Tools for Access Curriculum: People Who Use Drugs by CTAC

Tools for Access Workshop Curriculum

Tools for overcoming treatment access barriers facing people who use drugs living with HIV and Viral Hepatitis Co-infection

The following curriculum draws on surveillance data collated by the Public Health Agency of Canada, peer-reviewed academic literature, grey literature, narrative accounts and information based on consultations with key stakeholders including community-based service providers and people living with HIV. The purpose of this Curriculum is to provide practical guidance for addressing barriers to treatment access among people who use drugs who are living with HIV and Viral Hepatitis. Treatment access is considered in its holistic form, encompassing the range of treatment, care and support needs required to reach the most successful treatment experience possible for people who use drugs who are living with HIV and Viral Hepatitis in Canada.

Tools for overcoming treatment access barriers facing people who use drugs living with HIV and Viral Hepatitis Co-infection

Contents Contents................................................................................................................................................................................................ 3 1. Overview of people living with HIV in Canada who use(d) drugs.................................................................................. 4 Epidemiology....................................................................................................................................................................................................4 2. Structural, Social and Personal Barriers to Treatment, Care and Support....................................................................7 Criminal law, drugs and HIV........................................................................................................................................................................7 Mental health and wellness.........................................................................................................................................................................9 Gender, Culture and Identity......................................................................................................................................................................11 3. Impacts of HIV stigma and discrimination on access to treatment, care and support...........................,...............12 4. Barriers faced by People living with HIV people who use drugs in accessing holistic health care....................14 5. Tools: solutions & alternatives...................................................................................................................................................16 Works Cited........................................................................................................................................................................................18

Overview of People Living with HIV in Canada who Use(d) Drugs

The first section of this curriculum is intended to provide general background information on demographic trends in HIV and co-infection among people who use(d) drugs in Canada. This information provides us with an overview of who is affected by HIV, Viral Hepatitis and drug use. Factors considered in this section include sex and gender, ethnic and cultural background, age, modes of transmission and HIV/AIDS prevalence. Epidemiology1 • I n Canada, the influx of drug use is considerable and diverse. Some drugs are currently legal, while others are not. Canadians use a variety of different drugs, including: - alcohol (77%) - tobacco (17%) - cannabis (25%) among youth aged 15 to 24 and (10%) among all adults - psychoactive pharmaceuticals (26%) - cocaine or crack (1.2%) - ecstacy (0.9%) - LSD (0.7%) - speed (0.4%) - methamphetamine (0.1%) • T he majority of people who use drugs are able to avoid serious consequences. For others, however, the use of drugs can have serious health, social and legal consequences.2 • A ll forms of drug use can influence vulnerability to HIV infection. Sharing injection drug equipment can result in HIV and Hepatitis C infection, while using drugs and alcohol can lower inhibitions and compromise decision-making in sexual activity. The use of drugs can also have damaging effects on the body and immune system, increasing the physiological risk of contracting the virus when exposed to it. The social environment of drug use can be characterized by dependency and imbalances in power relations

between men, women and transgender people in intimate relationships, as well as between people who buy and sell drugs. These factors can also increase vulnerability to infection. • S ocial practices among communities of men who have sex with men may increase vulnerability to HIV and Hepatitis C. These include popular “Party N’ Play” (PNP) gatherings, also known as chemical sessions, between men who have sex with men involve combining methamphetamine (crystal meth) and Viagra, as well as ‘poppers’ (muscle relaxants also used in conjunction with these drugs). MDMA and GHB are less associated with the term PNP but are sometimes used in these interactions. Mehtamphetamines can inhibit penile erection and as a result, many men who engage in PNP use erectile dysfunction drugs, such as sildenafil, vardenafil and tadalafil in addition to other drugs. The use of erectile dysfunction drugs is particularly problematic because nitrates contraindicate with erectile dysfunction drugs. • I njection drug use accounted for 17.% of HIV reports in 2011. Epidemiological trends show a decrease in the number of males who acquired HIV through injection drug use; however, increases have been observed in the total number of positive test reports among females. In 2010, women were significantly more likely to acquire HIV through injection drug use compared to men (30.1% vs. 13.5%).

1 ( Public Health Agency of Canada, 2010A; Public Health Agency of Canada, 2010B; Public Health Agency of Canada, 2010C; Public Health Agency of Canada, 2009A) (Canadian Drug Policy Coalition, 2012)

Tools for overcoming treatment access barriers facing people who use drugs living with HIV and Viral Hepatitis Co-infection

Proportion of positive HIV test reports among adult males and females (≥15 years), by exposure category, 20113 ADULT MALES

ADULT FEMALES

MSM 61.4%

Heterosexual contact 64.5%

MSM/IDU 2.3%

Other 4.2%

IDU 13.6%

IDU 29.9%

Blood/blood products 0.4%

Blood/blood products 1.4%

Heterosexual contact 20.5% Other 1.8%

• I n 2008, an estimated 25% (2000-3600) of people living with HIV who were infected through injection drug use were believed to be unaware of their infection. • H epatitis C is common among people who use injection drugs in Canada. Sharing drug equipment, such as pipes with blood residue from cracked lips, is one example of how Hepatitis C can be transmitted. Recent national data surveying over 3000 participants in multiple cities across the country showed that 11.7% of people who injected drugs were co-infected with HIV and Hepatitis C. Data of people who were surveyed who were injection drugs users and living with HIV indicated that 67% were co-infected. This data suggests that people who use drugs and who are living with HIV are highly likely to be co-infected with Hepatitis C.

• I njection drug use has been the main route of HIV transmission among Indigenous people (First Nations, Inuit and Métis). Injection drug use accounted for 58.8% of HIV-positive test reports among Indigenous people between 1998 and 2006 and 40% of reported AIDS cases between 1979 and 2006. In 2005, 53% of new HIV infections among Indigenous people were a result of sharing injection drug equipment. Indigenous women are particularly vulnerable to HIV and Hepatitis C through injection drug use.

3 (Public Health Agency of Canada, 2011)

Distribution of exposure categories among positive HIV test reports of Indigenous males (n=732) and Indigenous females (n=672), 1998 to December 31, 2006 Indigenous MALES

Indigenous FEMALES

IDU 53.7

IDU 64.4%

Recipient of blood or blood product 0.7%

Recipient of blood or blood product 1.2%

Heterosexual 25.3%

Heterosexual 34.1%

Other 0.1%

Perinatal 0.5%

Perinatal 0.1%

MSM 13.0% MSM/IDU 6.7% Source: (Public Health Agency of Canada, 2009A)

• S ocio-economically disadvantaged neighbourhoods in urban centres are the setting for much of Canada’s injection drug use. Evidence from the Vancouver Injection Drug Use Study (1996-2004), for example, found that residing in Vancouver’s downtown eastside neighborhood was an independent predictor of HIV infection. Similarly, residents from Regina who use drugs have recently been found to be at heighted risk of HIV infection and account for a disproportionate number of new HIV infections in that province.4

• C ertain areas in Canada, such as Regina, rural Saskatchewan, Winnipeg, Sudbury and Vancouver, can be considered hot spots for drug use. As a result of drug use, these areas are disproportionately represented in national HIV and Hepatitis C transmission surveillance data.

4 (Urban Health Research Institute, 2012)

Tools for overcoming treatment access barriers facing people who use drugs living with HIV and Viral Hepatitis Co-infection

Structural, Social and Personal Barriers to Treatment, Care and Support

Section 2 of this curriculum explores the specific structural, social and personal barriers preventing people who use drugs who are living with HIV or HIV/Hepatitis C co-infection from accessing treatment, care and support. The critical role of mental health and personal coping strategies in treatment access among people who use drugs is discussed. Social determinants of health including gender, culture and race are highlighted as influences that can sometimes create challenges to treatment access. The curriculum also outlines the relationship between the illegality of drugs and punitive laws against people who use drugs and the relevance of this relationship to treatment access. The following section of the curriculum addresses the ways in which stigma and discrimination of HIV is at the core of understanding all barriers to treatment access. It is important to consider all barriers, whether structural, social, or personal, in the context of HIV as a stigmatized and isolating illness.

Criminal Law, Drugs and HIV • P eople have been using substances, today known as drugs, for medicinal, spiritual and recreational purposes since the beginning of documented human existence.5 Some drugs such as alcohol, tobacco, narcotic painkillers (oxycodone, meperidine etc.) and anti-depressants are legal in Canada, while other drugs such as cannabis, cocaine, opiates and methamphetamines are not legal for sale or for use. • L aws prohibiting the use of drugs are related to the International War on Drugs, which dictates what drugs are legal for sale and consumption, who is legally able to produce and sell drugs and when and to who drugs can be sold to. Enforcement of drug regulation involves punitive laws for punishing people who use drugs. As a result, activists have dubbed the International War on Drugs as truly a war on people who use them.6 • P unitive laws that criminalize people who use drugs create barriers between people and available services and supports by pushing people to conceal their use of drugs and related health concerns from

5 6 7 8

providers. Negative social attitudes regarding illegal drug use and the people who use them are often imbedded in social structures. Discriminatory practices in health service provision have often resulted in preventing access to treatment, care and support.7 • T he stigmatization and discrimination of people who use drugs may stem from the belief that drug use is morally wrong and those who use drugs are at fault for their actions. As a result, people who use drugs are believed to be deserving of the consequences of drug use, including blood-borne virus infections and undeserving of society’s limited resources. • B arriers to health services for people who use drugs often stem from stigma and discrimination of HIV and drug use by health service providers. People have reported discriminatory treatment by service providers in hospitals, clinics and physician offices.8 • P unitive laws against people who use drugs lead to arrests. People who are arrested are often taken to a holding cell where they await their charges. An arrested person can be legally detained for a total of 48 hours. There are circumstances, however, when people are held even longer. Those who were not carrying their medicines during the time of arrest are prevented from accessing their HIV treatment, often resulting in some entering a guilty plea in order to access treatment. Missing treatment dosages is particularly concerning, given the nature of current

( Canadian Drug Policy Coalition, 2012) (Canadian Coalition for Drug Policy, 2012)(CTAC Working Group on People Who Use Drugs, 2012) (Small, 2006) (AIDS Committee of Toronto, 2008)

treatments where failing to take required doses of treatment can lead to the development of drug resistance.9

be family or friends of the patients they treat. As a result, there is increased risk that confidentiality may be compromised.

• P eople who use drugs and living with HIV face challenges accessing treatment, care and support both while they are in prison and following their release from custody. Drug use in prison is prominent and drug use or involvement with illegal drugs can sometimes be the reason for incarceration. Access to treatment in prisons is often limited due to several factors, including lack of awareness, lack of confidentiality and competing clinical demands on health service staff within institutions. People living with HIV have also noted difficulties in accessing specialized co-infection medical support while incarcerated. Incarceration and post-incarceration circumstances in Canada have been associated with treatment interruptions, lowered adherence and inhibited treatment outcomes.10

• S tigma around HIV and drug use, often more substantial in reserve communities, deters people living with HIV and people who use drugs from seeking health services and supports. For these people, the potential consequences of seeking services and disclosing their HIV status outweighs the benefits of treatment, care and support that is available to them in these settings. As a result, many people living with HIV who use drugs are forced to leave these communities and relocate to urban centres where specialized services are available and privacy can be better maintained.12

• T he success of HIV treatment is highly dependent on the financial resources and financial stability of the person living with HIV. Low income and unemployment are associated with increased risk of disease progression. People living with HIV who use drugs are vulnerable to unstable incomes and face significant social barriers to employment. Criminal records, often associated with involvement with illegal drugs, prevent many people living with HIV who use drugs from obtaining suitable employment.11 • P eople who use drugs and who are living with HIV that reside in rural and remote settings, particularly small and reserve communities, face service access barriers due to a considerable lack of privacy protection in health service delivery. Due to the small population of people that reside in these communities, most health service providers are very familiar with their patients. For example, service providers may

9 10 11 12 13

• A lack of specialized services or knowledge regarding key issues among service providers in remote and rural communities exists. Addictions counsellors often have minimal HIV knowledge and HIV specialists may lack expertise regarding co-infection. Similarly, providers may also lack awareness regarding the social determinants of health, such as access to housing and employment and its relation to managing HIV treatment and drug use. • M any people who are living with HIV experience homelessness or unstable housing, often as a consequence of discriminatory treatment and regulations against people who use drugs. People who lack stable housing and living conditions are at increased risk of Hepatitis C infection, heightened morbidity and mortality and progression to AIDS. This is mainly due to the fact that such individuals are more vulnerable to poorer treatment outcomes and are often less likely to adhere to treatment regimens. Unstable housing is associated with poverty and lack of adequate nutrition, further limiting treatment success.13

(CTAC Working Group on People Who Use Drugs, 2012) (Palepu, 2004; www.pasan.org; Canadian Drug Policy Coalition, 2012) (Public Health Agency of Canada, 2010A; Canadian Working Group on HIV and Rehabilitation, 2011) (www.caan.ca, 2012) (Ontario HIV/AIDS Treatment Network, 2012; S Parashar, 2011)

Tools for overcoming treatment access barriers facing people who use drugs living with HIV and Viral Hepatitis Co-infection

• T he inability to find a permanent residence creates challenges to societal participation and program/ service accessibility. Logistical aspects of being without permanent residence or employment prevent service access. Sometimes services are denied to people who use drugs simply because they do not have a valid health card, which relies on proof of residence to maintain.14 Homeless shelters are often abstinence based, which discriminates against people who use drugs and denies them access to their services. • T he Government of Canada, as well as some provincial and local governments, recently imposed significant reductions in the available funding for addressing HIV treatment, care and support. Recent funding cuts to harm reduction services for people who use drugs are ideologically and politically driven and do not reflect evidence or best practices in the provision of treatment, care and support. • C ontinuing budget cuts to services for people who are living with HIV and for people who use drugs prevents them from obtaining the benefits of services available and decreases the availability of resources for managing HIV and co-infections. That is, reduced access to harm reduction resources increases risk of HIV transmission and limits the ability of people who use drugs from successfully managing their health. • P ublic health cuts in Canada are also impacting service provision in hospital settings. Loss of funding for public health nurses, for instance, has led to decreases in medical staff and existing staff being overworked. Reduced funding availability for governance functioning in HIV and harm reduction service provisions, including reduced availability of financing for strategic planning and Board of Directors governance activities of non-governmental organizations, limits the ability of these actors to work collectively and strategically.

14 15 16 17

• S ignificant cuts to health research funding, particularly community-based health research, prevent the development of the evidence-base needed to inform public health policy, community-level HIV and harm reduction interventions.15 • T here are several accounts of culturally insensitive service provisions and negative treatment by service providers. Indigenous people who use drugs and are living with HIV, as well as HIV/Viral Hepatitis co-infection, have reported that their traditional healing practices are criticised and dismissed as ineffective and counterproductive to HIV management. Thus, a lack of cultural competence in care, particularly the ability to help people compliment traditional medicines with HAART, is a barrier to holistic treatment access.16

Mental health and wellness • M ental health and wellness is essential in ensuring treatment access and adherence among people living with HIV, particularly those co-infected with Viral Hepatitis who use drugs or who have a history of drug use. The state of a person’s mental health impacts willingness to seek treatment, care and support that is available and prescribed. Low self-esteem, depression, post-traumatic stress symptoms and cognitive issues common among people living with HIV who use drugs jeopardizes the ability to adhere to prescribed treatment or follow-up with providers on managing treatment responsibilities and side-effects. Mental health is also associated with negative coping strategies and choices that impact treatment outcomes (drug use, abusive relationships, self-destructive behaviours).17 • M any people who experience mental health problems use drugs to address their symptoms. Traumatic childhood experiences, particularly sexual abuse against children, can lead to mental health challenges, such as post-traumatic stress syndrome, suicide vulnerability, anxiety disorders and depression in adult life.

(CTAC Working Group on People Who Use Drugs, 2012) (CTAC Working Group on People Who Use Drugs, 2012) (Canadian Indigenous AIDS Network, 2009) (Urban Health Research Institute 2012)

• T he impacts of colonization on Indigenous people in Canada, particularly the residential school system and appropriation of Indigenous children by Canadian authorities in the 1960’s, has been linked to vulnerability to HIV and drug use in Canada.18 Indigenous people, particularly Indigenous women and girls, are known to use drugs in response to experiences of physical, sexual and mental abuse related to colonization. Learned patterns of abuse in Indigenous communities, including gender inequality and homophobia, causes the cycle of violence and neglect to perpetuate in many Indigenous communities. This is often referred to as intergenerational trauma.19 • C olonization has also been linked to homophobia in Caribbean and African cultures and is understood to influence vulnerability to HIV, as well as create socially-based barriers to treatment, care and support for people living with HIV in these communities. Homophobic discrimination is prominent in many Newcomer communities in Canada. Colonization imposed social values, laws and legislation, much of which was rooted in European Christian doctrines that dictated intolerance of gay and lesbian relationships. Many cultural communities originating from countries that were formally colonized have held on to discriminatory legislation and prejudicial “Mental health is the capacity of each and all of us to feel, think and act in ways that enhance our ability to enjoy life and deal with the challenges we face. It is a positive sense of emotional and spiritual well-being that respects the importance of culture, equity, social justice, interconnections and personal dignity. Mental illnesses are characterized by alterations in thinking, mood or behaviour – or some combination thereof – associated with some significant distress and impaired functioning. … Mental illnesses take many forms, including mood disorders, schizophrenia, anxiety disorders, personality disorders, eating disorders and addictions such as substance dependence and gambling.” (Public Health Agency of Canada, 2011)

attitudes toward gay people. Homophobic discrimination causes men and women to hide their sexual activities from healthcare providers, family and loved ones, which can negatively impact access to health and social supports essential in managing HIV illness.20 • P eople who use drugs are less likely to adhere to treatment, increasing risk of morbidity and mortality among this population. Barriers to treatment access and obstacles to adherence are related to mental health and drug dependence. Lowered sense of self-esteem, social exclusion and feelings of isolation may lessen the motivation of people living with HIV to seek and continue treatment.21 • T he decision to initiate treatment and which treatment option to pursue requires careful consideration of personal life circumstances. Treatment of HIV and HIV/HCV co-infection is dependent on the ability of patients to remain on a strict treatment regimen for the rest of their lives. Once patients discontinue a particular treatment, they can develop drug resistance, thereby narrowing the range of treatment options available to them. In addition to learning and understanding the medical aspects of HIV treatment, people living with HIV must decide at what point they are ready to commit to the requirements of treatment. Due to the strict dosing requirements necessary for effective response from HIV medications, lifestyles and personal life circumstances play a role in predicting the success of treatment. Many people who use drugs may not be in a ‘stage of readiness’ (physically, mentally, logistically prepared) where they are willing and able to adhere to treatment and actively seek essential supports.22

18 (www.caan.ca) 19 (Canadian Indigenous AIDS Network , 2009) 20 (Public Health Agency of Canada, 2009) 21 (Urban Health Research Institute 2012) 22 (CATIE, 2009; Urban Health Research Institute 2012)

Tools for overcoming treatment access barriers facing people who use drugs living with HIV and Viral Hepatitis Co-infection

Gender, Culture and Identity • G ender inequalities between men, women, girls, boys and transgendered people yield barriers to health service and treatment access. • W omen are more likely than men to have acquired their HIV infection from sharing injection equipment. This is believed to be related to the higher likelihood of women to need assistance injecting, suggesting that they are at increased risk of being vulnerable to using equipment that was also used by others.23

The World Health Organization defines gender as “what a society believes about the appropriate roles, duties, rights, responsibilities, accepted behaviours, opportunities and status of women and men in relation to one another.” Gender relationships are experienced within the social environment we live in and are rooted in cultural norms, beliefs and traditions. (The World Health Organization 2012)

• W omen and girls who use drugs, including transgendered women, face unique barriers to managing their HIV. The challenges that these groups of women face may stem from unequal gender relationships in society and in intimate relationships. Societal roles bestowed upon women, such as women as the primary caregiver in the family, can negatively affect treatment access and adherence, as well as overall health management. For example, many women will prioritize the health of other family members at the expense of their own health. For women living with HIV who use drugs, these responsibilities are magnified if the consequences of drug use limit the ability of women to care for their families. Mothers with HIV may avoid accessing services out of fear that their children will be apprehended by government officials because of their drug use.24

• I ndigenous women are disproportionately represented among positive HIV test reports attributed to drug use. Indigenous women who use drugs, particularly those engaging in street level sex work, are more vulnerable than others to gender-based violence and associated barriers to accessing treatment, care and support. Violence against Indigenous women is 3 - 14 times higher than the national average, with Indigenous women being twice as likely as non-Indigenous women to be sexually assaulted by their intimate partner.26 Violence against Indigenous women is linked to the impacts of colonization on Indigenous communities in Canada, including povertry, gender-based role discrimination, prejudices against Indigenous culture and race, sexualized imagery of Indigenous women, general health and social inequities facing indigenous women.27

• V iolence against women who use drugs in Canada is perpetrated by intimate partners, family and police. Reports of repeated violence (sexual and physical) with a positive test report for women, suggests that the incidence of violence against HIV-positive women in Canada is common. For instance, there are strong connections between HIV and Hepatitis C, drug use, gender-based violence and commercial sex work among women in Canada. Women living with HIV who use drugs often engage in sex work and as a result, are highly vulnerable to gender-based violence, including physical Injury, emotional scarring and threats of further violence. This influences women’s ability to adhere to treatment, seek health services and support, or escape vulnerable situations which negatively affect overall health.25

• R acism against people of visible minority groups by service providers can create barriers in health care service delivery. Prejudices and discrimination against cultural beliefs and traditions can also act as a barrier to health service.28 Racism and prejudice also affects access to treatment, along with treatment success. These are impacted by the social determinants of health, which include affordable housing, service provision, employment and education opportunities. 23 (Public Health Agency of Canada, 2010) 24 (Greene, 2009) 25 (Public Health Agency of Canada, 2012) 26 (Statistics Canada, 2010) 27 (Public Health Agency of Canada , 2012; Public Health Agency of Canada, 2009A; www.caan.ca) 28 (Public Health Agency of Canada, 2009)

Impacts of HIV Stigma and Discrimination on Access to Treatment, Care, and Support

HIV-related stigma and discrimination are at the root of many barriers to accessing holistic treatment, care and support for people living with HIV. People living with HIV face severe stigma and discrimination as a result of societal ideologies, attitudes and behaviours towards HIV and AIDS, as well as the use of drugs. This section of this curriculum provides an overview of stigma and discrimination as it impacts on holistic treatment access for people who use(d) drugs.

Intersections of Stigma homelessness and unstable housing

involvment in commercial sex

mental health

race and culture

sexual preference

HIV and HIV/Hepatitis C Co-infection

substance use

“HIV-related stigma refers to the negative beliefs, feelings and attitudes towards people living with HIV and/or associated with HIV. Thus, HIV-related stigma may affect those suspected of being infected with HIV; those who are related to someone living with HIV; or those most at risk of HIV infection, such as people who inject drugs, sex workers, men who have sex with men and transgender people.” “HIV-related discrimination refers to the unfair and unjust treatment (act or omission) of an individual based on his or her real or perceived HIV status. Though HIV-related stigma often leads to discrimination, it is important to note that even if a person feels stigma towards another, s/he can decide not to act in a way that is unfair or discriminatory. Conversely, a person may discriminate against another without personally holding stigmatising beliefs, for example, where discrimination is mandated by law.” (UNAIDS, 2010)

Tools for overcoming treatment access barriers facing people who use drugs living with HIV and Viral Hepatitis Co-infection

• Insensitivity, ignorance and prejudices, as well as Stigma and discrimination against those who use outright discrimination by health services providers, gs in service provision, criminal legislation, employment generate mistrust and leads to avoidance of health and by society at large is a primary cause for services. to treatment access and managing HIV illness. Punitive laws against drug use send people who use drugs to • Contributes to gender-based violence against womprison where they may experience treatment interrupen who use drugs that is perpetrated by partners, tions and inability to access specialized HIV and cofamily, police and the general public. Physical injury, infection services. Criminal records associated with drug emotional scars and/or threats of further violence involvement can prevent people living with HIV from can limit women’s ability to adhere to treatment, obtaining employment. Poor treatment of people who seek health services and supports, or escape vulneruse drugs causes avoidance of health systems and able situations which negatively affect overall health. support services. Stigma and discrimination of HIV and Hepatitis C intersects with stigma and discrimination against drug use, commercial sex work, race and culture, mental health, homelessness and unstable housing and sexual preference. The diagram on page 12 depicts the layers of stigma and discrimination people experience when attempting to access services and supports.

• I solates and excludes people living with HIV who use drugs from participating in the development of research, policy and programs designed for them. • F uels opposition to funding of health services, including harm reduction services designed to help people living with HIV who use drugs to manage their illness and personal life circumstances.

Stigma and discrimination against HIV affects access to treatment, care and support for people living with HIV who use drugs in the following ways: • T he mental health and overall resilience of people who use drugs to seek services and support to manage personal health is impacted. It is not uncommon for people with HIV or HIV/Hepatitis C co-infection to internalize stigma.

Barriers to Holistic Treatment Access

This section of the curriculum provides a summary overview of the barriers, including social, structural and personal barriers preventing people living with HIV or Viral Hepatitis co-infection from accessing holistic treatment, care and support required to achieve the best treatment experience possible. Barriers to Accessing Treatment, Care and Support: • P unitive laws that criminalize people who use drugs create barriers between people and available services and supports by forcing people who use drugs to conceal their use of drugs and related health concerns from providers.

egative social attitudes regarding illegal drugs and • N people who use them prevent access to treatment, care and support through discriminatory practices in health service provision. Stigmatized ideologies by service providers, hospitals, clinics and physician offices have inhibited people from benefiting from available services and treatment options. Racism affecting visible minority groups, including prejudices against cultural norms and practices, often impedes people from accessing treatment services. • A failure to maintain patient privacy protection exists for certain populations. Some individuals, such as those residing in rural and remote settings, are often put in the position where accessing treatment and services may come at the expense of having their confidentiality compromised. As a result, many people, in fear of having their status disclosed to others, are reluctant to access services. • A lack of specialized services, support, knowledge and expertise exists among service providers in Canadian prisons, as well as rural and remote areas. Competing clinical demands and lack of comprehensive HIV/Hepatitis C co-infection treatment options and services have been commonly noted as challenges resulting in interruptions in treatment, lowered adherence and poor treatment comes.

• G ender-based inequities against women who use drugs and who are living with HIV limits their willingness to access health services, adhere to treatment and manage overall health. Gender roles assigned to women, such as the primary caregiver role, perpetuates treatment access issues. Women, for example, often feel that they have the responsibility of giving their health secondary status over other family members. At the same time, women who use drugs may experience even greater challenges caring for family members due to their addiction. • V iolence against women who use drugs and who are living with HIV, including injury, emotional scars and threats of further violence, inhibits women from seeking health services and support tools, limits adherence to medications and thereby decreases women’s ability to escape violent and vulnerable relationships. • P overty, low income, unemployment, homelessness and unstable housing are common among people living with HIV who use drugs, all which can impact treatment access through a general condition of vulnerability and hardship that does not allow for adequate disease management. • L ow self-esteem, depression, post-traumatic stress symptoms and cognitive issues are common among people living with HIV who use drugs, which jeopardizes their ability to adhere to prescribed treatment or follow-up with providers on managing responsibilities of treatment and treatment side-effects.

Tools for overcoming treatment access barriers facing people who use drugs living with HIV and Viral Hepatitis Co-infection

• C ontinuing cuts to services for people who use drugs further pushes people to the margins of service provision and decreases available resources for managing HIV and co-infections. Funding cuts limit the availability of harm reduction services that reflect best practices, as well as reduce available services and staff in hospital settings. • C ulturally insensitive service provisions and negative treatment by service providers that dismiss traditional healing practices and marginalize people who use drugs and who are living with HIV/Viral Hepatitis co-infection inhibit access to holistic forms of treatment.

• M ental health has a significant impact on an individual’s overall quality of life. Many people living with HIV/Hepatitis co-infection are more vulnerable to symptoms, including depression and anxiety. Experiencing increased rates of issues pertaining to mental health can result in negative and potentially damaging coping strategies, such as alcohol and drug abuse. Such addictions and coping mechanisms can deter individuals from seeking treatment and support services.

• S trict dosing dosing requirements necessary for effective HIV medication management and care requires a certain level of readiness, will and commitment on the individual’s part. The substantial lifestyle changes necessary to accommodate treatment requirements decrease levels of adherence.

Take Action: Tools, Solutions and Alternatives

Below is a list of Actions you can take as a person living with HIV or Viral Hepatitis co-infection and as a service provider, as a researcher or policymaker, or as an allied member of the community. Actions • E liminate bias, ignorance and discriminatory practices within the healthcare settings, including HIV-related stigma and acts of discrimination based on sex work, drug use, gender, race, culture and age through knowledge exchange and policy changes. Educate and train service providers in the material presented in this curriculum.

rovide people who use drugs and who are living • P with HIV a range of information on treatment options and support them through the decision making process around treatment regimens and treatment initiation. Linking people to the appropriate services and resources is essential in effective treatment management.

• A dvocate and support greater access to harm reduction and social support resources that speak to the social realities of people who use drugs and who are living with HIV and Viral Hepatitis co-infection. Implement peer-based mentoring and support services and programs for people who use drugs.

• D evelop and provide adherence support programs and resources for people who use drugs and are living with HIV or Viral Hepatitis co-infection that are reflective of the unique challenges facing this population. This may include support for managing side effects of treatment and support for complications associated with drug use.

• O ffer culturally appropriate programming for Indigenous people who use drugs and are living with HIV. Incorporate peer-based approaches into programming. Link Indigenous people with resources to address residential school and intergenerational trauma. • L ink people who use drugs with physco-social support services and programs. Ensure that these programs and services are reflective of the needs of this particular population and foster compassionate and equitable treatment. • I nvolve people who use drugs living with HIV in designing services. Develop specific forums and spaces to engage people who use drugs and live with HIV or Viral Hepatitis co-infection in dialogue about treatment access barriers and programs for addressing them.

• P romote specialized co-infection services for people who use drugs and are living with HIV or Viral Hepatitis co-infection who are incarcerated in federal and regional prisons. Facilitate and help generate resources for legal support for such people facing criminal charges and legal complications. Support community programming that brings harm reduction resources to people living with HIV in prison. In addition, regional and federal prisons must develop policies to ensure that those arrested have access to medications while incarcerated at all times to ensure that treatment is not discontinued. • P rovide referrals to legal and social supports for people who use drugs and who are living with HIV who experience violence or who are at risk of violence if you cannot provide them through your service centre. Provide additional support to such populations to ensure they are following through with referral appointments.

Tools for overcoming treatment access barriers facing people who use drugs living with HIV and Viral Hepatitis Co-infection

• P rovide housing and shelter resources for people who use drugs and who are living with HIV who require assistance. This includes providing safe housing for children and young people escaping violent and abusive situations. Support initiatives promoting greater access to housing in your community. • P romote public health policies and programs that facilitate knowledge transfer and exchange among providers, policy researchers and other decision makers. Encourage people who use drugs and living with HIV and Viral Hepatitis co-infection to get involved in research dialogue and study design. Ensure research on HIV among these groups of people employs the Greater Involvement of People Living with HIV and AIDS (GIPA) principles and is evidence-based. rovider-patient relationships need be strength• P ened. Providers must increase their awareness of culturally competent care and support holistic forms of treatment. This involves including patients in all aspects of decision-making. Providers should engage in meaningful dialogue with patients regarding psychosocial and medical factors that influence their treatment outcomes.

place to ensure that patient-sensitive information is not compromised. • S trengthen social support networks and enhance community engagement among people who use drugs and live with HIV and Viral Hepatitis co-infection. Supportive interaction with other members of the community may positively impact healthy coping mechanisms and strategies, as well as help overcome the effects of stigma and discrimination. In addition, community involvement gives members a sense of purpose and allows them to provide meaningful contributions and inspiration to others. • I ncrease awareness and advocate for social change. Policies in health care must foster gender-equitable and social determinants of health approaches. Treatments and programs need to shift from medicalized ideologies to ones that are reflective of how people’s living conditions affect the risk of exposure to HIV and Viral Hepatitis co-infection, as well as how it impacts their journey through the course of treatment.

ealth care institutions, including hospitals, com• H munity health centres and physician offices should adopt and comply with privacy and confidentiality policies. Such policies should be routinely enforced, with evaluation and surveillance mechanisms set in

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