucasian people living with HIV, suggesting remarkable strengths within Aboriginal people living with HIV and their communities.

Food insufficiency, housing and health-related quality of life: results from the Positive Spaces, Healthy Places study.

Studies of people living with HIV who are homeless or unstably housed show a high prevalence of food insufficiency (>50%) and associated poor health outcomes; however, most evidence is in the form of cross-sectional studies. To better understand this issue, we conducted a longitudinal study to examine the impact of food insufficiency and housing instability on overall physical and mental health-related quality of life (HRQoL) among people living with HIV in Ontario. Six hundred and two adults living with HIV were enrolled in the Positive Spaces, Healthy Places study and followed from 2006 to 2009. Interviewer-administered questionnaires were used, and generalized linear mixed-effects models constructed to examine longitudinal associations between food insufficiency, housing instability and physical and mental HRQoL. At baseline, 57% of participants were classified as food insufficient. After adjusting for potential confounders, longitudinal analyses revealed a significant, negative association between food insufficiency and physical and mental HRQoL outcomes, respectively [effect size (ES) with 95% confidence interval (CI): (ES = -2.1, CI = -3.9,-0.3); (ES = -3.5, CI = -6.1,-1.5)]. Furthermore, difficulties meeting housing costs were shown to have additional negative impacts on mental HRQoL. Food insufficiency is highly prevalent among people living with HIV in Ontario, particularly for those with unstable housing. This vulnerable group of individuals is in urgent need of changes to current housing programmes, services and policies, as well as careful consideration of their unmet nutritional needs.

Comparison of late HIV diagnosis as a marker of care for Aboriginal versus non-Aboriginal people living with HIV in Ontario.

BACKGROUND: Studies have found that Aboriginal people living with HIV/AIDS (APHAs) are more likely than non-APHAs to receive suboptimal HIV care, yet achieve similar clinical outcomes with proper care. OBJECTIVE: To compare the proportions of individuals diagnosed late with HIV between APHAs and non-APHAs within the Ontario HIV Treatment Network Cohort Study (OCS). METHODS: The analysis included OCS participants who completed the baseline visit by November 2009. Two definitions of the outcome of late HIV diagnosis were used: the proportion of participants with an AIDS-defining illness (ADI) before or within three months of HIV diagnosis; and the proportion of participants with a CD4(+) count <200 cells/mL at diagnosis. Logistic regression analysis was used to assess the association between Aboriginal ethnicity and late HIV diagnosis. RESULTS: APHAs were more likely to be female and have lower income, education and employment. No statistically significant differences were noted in the proportions receiving a late HIV diagnosis defined by ADI (Aboriginal 5.2% versus non-Aboriginal 6.3%; P=0.40). Multivariate logistic regression analysis revealed a significant association between Aboriginal ethnicity and late HIV diagnosis defined by CD4(+) count after adjusting for age and HIV risk factor (OR 1.55; P=0.04). DISCUSSION: APHAs were more likely to have a CD4(+) count <200 cells/mL at diagnosis but had similar clinical outcomes from late diagnosis when defined by ADI. However, differences may be underestimated due to recruitment limitations and selection bias. CONCLUSION: Additional work is needed to address the socioeconomic and health care needs of APHAs.

HISTORIQUE: Les études ont démontré que les Autochtones qui vivent avec le VIH ou le sida (AVVS) sont plus susceptibles que les non-Autochtones qui vivent avec le VIH ou le sida (NAVVS) de recevoir des soins sous-optimaux, mais présentent des issues cliniques similaires lorsqu'ils reçoivent des soins convenables. OBJECTIF: Comparer la proportion d'AVVS et de non-AVVS de la cohorte OCS du réseau thérapeutique du VIH qui reçoivent un diagnostic tardif de VIH de l'Ontario. MÉTHODOLOGIE: L'analyse incluait les participants de l'OCS qui avaient eu leur première visite avant novembre 2009. Deux définitions de l'issue de diagnostic tardif du VIH ont été utilisées : la proportion de participants ayant une maladie symptomatique du sida (MSS) avant ou dans les trois mois suivant le diagnostic du VIH, et la proportion de participants ayant une numération de CD4+ inférieure à 200 cellules/mL au diagnostic. Les chercheurs ont utilisé l'analyse de régression logistique pour évaluer l'association entre l'ethnie autochtone et le diagnostic tardif de VIH. RÉSULTATS: Les AVVS étaient plus susceptibles d'être des femmes et d'avoir un revenu et une scolarisation plus faibles ainsi qu'un emploi moins bien rémunéré. Les chercheurs n'ont perçu aucune différence statistiquement significative dans la proportion qui avait reçu un diagnostic tardif de VIH défini par une MSS (Autochtones 5,2 %, non-Autochtones 6,3 %; P=0,40). L'analyse de régression logistique multivariée a révélé une association significative entre l'ethnie autochtone et un diagnostic tardif de VIH défini par la numération de CD4+ après rajustement compte tenu de l'âge et du facteur de risque de VIH (RRR=1,55; P=0,04). EXPOSÉ: Les AVVS étaient plus susceptibles de présenter une numération de CD4+ inférieure à 200 cellules/mL au diagnostic, mais avaient des issues cliniques similaires de diagnostic tardif lorsqu'on le définissait par une MSS. Cependant, les différences sont peut-être sous-estimées en raison des limites de recrutement et du biais de sélection. CONCLUSION: D'autres travaux s'imposent pour connaître les besoins socioéconomiques et en soins de santé des AVVS.