1.Overview of Aboriginal People living with HIV in Canada 2.Structural, Social and Personal Treatment Access Barriers Gender Culture Income, Education, and Employment 3.Impacts of HIV Stigma and Discrimination on Access to Treatment, Care, and Support 4.Barriers to Holistic Treatment Access 5.Take Action: Tools, solutions and Alternatives Contents

Epidemiology Under the 1982 Constitution Act, Aboriginal people of Canada encompass three recognized groups: First Nations, Inuit/Inuk/Innu and Métis. First Nations refers to Aboriginal people that represent both Status and Non-Status Indians. Inuit refers to Aboriginal people from the Arctic region. Métis represent Aboriginal people that are of mixed Aboriginal and European ancestry. HIV disproportionately affects Aboriginal people. From the overall population in Canada, Aboriginal people accounted for only 3.8% of the population in (Public Health Agency of Canada, 2013) 1. Overview of Aboriginal People Living with HIV in Canada

More Aboriginal people are becoming infected with, and living with HIV/AIDS than any other population in Canada. In 2011, Aboriginal people accounted for approximately 12.2% of new HIV infections and 8.9% of all prevalent infections. 2 The Canadian Aboriginal population new infection rate was 3.5 times higher than the non- Aboriginal population. 3 According to routine surveillance data, the majority of positive HIV tests among Aboriginal people are attributable to injection drug use or heterosexual contact (89.6%). 4 Aboriginal people living with HIV had experienced greater difficulties gaining access and adhering to treatment than other members of the population. 2, 3, 4 (Public Health Agency of Canada, 2013)

Gender Aboriginal women are considerably more likely than women in the general public to be diagnosed with AIDS, accounting for nearly 50% of all Indigenous people living with HIV or AIDS in Canada. 5 Between 1998 and 2009, 66.3% of Indigenous women were infected with HIV through injection drug use and 33.4% through heterosexual contact. 6 Drastic growth in HIV infection among Aboriginal women have been attributed to the impacts of colonization on Indigenous people, sexual violence against Aboriginal women and girls, as well as increased exposure risk associated with drug use and survival sex work. 5, 6 (Public Health Agency of Canada, 2010A) (Public Health Agency of Canada, 2010B) (Public Health Agency of Canada, 2010C) (Public Health Agency of Canada, 2012) 2. Structural, Social and Personal Treatment Access Barriers

Violence against Aboriginal women is 3-14 times higher than the national average. 7 Violence against Aboriginal women is augmented due to poverty, prejudices against culture and race, sexualized imagery of Aboriginal women, as well as social inequities facing Aboriginal women. 7 (Statistics Canada, 2010)

Culture Complementary and Alternative Medicine Therapies (CAMT) include any therapy that does not fall under the standard Western-oriented model of care. There are several North American Aboriginal healing traditions that aim to improve the quality of life for people living with HIV, help reduce side effects of other medications and/or to alleviate symptoms of HIV. Despite the potentially beneficial outcomes of CAMT, public health care plans in Canada seldom cover such costs. Many Aboriginal women have reported that their traditional healing practices have been dismissed as ineffective and counterproductive to HIV management. Lack of cultural sensitivity has hindered Aboriginal people from accessing holistic treatment options.

Income, Education, and Employment Income is a good predictor of overall health quality of life. The level of income is often affected by education. That is, people with higher levels of education generally fall into higher income brackets. Similarly, education provides people with the literacy, language, and critical skills necessary to understand how to manage HIV treatment as well as become informed and involved in the decision-making process. Aboriginal people represent a group with lower levels of education and income. Aboriginal people, along with women and those who have lower income, represent groups in the population that were more likely to not access HIV treatment before death. Similarly, if treatment was accessed, adherence became an issue where treatment was often discontinued. Employment offers several benefits, including a sense of identity, opportunities for socialization, and participatory engagement. Aboriginal people have some of the highest unemployment rates in Canada. Unemployment is associated with increased risk of disease progression.

Among Aboriginal youth living with HIV, poor adherence to treatment outcomes has been attributed to misconstructions surrounding treatment, as well as social marginalization and other forms of oppression. Stigma and discrimination bolsters both social inequalities and inequities, which lead to social isolation, withdrawal, and exclusion on the micro, meso, and macro level. Stigmatization also increases risk to issues pertaining to well-being and mental health, including depression, anxiety, and low self-worth. The consequences that result from stigma and discrimination can have several detrimental effects, such as increasing the risk of adopting negative coping practices and housing instability. 3. Impacts of HIV Stigma and Discrimination on Access to Treatment, Care, and Support

Aboriginal people that are victimized by stigma and discrimination often lead to poorer quality of care, mistrust in government and institutions, as well as inadequate confidentiality and privacy protection. People fear disclosing HIV status due to cultural abandonment, which would impact loss of culture and identify, as well as self-esteem. Stigma contributes to gender-based violence against women. Physical and emotional threats of violence can limit a women’s ability to seek and adhere to treatment and potential to escape violent relationships. Because HIV is perceived to be a “Gay Disease”, many Aboriginal men and women feel the need to remain isolated and avoid treatment in order to protect loved ones.

Duties and responsibilities between federal and provincial/territorial governments in terms of health care delivery is unclear. Lack of accountability, responsibility, and priority has impeded access to HIV treatment. Cultural sensitivity, especially traditional healing practices and customs, have been dismissed as ineffective options. Most non-Western medical approaches are not publicly funded. Stigma, discrimination, and racism are all factors that deter Aboriginal people from disclosing their status to loved ones, as well as accessing programs and services imperative in HIV management. Negative coping strategies, including drug and alcohol use, has impeded efforts to seek and adhere to treatment. 4. Barriers to Holistic Treatment Access

Geography plays a critical role in inhibiting access to treatment. Aboriginal people residing in rural and remote settings, particularly small and reserve communities, face a considerable lack of privacy protection in health service delivery. Many Aboriginal people living with HIV are forced to leave their communities and relocate to urban centres where specialized services are available and privacy can be better maintained. A lack of specialized services or knowledge regarding key issues among service providers in remote and rural communities exists. Many providers, such as addictions counsellors, often have minimal HIV knowledge, and HIV specialists may lack the expertise that are required to treat Viral Hepatitis co-infection. Providers may also be unaware of how the social determinants of health, such as access to housing and employment, impact HIV treatment management and care.

Healthcare provider education is critical. Providers must possess knowledge regarding HIV management, care and treatment that is current and up-to-date. Culturally competent care, which incorporates traditional medicines and healing practices, is required to adopt more holistic approaches to care. While it is important to include these practices in care, it is also important to have knowledgeable staff on how and if traditional medicines and practices impact other forms of treatment management. Staff must be knowledgeable and responsible for abiding to non-discriminatory policies, as well as comprehensive confidentiality and privacy training. Such efforts must be effectively maintained through surveillance and evaluation methods. Those who compromise privacy and confidentiality should be held accountable and be reprimanded. Community outreach programs that facilitate education and direct HIV positive people to support services and programs is necessary. 5. Take Action: Tools, Solutions and Alternatives

HIV/AIDS education in communities and within the schooling system is necessary to sensitize young Aboriginal people to HIV/AIDs, as well as to reduce discriminatory practices. Federal and provincial/territorial/municipal governments must delegate clear duties and responsibilities. This involves outlining accountability and responsibility for health care delivery. In addition, improved communication and service coordination among all levels of government and inter-departmentally is required. Community engagement is fundamental to improving access barriers. Aboriginal people need to actively participate in and provide input into decision-making processes. The power of mobilization and community solidarity is essential in making positive changes. This requires developing sustainable partnerships in order to know who to approach and how to approach them. Initiatives that foster a social of determinants of health approach, such as employment, education, and housing strategies, must be given priority. Not only do higher levels of socio-economic status improve treatment management and adherence, enhance overall quality of life, but also contribute to economic prosperity.

Public Health Agency of Canada. (2010A). At a Glance - HIV and AIDS in Canada: Surveillance Report to December 31st, Retrieved from sida/publication/survreport/2010/dec/index-eng.php Public Health Agency of Canada. (2010B). HIV and AIDS in Canada. Surveillance Report to December 31, Ottawa, Canada: Public Health Agency of Canada. Public Health Agency of Canada. (2010C). HIV/AIDS Epi Updates - July Ottawa, Canada. Public Health Agency of Canada. (2010D). Population Specific HIV/AIDS Status Report: People from countries where HIV is endemic. Ottawa, Canada. Public Health Agency of Canada. (2013). Population-Specific HIV/AIDS Status Report: People living with HIV/AIDS. Ottawa, Canada. Public Health Agency of Canada. (2012). Population-Specific HIV/AIDS Status Report: Women. Ottawa, Canada. Statistics Canada. (2010). Measuring violence against women: Statistical trends Ottawa, Canada. Bibliography