Evolution and Possible Explanations for the Trends in New HIV Diagnoses in Alberta, Saskatchewan, and Manitoba, Compared to the Rest of Canada, 1985–2022

Abstract

Background:

Canada aims to end the HIV epidemic as a public health threat by 2030. However, the provinces Alberta, Saskatchewan, and Manitoba reported 564 new HIV diagnoses in 2021 and over 600 in 2022. This study describes changes in HIV epidemiology in these three provinces compared to the rest of Canada between 1985 and 2022.

Methods:

This was an ecological study that used data from publicly available HIV reports published by the Governments of Manitoba, Saskatchewan, Alberta, and Canada from the first reported HIV diagnoses to the latest available information. Variables of interest included number of HIV diagnoses per year (new, introduced), advanced HIV disease, proportion of diagnoses by sex (female/male), ethnicity, age, self-reported HIV mode of transmission, and mortality. We report the HIV incidence, advanced HIV disease, and mortality over time by province, and by sex, ethnicity, age, and mode of HIV transmission when data are available.

Results:

Canadian HIV incidence decreased over time, while new HIV diagnoses in Manitoba and Saskatchewan increased to the highest ever recorded. In Saskatchewan and Manitoba, the male-to-female ratio is 1:1, while in Alberta and Canada, it is 2:1. Indigenous people have been overrepresented in Saskatchewan and Manitoba diagnoses since 2006 and 2016, respectively. The most common modes of HIV transmission are injection drug use and heterosexual sex in Saskatchewan and Manitoba for several years, while “out-of-country” is the most common category in Alberta. The advanced HIV disease and mortality statistics have decreased over time in Canada and the three provinces.

Conclusion:

HIV incidence in Canada has slowly decreased; however, Manitoba and Saskatchewan have shown unprecedented increases in HIV incidence. The current epidemiology requires immediate public health action from local, provincial, and federal governments, considering that Alberta, Saskatchewan, and Manitoba contribute to about 40% of all new HIV diagnoses in Canada.

Introduction

HIV continues to be a significant public health challenge. In 2022, there were 39.0 million (33.1–45.7 million) people living with HIV and 1.3 million (1.0–1.7 million) new infections, globally (1). The number of new HIV diagnoses was static or declined in Canada from 2012 to 2021 (2). However, in 2022, Canada reported 1,833 new HIV diagnoses (national HIV rate of 4.7 per 100,000 population), an increase of 24.9% compared to 2021 (3). The prairie provinces of Alberta, Saskatchewan, and Manitoba contributed to over 600 HIV diagnoses in 2022, with HIV incidence rates up to 4.5 times higher than the national rate.

In 2022, the Canadian rate of new HIV diagnoses for males was two-fold greater than for females (6.3 versus 3.1 per 100, 000). Overall, Indigenous populations accounted for 23.9% of all new HIV diagnoses in 2021 (First Nations 12.7%, unspecified Indigenous 10.4%, Métis 0.8%, Inuit 0.2%) (2). Indigenous Peoples in Canada continue to face structural and social health inequities and inequalities (4, 5, 6), with disproportionate HIV rates when compared to the non-Indigenous population (2,7). This situation was worsened by the COVID-19 pandemic, as people experienced social isolation, the loss of community support, and deleterious effects on their mental health and substance use (8,9). Distribution of cases with respect to exposure types was: for males via male-to-male sexual contact (54.2%), followed by heterosexual contact (24%) and injection drug use (15.9%); and in females by heterosexual contact (60.4%) and injection drug use (38.3%) (2).

Significant heterogeneity exists among provinces and territories with regard to the affected priority populations. While the majority of new HIV diagnoses from Ontario, Quebec, and British Columbia are reported to be through male-to-male sexual contact, data from the prairie provinces has shown that the affected priority populations are different. A previous study examining the characteristics of persons living with HIV (PLWH) in care at four clinics in the prairie provinces between 2003 and 2007 reported that there was an overall 12% increase in HIV cases, with 74% of cases among males and with heterosexual sex being the most commonly reported mode of acquisition (10). During that period, 36% of HIV diagnoses were reported in Indigenous populations (among Indigenous people 56.6% were female and 23.7% male; and in Saskatchewan, Indigenous females accounted for 84.4% of all females diagnosed with HIV) (10). Persons who inject drugs represented 61% of cases among males and 87% of cases among females in Saskatchewan compared to 15% among males and females in Manitoba and 3.6% among males and 11% among females in southern Alberta between 2003 and 2007 (10). A recent study from Manitoba from 2018 to 2021 identified 404 adults newly diagnosed with HIV, with 76% of cases reported among persons self-identifying as Indigenous (85.1% females, 68.6% males), and with heterosexual sex reported as the most common mode of HIV acquisition (63.6% overall; females: 77.9%; males: 52%), followed by injection drug use (56.2% overall; females: 71.8%; males: 43.5%) and 11% reporting male-to-male sexual contact (11). Additional research from Manitoba and Saskatchewan has found that people newly diagnosed with HIV are experiencing intersecting conditions of houselessness, drug use (mostly injection and methamphetamine use), and mental health conditions, with only two-thirds achieving undetectable viral loads (11, 12, 13, 14, 15).

We aim to describe the evolution of all new HIV diagnoses and possible explanations for the observed trends in the three prairie provinces relative to the rest of Canada from 1985 to 2022.

Methods

Study design and settings

Ecological study of all annual HIV diagnoses in persons of all ages from publicly available HIV reports from Canada, Saskatchewan, Manitoba, and Alberta. Geographically, the three provinces are adjacent to each other and, in the Canadian 2021 census, had a total population of 6,737,293 with 4,262,635 in Alberta, 1,342,153 in Manitoba, and 1,132,505 in Saskatchewan. Overall in Canada, 5% of the population identified as Indigenous.

Time frame

Canada HIV incidence: 1985–2022, with additional data for 1977–1984; Manitoba, Alberta, and Saskatchewan from 1985, 1986, and 1991, respectively, to 2022. All data extracted from the national and provincial reports are available in the Supplemental Tables 1–6.

Data sources

As websites may change over time, all downloaded reports are available upon request. All data were open access and available from the following federal and provincial governments:

• •Canada: Government of Canada publications (16,17): HIV and AIDS in Canada Surveillance Reports from Health Canada (16), and HIV in Canada, Surveillance Reports from the Public Health Agency of Canada (17).
• •Manitoba: Government of Manitoba, Department of Health, Seniors, and Long-Term Care, publishes an Annual Surveillance Update on HIV/AIDS (18), and Manitoba HIV Program Reports (19).
• •Saskatchewan: Government of Saskatchewan: HIV AIDS Annual Reports and Infographics (20); additional information collected from the Ministry of Health.
• •Alberta: Government of Alberta, Alberta Health publishes annual reports of Alberta Sexually Transmitted Infections and HIV (21). In addition, we downloaded HIV data disaggregated by age, sex, and year from the Interactive Health Data Application (22) of the Government of Alberta.

To estimate the HIV incidence, the denominator of the total population for Canada, Alberta, Saskatchewan, and Manitoba were taken from Statistics Canada (23), specifically, the second quarter of each year.

Variables collected from the HIV reports

Number of HIV diagnoses per year (new, introduced [diagnosed out of country/province], sex at birth (female, male), and age in years by groups (0–19, 20–29, 30–39, 40–49, 50+). Ethnicity was not consistently reported; however, we extracted all available data for this variable. In routine surveillance reporting, ethnicity is recorded as reported either by the individual or the provider. The categories have also changed over time to use inclusive and non-stigmatizing language. Within the manuscript, we aggregated the data as Indigenous and non-Indigenous. Self-reported HIV mode of transmission: men who have sex with men (more recently reported as male-to-male sexual contact), injection drug use, heterosexual contact, blood products, endemic countries, perinatal, other, and missing data/not reported. Number of advanced HIV disease (24,25) (previously known as AIDS), and number of deaths per year. Mortality in some reports was described as deaths attributed to HIV or AIDS and in others as deaths.

Data analysis

We used descriptive statistics to report the HIV incidence in Canada, Saskatchewan, Manitoba, and Alberta from 1985 to 2022. We reported the proportion of people diagnosed with HIV by sex, age, and self-identified mode of HIV transmission for the three provinces, and by ethnicity for Saskatchewan and Manitoba. Alberta reports did not disaggregate information by ethnicity. We also depicted the number of advanced HIV diagnoses per year and the number of deaths per year for Canada and the three provinces.

Ethics statement

This research did not require ethics approval because it uses publicly available aggregated data. Members of our research team identify as Indigenous, and some are co-authors of this manuscript. Our studies are guided by an Indigenous Elder and persons living with HIV, consistent with Chapter 9 of the Tri-Council Policy Statement.

Results

HIV incidence in the three provinces and Canada

The Canadian HIV incidence was ≥10 new HIV diagnoses/100,000 population between 1982 and 1989 and in 1995. Since then, the incidence has decreased to <5/100,000. Saskatchewan has had an HIV incidence ≥10/100,000 since 2006, with the highest rates in 2009 (19.3/100,000) and 2021 (20.1/100,000). Manitoba has had an increasing HIV trend over time; in 2010, the HIV incidence reached ≥10 new HIV diagnoses/100,000, with further increases in 2021 (12.1/100,000), and in 2022 Manitoba reported the highest HIV rates (13.9/100,000) in the province's history. Alberta had the highest HIV rates between 1987 and 1992, and since then, incidence has decreased. However, from 1999 until 2022, HIV incidence remained stable at 5–6/100,000 (Figure 1). In 2022, HIV incidence was 4.7 people newly diagnosed/100,000 population in Canada [1,833 new HIV diagnoses], 19/100,000 in Saskatchewan [227 new HIV diagnoses], 13.9/100,000 in Manitoba [196 new HIV diagnoses], and 6.3/100,000 in Alberta [196 new HIV diagnoses] (Figure 1). Supplemental Table 1 shows all data regarding HIV incidence for Canada, Saskatchewan, Manitoba, and Alberta, per year.

Figure 1: People newly diagnosed with HIV/100,000 population in Canada, Alberta, Manitoba, Saskatchewan, 1977–2022.

Black line depicts the HIV incidence in Canada, purple Saskatchewan, green Manitoba, and orange Alberta

HIV incidence by sex, ethnicity, age, and mode of HIV exposure factors

The proportion of HIV incidence in Canada and Alberta has always been higher in males compared to females (Figures 2A and 2B). Saskatchewan had a similar pattern, but between 2004 and 2007, the proportion was similar or higher among females. Since 2019, the female-to-male ratio has been 1:1 (Figure 2C).

Figure 2: HIV incidence by females and males in Canada (A), Alberta (B), Manitoba (C), and Saskatchewan (D), 1985–2022.

Manitoba reported similar male-to-female ratios in 2001 and 2009 (1.3:1 and 1.2:1, respectively), but since 2018, the proportion of HIV has steadily increased in females. In 2022 for the first time in the province history, females accounted for a higher proportion of new infections in Manitoba compared to males (Figure 2D). Supplemental Table 2 shows all data extracted regarding HIV incidence by sex, per year.

Data on race/ethnicity were missing in most of the reports, and when reported, all noted a significant proportion of missing/unknown data (>50%). Based on available information, the proportion of HIV in Canada and Alberta has been higher among non-Indigenous populations, mostly among white/Europeans (Figures 3A and 3B). Saskatchewan had ethnicity information between 2006 and 2018, and the proportion ranged between 60% and 80% of HIV diagnoses self-identified as Indigenous (Figure 3D). Manitoba has reported ethnicity data since 2001, and HIV rates were higher among non-Indigenous populations, but since 2016 there has been a significant overrepresentation of the Indigenous population (>50% self-identified as Indigenous since 2016) (Figure 3C). Supplemental Table 3 shows all data extracted regarding HIV incidence by ethnicity per year.

Figure 3: HIV incidence by ethnicity in Canada (A), Alberta (B), Manitoba (C), and Saskatchewan (D), 1985–2022.

The ethnicity variable had significant missing values over time. The proportions were estimated using the available data for the numerator and denominator

Figure 4 shows that the majority of new HIV diagnoses in Canada, Alberta, and Manitoba occurred in persons between the ages of 30 and 39, followed by persons 20–29 years old. In Saskatchewan, the highest proportion was among the age group of 40–49 years old.

Figure 4: HIV by age groups in Canada (A), Alberta (B), Manitoba (C), and Saskatchewan (D), 1985–2022.

Supplemental Table 4.1 (Canada), Supplemental Table 4.2 (Manitoba), Supplemental Table 4.3 (Saskatchewan), and Supplemental Table 4.4 (Alberta) show all data extracted regarding HIV incidence by self-reported mode of HIV transmission per year.

As seen in Figure 5, the predominant mode of HIV transmission nationally is male-to-male sexual contact among males and heterosexual sex among females (Figure 5A). A similar pattern was seen in Alberta (Figure 5B). During this time period in Saskatchewan, the predominant mode of HIV acquisition was injection drug use, followed by heterosexual sex (Figure 5D). In Manitoba, heterosexual sex has been the main mode of HIV transmission, but since 2018, injection drug use became the second most common exposure factor (Figure 5C), and in 2022, injection drug use became the most common. Prior to 2018, male-to-male sexual contact was the second most common mode of transmission. Supplemental Table 5.1 (Canada), Supplemental Table 5.2 (Manitoba), Supplemental Table 5.3 (Saskatchewan), and Supplemental Table 5.4 (Alberta) show all data extracted regarding HIV incidence by age groups per year.

Figure 5: HIV incidence by self-reported mode of HIV transmission in Canada (A), Alberta (B), Manitoba (C), and Saskatchewan (D), 1985–2022.

Canada's (Figure 6) and Manitoba's epidemiology (Supplemental Table 6) have been mostly local, rather than introduced diagnoses. However, Alberta reported in 2019 and 2022 that the main mode of HIV acquisition was “out of the country” (Supplemental Table 6).

Figure 6: HIV incidence by tested in Canada and tested overseas in Canada.

Advanced HIV disease and mortality

The numbers of advanced HIV disease (Figures 5B, 5C, 5D, and 7A) and deaths (Figures 6B, 6C, 6D, and 8A) have decreased over time in Canada and the three provinces. In 2022, they represented 4.6% of all new HIV diagnoses in Canada. Alberta has not reported the numbers of advanced HIV disease since 2010, Manitoba since 2017, and Saskatchewan since 2019. Supplemental Table 7 shows all data extracted regarding advanced HIV disease diagnoses and deaths per year.

Figure 7: Advanced HIV disease diagnoses per year in Canada (A), Alberta (B), Manitoba (C), and Saskatchewan (D), 1985–2022.

Figure 8: Deaths related to advanced HIV disease per year in Canada (A), Alberta (B), Manitoba (C), and Saskatchewan (D), 1985–2022.

Discussion

Alberta, Saskatchewan, and Manitoba represent 16.2% of the Canadian population; however, in 2021, they contributed to 38.5% of new HIV diagnoses. For reporting and surveillance internationally, the World Health Organization (WHO) divides the world into six WHO regions. Saskatchewan and Manitoba HIV rates are above those in several WHO regions, and Manitoba and Saskatchewan is above the Region of the Americas’ average HIV rate (Figure 9). Our study found key differences in the rates of HIV and affected populations in Alberta, Saskatchewan, and Manitoba, compared to the rest of Canada. Since 1995, the incident HIV rate in Canada has slowly decreased, and it has been relatively stable. While most parts of Canada have reported the primary mode of HIV transmission as male-to-male sexual contact, marked differences have been noted in the prairie provinces.

Figure 9: HIV incidence rates for World Health Organization regions compared to Canada and the Canadian provinces of Alberta, Saskatchewan, and Manitoba in 2023.

Manitoba and Saskatchewan have reported unprecedented increases in HIV incidence, with Saskatchewan reporting the initial dramatic rise in cases in approximately 2008–2009. The reasons for this rapid rise are attributed to needle sharing with partners and heterosexual transmission (26). Since 2007, the most common mode of HIV exposure in Saskatchewan continues to be injection drug use, and injection drug use in Manitoba has now surpassed heterosexual sex as the most common. Responding with a provincial strategy in 2014, rates in Saskatchewan declined over the next few years. However, after targeted funding ended in 2018, rates began to increase in 2021 and 2022, when Saskatchewan reported the highest incidence ever, at four to five times the national average. Part of the resurgence was also attributed to limited access to care, treatment, and support, and needle exchange programs during the COVID-19 pandemic (26).

Given the geographical proximity of the provinces and the movement of persons between neighbouring communities (27, 28, 29), some experts in these three provinces have been concerned about possible transmission due to overlapping syndemics and affected populations. Interestingly, Manitoba has noted a steady increase in new HIV diagnoses, with a 48% rise in cases from 2017 to 2022, with the highest rates reported in 2022. In Manitoba, there has also been a shift over time from predominantly male-to-male sexual transmission to similar proportions between males and females, and in 2022, higher in females. Both Saskatchewan and Manitoba have seen a disproportionate rise in cases among females, those reporting Indigenous ethnicity, heterosexual sex and injection drug use. While Indigenous persons represent 5% of the overall Canadian population, 17% in Saskatchewan, 18.1% in Manitoba, and 6.5% in Alberta, they represented 75.6% of new HIV diagnoses in Saskatchewan in 2018, 76.1% of cases in 2021 in Manitoba, and 17.4% in 2013 in Alberta. The overrepresentation of Indigenous people is not new; in Saskatchewan, it has been documented in the HIV reports since 2006 and in Manitoba since 2016. First Nations, Inuit, Métis, and other scholars call for consistent collection, analysis, and presentation of Indigenous identity data, that is led by communities (30,31). Several authors have advocated separating “race” from “ethnicity,” and understanding “race” as a social construct that focuses on the impacts of racism on health care access and outcomes (32, 33, 34, 35, 36). Recent research has shown how race and intersectional stigma are associated with poor HIV outcomes, such as having detectable viral load and lower antiretroviral therapy adherence (37). Previous data have also documented structural inequities in the HIV infection rates among certain racialized groups rather than due to individual behaviours (38,39). Collecting racial, ethnicity, and identity data along with equity indicators and sociodemographic factors will allow a better understanding of the root causes of intersecting factors affecting Indigenous people and other racialized communities.

In Alberta, new HIV diagnoses have remained largely static, with recent increases noted primarily among persons reporting heterosexual contact. In contrast to Saskatchewan and Manitoba, Alberta surveillance reports include new HIV diagnoses that were likely acquired out of the country, resulting in 40.1% of new male cases and 46.3% of female cases being attributed to heterosexual exposure and acquired out of the country (40). The recent increases are in part related to changes in immigration policies such as the Alberta Advantage Immigration Program (41), which resulted in more newcomers to Alberta, some newly diagnosed upon arrival or previously living with HIV. Newcomers to Alberta have come from many countries, including some with high HIV prevalence, including from the Ukraine where the HIV prevalence in 2021 was estimated to be approximately 0.99% (42). Since Russia's invasion of Ukraine in February 2022, an estimated 57,000 Ukrainians have moved to Alberta (43) and 20,000 to Manitoba (44). Anecdotally, the HIV clinics in both provinces have reported an increase in the number of new cases from Ukraine. However, since details regarding the country of origin are not available for “imported/introduced” HIV in Alberta and Manitoba from publicly available data, an accurate estimate of the effect of this migration on out-of-country HIV cases cannot be calculated. Within Alberta there are noted differences in the main modes of HIV acquisition. For example, in 2022, the main mode of HIV acquisition in the South Zone was injection drug use (55.6% of males and 75% of females), while male-to-male sexual transmission among males (40%), and heterosexual exposure among females (66.7%) were the main HIV exposures categories in the North Zone (40).

A recent study from Manitoba also noted that 61% of females and 41% of males had at least one or more sexually transmitted and blood-borne infection (STBBI) co-infections; females had up to 16 and males had up to 9 concurrent or previous and distinct diagnoses of syphilis, chlamydia, gonorrhea, or hepatitis C before HIV diagnosis (45). The resurgence of HIV in Saskatchewan and Manitoba is occurring at the same time as a resurgence in syphilis cases among heterosexual persons also experiencing houselessness, those using substances, and those who inject drugs (11,45). Methamphetamine has become widely available across the prairie provinces, with police services reporting dramatic rises in methamphetamine use, in part related to the lower cost compared to fentanyl (CAD$5–10 for a tenth of a gram of meth compared to CAD$40–60 for a single hit of fentanyl) (46). Stimulants such as methamphetamine are known to enhance sexual desire, and their use is associated with transactional sex, multiple partners, and inconsistent condom use contributing to sexually transmitted infections and HIV acquisition (47, 48, 49). In Manitoba, persons who use methamphetamine had up to 16 new STBBI diagnoses preceding the diagnosis of HIV (45). New diagnoses in Saskatchewan are largely associated with heterosexual transmission and are coupled with multiple sexually transmitted infections, particularly syphilis. Current data trends suggest that Alberta may be seeing an initial rise in new HIV cases related to injection drug use in the southern part of the province. Given the similarities in behavioural and demographic characteristics of the affected populations and the unprecedented concurrent rise in infectious syphilis among heterosexual persons (50), ongoing close monitoring of the trends in new HIV diagnoses remains critical. In Alberta, the syphilis resurgence is largely occurring among heterosexual persons, with a disproportionate number of cases among Indigenous persons and a significant association with stimulant drug use, injection drug use, and correctional involvement (51).

HIV and houselessness are strongly linked. Persons who are houseless or unstably housed have HIV infection rates that are three to nine times higher than persons who are stably housed (52). These increased rates are attributable to exposure behaviours associated with HIV risk, including substance use, injection drug use, multiple sex partners, and unprotected sex with casual partners (53). Lack of housing operates as a contextual and environmental influence that interacts with other associated factors such as substance use, poor mental health, sex work, and poverty. First Nations people are overrepresented among the houseless population across Canada and are 23 times more likely to experience houselessness compared to non-Indigenous people (54). The reasons for this social crisis with overlapping syndemics are largely attributed to the impact of historical and intergenerational trauma on Indigenous persons in Canada (55).

Fortunately, in Canada, the proportion of new HIV diagnoses with advanced infection has declined over time and represented 4.6% of all new diagnoses in Canada in 2022. However, the regional proportion of new advanced HIV diagnoses have not been reported in Alberta since 2010, Manitoba since 2017 and Saskatchewan since 2019. The reporting of advanced HIV disease at the time of diagnosis is an important indicator of the timeliness of new HIV diagnoses, because late presentation represents missed opportunities to diagnose and treat HIV infection and to prevent transmission (56). Globally, the proportion of people with HIV presenting with advanced HIV infection is high at approximately 30% (57).

The main limitation of our study is that surveillance reports are heterogeneous between provinces and Canada as a whole, making comparisons challenging. We identified four main issues in the HIV reports reviewed: (1) variability in data collection and reporting over time; (2) a lack of interoperability to exchange information between the different systems that collect data within provinces, and between provinces and Canada's surveillance; (3) a lack of timeliness; and (4) (most critically) the lack of consistent granularity and data disaggregation at all levels. Most reports show the total numbers of testing and diagnoses, main modes of HIV transmission, and—depending on the years—may have data disaggregated by sex, age, race/ethnicity, province, territory, or regional health authority, and sometimes other geographic information. Many of the reviewed reports acknowledged missing data in the HIV data collection but also did not consistently report the same information over time. Often, data are rolled up so that it is not possible to see where there are shifts in epidemiology at a sub-provincial level, or data are not cross-tabulated, by sex and age, or by sex, other STBBI co-infections, and health authority, for example. The lack of granularity means that responses cannot be tailored for particular sub-populations.

In 2024 the WHO published new guidance on monitoring social determinants of health equity (58) to encourage a common framework and standards. As the authors note, monitoring social determinants of health indicators is critical to make injustices visible, as well as to point to interventions and policies to improve them. Indicators should be relevant and meaningful for local communities (59), but at a minimum should consistently include variables for gender identity (as well as sex), race/ethnicity, housing status, substance use, country of last residence, and geographic location (eg, rural or urban), because these variables are essential to understanding where and when there are shifts in local epidemiology. Supplemental Table 8 includes a minimum set of HIV indicators and equity stratifiers. They illustrate what drives health inequalities; monitoring social determinants of health equity is necessary to track progress and improvements in outcomes, while keeping health authorities and governments accountable and transparent. Similarly, the Government of Canada published the STBBI action plan 2024–2030 (60), and listed as a priority, “improve STBBI data monitoring and collection practice by improving monitoring of STBBI trends and progress for key populations, regions, ages, sexes, and race/ethnicity, and facilitate access to data on key STBBI” and mentioned, “we need to understand equity within an intersectionality framework.” (60) However, none of the notification forms or the surveillance reporting in Canada, Alberta, Saskatchewan and Manitoba include social determinants of health such as housing or food deprivation, employment and working conditions, education or literacy, types and frequency of substance use, mental health conditions, co-infections and chronic conditions, urban versus rural and/or remote residence, or population mobility between corrections, shelters, and the community. All these factors have been shown to affect HIV acquisition and treatment outcomes (11–13,37,45,61,62).

Disaggregating or cross-tabulating data by equity-informing indicators and implementing a syndemic lens are essential to understand the magnitude of HIV, co-infections and co-morbidities, the most affected groups in any jurisdiction, and to allocate resources for prevention, testing, and treatment, deploy localized strategies, and evaluate the results of those strategies and actions.

Furthermore, consistent application of syndemic and equity frameworks will illuminate where changes in prevention, screening, and treatment are needed. It is also necessary to conduct trend analyses to identify changes in the epidemiology of HIV over time, and by the most affected communities and sub-groups. Having the information available on an ongoing basis with minimal delays will make it possible to strategically utilize public health resources to prevent HIV acquisition through pre- and post-exposure prophylaxis, treatment as prevention, education, and other non-HIV strategies, such as harm reduction programs. Without timely access to this information, public health initiatives and HIV programming cannot be proactive in their response, nor can their resources be implemented in the most cost-effective and evidence-based manner.

It is similarly important to consider the intersections between HIV, (injection) drug use, and harm reduction supports. Existing research shows that harm reduction services, such as safe consumption sites, are effective in decreasing drug-related risks, including HIV infection, while increasing people's access to drug treatment and other services (63). Portugal has the most well documented experience regarding the decriminalization of drug use and personal possession and use and the implementation of harm reduction programs. In 2001, illicit drug use was decriminalized in Portugal as part of its response to the growing use of injectable drugs and transmission of HIV and viral hepatitis. This change allowed for a series of clinical, social, and political reforms and harm reduction strategies. The number of people using heroin fell from an estimated 100,000 in 2001 to 25,000 in 2017; fatal overdoses decreased by more than 85%, and new HIV diagnoses by more than 90% (64). However, in Canada's prairies provinces, access to such harm reduction services continues to be limited. To illustrate, Winnipeg (Manitoba) is one of the few urban centres in Canada without safe consumption sites services, although one is slated to open by 2025. In 2020, the Alberta Government shut down the province's busiest safe consumption sites, located in Lethbridge, further limiting access to comprehensive harm reduction supports (65). The Saskatchewan Government has also ceased funding harm reduction programs. Further research is necessary to document the impact of the availability of harm reduction services on the risk of HIV, and to identify the most effective harm reduction strategies in diverse contexts across the provinces. Our data suggest an urgent need to widely implement harm reduction programs, including safe consumption sites and drug toxicity testing programs, and investigate how lack of harm reduction, stigma, and criminalizing policies may exacerbate HIV transmission risks.

Conclusion

This study highlights key differences in the epidemiology of HIV in Alberta, Saskatchewan, and Manitoba compared to the rest of Canada. The three prairie provinces currently contribute to about 40% of all new HIV diagnoses in Canada. Annual HIV reports should routinely collect, analyze, and describe the epidemiology disaggregated by equity indicators, including but not limited to sex, race/ethnicity, age, income, place of residence, housing status, and substance use, and take a syndemic approach in order to understand some of the drivers of HIV epidemiology and concurrent needs. The current epidemiology requires immediate public health action from local, provincial, and federal governments, with a focus on gendered, culturally appropriate, and intersectional approaches from intersectoral agencies. Working with community leaders is critical to address the needs of the most affected populations in these provinces.

Funding Statement

This research was supported by the Canadian Institutes of Health Research (CIHR) (Grant number PJH-185724). This research was also supported, in part, by the Canada Research Chairs Program for ZVR (Award # 950-232963). MH received the CIHR Research Excellence, Diversity, and Independence (REDI) Early Career Transition Award [CIHR: OS3 –190782; ED6-190717]. The funders did not have any role in the study design, collection, analysis and interpretation of data; in the writing of this paper; and in the decision to submit the article for publication.

Contributors:

Conceptualization, ZV Rueda, Y Keynan; Data Curation, L Arroyave; Formal Analysis, L Arroyave; Funding Acquisition, ZV Rueda, M Herrera; Investigation, M Herrera, L Arroyave, ZV Rueda; Methodology, ZV Rueda; Project Administration, ZV Rueda; Software, L Arroyave; Validation, ZV Rueda, L Arroyave, M Herrera, AE Singh, S Skinner, C Spence, LJ MacKenzie, K Kasper, L Ireland, J Sanguins, K Maier, M Haworth-Brockman, Y Keynan; Visualization, L Arroyave, ZV Rueda, M Herrera; Writing – Original Draft: ZV Rueda; Writing – Review & Editing: ZV Rueda, L Arroyave, M Herrera, AE Singh, S Skinner, C Spence, LJ MacKenzie, K Kasper, L Ireland, J Sanguins, K Maier, M Haworth-Brockman, Y Keynan.

Ethics Approval:

Ethics approval was not required for this article.

Informed Consent:

N/A

Registry and the Registration No. of the Study/Trial:

N/A

Data Accessibility:

All data used in this study are included as Supplemental Tables 1 to 7. All data will not be made publicly available. Researchers who require access to the study data can contact the corresponding author for further information.

Funding:

This research was supported by the Canadian Institutes of Health Research (CIHR) (Grant number PJH-185724). This research was also supported, in part, by the Canada Research Chairs Program for ZVR (Award # 950-232963). MH received the CIHR Research Excellence, Diversity, and Independence (REDI) Early Career Transition Award [CIHR: OS3 –190782; ED6-190717]. The funders did not have any role in the study design, collection, analysis and interpretation of data; in the writing of this paper; and in the decision to submit the article for publication.

Disclosures:

The authors have nothing to disclose.

Animal Studies:

N/A