A-Track pilot survey in Regina: Preliminary findings

1. A-Track pilot survey in Regina: Preliminary findings Presented at the RQHR Research Showcase June 19, 2013 Dr. Maurice Hennink Deputy Medical Health Officer Population and Public Health Services

2. A-Track Surveillance Team

3. Overview • Background • Survey Implementation • Methodology • Results • Socio-demographics • Sexual behaviour • Injection and non-injection drug use • HIV testing history • History of STBBI • Use of health services and needle exchange programs

4. Background • Public Health Agency of Canada in collaboration with All Nations Hope AIDS Network, Aboriginal community groups and the Regina Qu’Appelle Health region conducted a behavioural and biological surveillance survey to determine the prevalence of HIV and associated infections, behaviours and socio-demographic factors among Aboriginal populations in Regina. • This survey collected self-reported information on socio-demographic factors and social determinants of health; sexual and drug-use practices; diagnostic testing and treatment for HIV, tuberculosis, and other infections; access to health services; and knowledge of modes of transmission for HIV and other sexually transmitted and blood-borne infections. • The pilot survey was conducted between December 2011 and June 2012.

5. Trends over time Time T3 prev. T2 prev. T1 prevalence Description of the A-Track system • Repeated cross-sectional surveys at selected sentinel sites (urban/semi-urban) across Canada • Venue-based sampling • Consistent sampling and recruitment strategies over time

6. Methodology • Anonymous cross-sectional survey with informed consent. • Participants recruited using venue-based sampling methods. • Venues were identified based on geographic clusters and neighborhoods where Aboriginal people mostly reside or socialize. • The target sample size was 1,100. • The dataset was checked for similarities in individual profiles (age and risk behaviours) to exclude duplicate entries.

7. Methodology • Eligibility criteria • participants be between 15 and 60 years of age, • could speak English, and • could provide informed consent. • Exclusion Criteria • A person who, in the judgement of interviewer, appears intoxicated, or incapacitated due to psychological or cognitive deficit or discomfort or distress and is hence unable to provide informed consent or is incapable of understanding the survey information. • A person who has already participated once in the current survey. • A person who does not self-identify as Aboriginal and who does not meet the age inclusion criteria.

8. Methodology • Interviewer-administered questionnaires • socio-demographic, • sexual behaviour, • drug use, • history of HIV testing, sexually transmitted infections and tuberculosis, • access to health services • knowledge of HIV • $20 provided for participation. • Questionnaires were administered using a laptop computer and interviewers entered responses directly into the computer during the interview.

9. Methodology • Participants were asked to provide a finger-prick blood sample and was tested for HIV, HCV (hepatitis C) and syphilis antibodies. • Counseling and HIV antibody testing was made available for participants who were interested in finding out their HIV status. • Community partners involved • having input into how the project will be organized, • part of the analysis and interpretation of data and how the results are distributed.

10. Ethical Aspects • Anonymous • Informed Consent • Ethics approval was obtained from the Research Ethics Boards for Health Canada/PHAC, Regina Qu’Appelle Health Region, and the University of Regina/First Nations University of Canada.

11. Limitations • A-Track survey was not population based and used venue-based sampling method to enroll survey participants. This may not reflect all Aboriginal people and their distribution in the population. • A-Track sample included: • A higher proportion of First Nations individuals • A lower proportion of Metis and Inuit people compared to these groups in Regina • Given the better representation of the First Nations peoples in the A-Track survey, survey findings may be more reflective of actual First Nations population living in Regina. • The findings are based on self-reported data (except for sero-prevalence of HIV and HCV) and may be subject to social desirability bias.

12. Results

13. Data Collection • Conducted between December 5, 2011 and June 15, 2012. • Total Interviewed 1,071 • Total duplicates 7 • Total available for analysis 1,064 • Total who didn’t provide a Dried Blood Sample 19 (1.8%) • A range of communication activities were implemented to highlight the study among the prospective study population at each venue prior to commencement.

14. Proportion of Participants by Geographic Location (n=1,064) The data for this variable was derived from the interview location and the geographic locations created using Regina census data

15. Who participated?

16. Self-Reported Ethnicity‡ ‡ Person who self-identify with an Aboriginal group (i.e., First Nations: Status/Non-status, Metis, Inuit) and or who reported Aboriginal ancestors were eligible to participate. * Person who did not identify as Aboriginal but did claim Aboriginal ancestry.

17. Age of Respondents [N=1,064]

18. Education Level of Respondents Highest level of education completed at the time of survey

19. History of Family Separation, Residential Schools and Foster Home Involvement [n(%)] The respondents were asked if they were removed from their family as a child for any length of time. This includes removal from family by welfare agencies, government officials or taken away by a church. 1 Data missing on one respondent 2 Data missing on three respondents 3 Data missing on four respondents

20. Correctional Services Involvement The respondents were asked if they have ever spent time in jail, prison or correctional facility. 1 Data missing on three respondents

21. Sexual behaviour

22. Sexual behaviours [n(%)] * Among person who ever had sex. ** Among person who had sex during the past 12 months. Age at first sex information missing for 8 respondents

23. Sexual Behaviour and Condom Use among Male Participants (n=448) Participants could report having more than one regular or casual partner in the past 12 months. ‡ Condom was used “100% of the time” * Exclude those who never had sex, or not had sex in the past 12 months, did not use condom the last time the respondent had sex ** Not reported because of small numbers

24. Sexual Behaviour and Condom Use among Female Participants (n=429) Participants could report having more than one regular or casual partner in the past 12 months. ‡ Condom was used “100% of the time” * Exclude those who never had sex, or not had sex in the past 12 months, did not use condom the last time the respondent had sex

25. Drug use behaviour

26. History of injection drug use among respondents * Among those who ever injected or tried injecting drugs or substances for non-medical purposes. ** Mean/Median age at initiation of injection drug use.

27. Frequency of injection among those who injected in the past six months (n=322)

28. Drugs Injected In Past Six Months (n=322) Study participants who had injected drugs in the past 6 months were asked if they had injected a variety of drugs or substances for non medical purposes. Categories are not mutually exclusive, participants could report use of more than one type of drug.

29. Places where respondent injected in the past six months‡ (n=322) ‡ Study participants could select more than one response

30. People with whom participants reported injecting within in the previous six months Study participants who had injected drugs in the past 6 months were asked about relationship to people with whom they reported injecting drugs or substances. Participants could select more than one response.

31. Sharing of needle/syringes in the previous six months (n=322) Among respondents who injected drugs during the past 6 months.

32. Non-injected drugs in past six months (N=1,064) Among all respondents. Respondents could select more than one option.

33. Testing for HIV and bloodborne infections

34. Respondent's reporting “ever tested for HIV” (n=750)

35. Main Reasons for seeking an HIV test among participants who had ever been tested Study participants were asked whether each factor contributed for seeking the most recent HIV test. The respondents could select more than one category.

36. Reasons for not seeking an HIV test among participants who never had an HIV test (n=299) Study participants were asked to indicate whether each factor to not being tested for HIV. Participants could select more than one response.

37. Facility ordering most recent HIV test (n=750)

38. Participants knowledge of HIV related risk behaviors Study participants were asked to respond to each statement to indicate their knowledge of HIV related risk behaviours. Participants could select more than one response.

39. Self-Reported HIV prevalence, among participants who reported previous HIV testing (n=750) * Includes respondents who indicated that they did not know the result of their last test and respondents who did not receive the result of their last HIV test.

40. Sero-prevalence of HIV among respondents who provided a Dried Blood Spot specimen and awareness of HIV positive status (n=1,045) Aware = positive HIV lab result and who reported that their last HIV test result was positive Unaware = those who had never been tested or who did not receive the result of their last test or who did not know the result of their last test or who reported that their last HIV test was negative but had a positive HIV lab result.

41. Self-Reported Hepatitis C (HCV) status (n=1,064) • Includes respondents who were never tested for HCV as well as those who did not know the results of their HCV test. • A positive HCV test indicate a past or current HCV infection. A negative antibody test result indicates that you have not been infected with the HCV.

42. Life-time Exposure to HCV among respondents who provided a Dried Blood Spot specimen (n=1,045)

43. HIV and HCV co-seropositivity (n=1,045) Total denominator includes 1 respondents who provided a DBS of insufficient quantity e for HCV lab test. This respondents was included in the denominator, but is not included in any of the categories presented.

44. Access to health services

45. Access to HIV Care among participants who are aware of their HIV positive status (n=29)

46. Access to health services in the previous 12 months (n=1,064) * Among those who had visited a health care professional during the past 12 months.

47. Accessed Aboriginal-specific services in the previous 12 months (n=232) People who accessed an Aboriginal –specific service may also have consulted other types of health professional in the previous 12 months. Respondent could select more than one response.

48. Health care access by health providers/facilities (n=821) Each respondent could select more than one category

49. Conclusions • The findings highlight some of the critical issues that exist around risk behaviours and the transmission of HIV in the Aboriginal population including: • education levels • history of family separations • correctional services involvement • a high HIV prevalence amongst survey participants, with strong correlation to past or current use of injection drugs • the proportion of participant who were unaware of their HIV infection is higher than the estimated proportion of 25% for the overall Canadian population of people living with HIV • RQHR and service provider agencies can use the information included in this report to better understand local harm reduction needs and to tailor services to prevent increased HIV transmission.

50. Conclusions • These data represent the best available findings on HIV prevalence and associated factors for First Nations and Métis people in Regina. However, these data cannot be generalized to the overall Aboriginal population of Regina. • The development and implementation process has illustrated many successes in collaboration between public health and community. • Lessons learned will also inform the utility and methodological feasibility of future wider implementation of the A-Track surveys at other off-reserve sentinel sites in Canada • Findings support continued work on the HIV strategy.