Saskatchewan: The Provincial HIV Program After Two Decades, We Have a Strategy Again Provincial Primary Care TB Ed Day Oct. 28, 2011

Overview of the History of AIDS in Saskatoon 1.Appearance of HIV in North America. 2.When did HIV get to Saskatoon? 3.How did HIV get to Saskatoon? 4.Support for PLAs/PLWAs in Saskatoon. 5.Current epidemiology of HIV/AIDS in Saskatchewan. 6.Current approach to prevention and treatment of HIV/AIDS. Provincial Primary Care TB Ed Day Oct. 28, 2011

Appearance of HIV/AIDS in North America 1981: NEJM and MMWR reports of rare opportunistic infections, ex. PCP. Excessive demand for pentamidine. Involving New York, Miami (Dade County) and San Francisco in a “Gay Plague”. “4-H Club”: homosexual, heroin, hemophilia, Haitian. Epidemiology implicated infection spread by blood and sex. Provincial Primary Care TB Ed Day Oct. 28, 2011

Clinical Spectrum in 1981 Only AIDS was recognized. No serologic test for HIV yet. Lymphadenopathy and lymphopenia were markers of involvement, as was thrush. Pneumocystis carinii pneumonia was recognized late and was often fatal. Therapy = pentamidine. Cryptococcal meningitis was recognized late and was often fatal. Kaposi’s sarcoma was new and aggressive. Provincial Primary Care TB Ed Day Oct. 28, 2011

Appearance of HIV/AIDS in Saskatoon Mostly imported from elsewhere: US, Toronto, Montreal, Vancouver (Calgary!). Young men returned home to Saskatoon to die. Little indigenous transmission. First cases: people with hemophilia and traveling gay men. Provincial Primary Care TB Ed Day Oct. 28, 2011

HIV/AIDS Clinic regular clinic attendees. 70% gay men. 10% hemophiliac. 20% all else. Less than 5% First Nations. Provincial Primary Care TB Ed Day Oct. 28, 2011

HIV/AIDS Support in Saskatoon AIDS Saskatoon: federally funded, relatively stable (formed 1987 for prevention/education). PLWA Network of Saskatoon (Persons Living With AIDS) (formed 1987, incorp. 1988) SAN (Saskatchewan AIDS Network). Provincial Primary Care TB Ed Day Oct. 28, 2011

Surviving HIV Prophylaxis for common opportunistic infections (sulfa for PCP, azithro for MAC) AZT monotherapy (good for 3 years). 1990s advent of Protease Inhibitors: stable suppression of HIV, immune reconstitution. HIV is a chronic manageable disease. HIV Clinic moves from Acute Care Medicine to Chronic Diseases Management to Public Health Provincial Primary Care TB Ed Day Oct. 28, 2011

Organizing an Approach to AIDS Early 1990s: mass meetings in Regina to develop a Provincial Strategy. Resulted in a ministerial advisory committee. Resulted in a Provincial AIDS Co-ordinator position. Mostly did education. Interest decreased with the avavilability of Protease Inhibitors. Provincial Primary Care TB Ed Day Oct. 28, 2011

Clinical Spectrum in 2011 Only AIDS is recognized. No serologic test for HIV is done before the AIDS- defining infection. Lymphadenopathy and lymphopenia were markers of involvement, as was thrush. Pneumocystis carinii pneumonia was recognized late and was often fatal. Therapy = TMP/SMX. Cryptococcal meningitis was recognized late and was often fatal. Kaposi’s sarcoma was new and aggressive. Provincial Primary Care TB Ed Day Oct. 28, 2011

Clinical Spectrum in 2011 Pneumocystis accounts for about 60% of all AIDS- defining illnesses in Saskatchewan. TB accounted for a similar proportion of AIDS- defining illnesses in the developing world. Provincial Primary Care TB Ed Day Oct. 28, 2011

Fig 2: HIV cases reported by Age and Gender in Saskatchewan, 2010 (Preliminary) Number of cases male female

Insert risk factors here Fig. 3: Selected Risk Factors Among HIV Cases in Saskatchewan,

Proportion of HIV cases reported by Year & Health Jurisdictions

POPULATION HEALTH BRANCH

Saskatchewan HIV Strategy Overarching goals are to:  reduce the number of new HIV infections,  improve the quality of life for HIV-infected individuals, and  reduce risk factors for acquisition of HIV infection.

POPULATION HEALTH BRANCH Accomplishments Funding allocated in Health Regions for:  9 nursing positions including  6 HIV Strategy Coordinator positions in 6 RHAs  6 social work/outreach positions  1 Medical Office Assistance position in Regina  HIV-dedicated Family Practitioner at an HIV Clinic Also:  HIV Strategy Evaluation Framework  Funding for HIV Point of Care Testing

POPULATION HEALTH BRANCH HIV Provincial Leadership Team  Clinical Directors (0.6 FTE).  Medical Health Officer (0.8 FTE), including FNIH MHO.  Pharmacist (0.5 FTE for 6 months).  Program Director (1.0 FTE).  Admin Support position (1.0 FTE).

POPULATION HEALTH BRANCH HIV Provincial Leadership Team This team will lead the implementation of the HIV Strategy, specifically the four strategic pillars: Community Engagement and Education Prevention and Harm Reduction Clinical Management Surveillance and Research

POPULATION HEALTH BRANCH Community Engagement increase community engagement to address community-related risk factors, e.g.: inadequate housing increase leadership participation to address community related risk factors, e.g.: stigma and discrimination

POPULATION HEALTH BRANCH Education increase knowledge of HIV among the residents of Saskatchewan through public awareness and prevention Increase capacity of service providers through education/training for health care professionals

POPULATION HEALTH BRANCH Prevention and Harm Reduction provide prevention (primary, secondary and tertiary) resources including best practices to the regions. establish centers delivering integrated, holistic prevention/well being/harm reduction services, via mobile services where possible.

POPULATION HEALTH BRANCH Clinical Management Objectives improve HIV client access to medical care provide rapid initiation of treatment to HIV- positive clients whenever appropriate increase frontline support including capacity, education and standards promote the use of HAART regimens to optimally treat the patient and reduce transmissibility of the virus

Movement Toward HIV Care In a Primary Care Setting West Side Community Clinic. Regular Clinics in Prince Albert, LaRonge, LaLoche, others. Dr. Skinner made a house call on a Northern Reserve. Provincial Primary Care TB Ed Day Oct. 28, 2011

POPULATION HEALTH BRANCH Surveillance and Research Objectives improve the provincial HIV surveillance system increase knowledge of HIV epidemiology in appropriate audiences increase sharing of HIV epidemiology information to appropriate audiences

POPULATION HEALTH BRANCH Moving forward in Funding for additional FTEs:  9 FTEs - outreach/social work  Community Development Coordinators in 3 RHAs  Enhanced RHA pharmacy support (Regina and Saskatoon)

POPULATION HEALTH BRANCH Moving forward in Funding for:  Provision of transportation for clients in 3 RHAs  Continued HIV POC testing  Wellness centre including harm reduction programming in 1 health region  Public Awareness and Prevention  Peer to Peer Network Programming (1 FTE)

POPULATION HEALTH BRANCH Moving forward in Funding for CBO’s and stakeholders to develop programs which will assist in achieving the goals of the Strategy  RHA’s are crucial partners in developing these initiatives  Funding will be phased in over 3 years  Funding amounts are determined on percentage of new HIV cases and percentage of population the RHA’s represent  Final approval of proposals from the PLT