HIV: A conversation on a Saskatchewan epidemic

Saskatchewan’s HIV infection rates are among the highest in the country and it’s created an epidemic. For those with the least access to care - the province’s First Nations communities – the impact is even greater. That was a topic of discussion among a panel of alumni and health care experts, Dr. Stuart Skinner (MD’02), Dr. Stephen Sanche (MD’90), and Dr. Lawrence Gelmon (MD’72), at the 2017 Highlights in Medicine Alumni Reunion Conference on June 23.

With Saskatchewan’s infection rates double the national average, the crisis is so bleak it has prompted the provincial government to declare a “state of emergency” for three First Nations communities. According to Indigenous and Northern Affairs Canada data, the province’s First Nations population is just over 141,000 with 49 per cent residing on First Nations reserves.

Sanche, an associate professor in the CoM with active clinical practices in the fields of Infectious Disease Medicine and Medical Microbiology, discussed how the epidemic disproportionately impacts the First Nations population. He pointed to provincial data that showed HIV infection rates from the 1990s to present and noted that new cases are increasingly being seen outside urban centres.

“It’s not just Saskatoon, Regina, and Prince Albert. It’s now a ‘beyond’ phenomenon,” Sanche said. “It’s no longer just a city disease. It’s rural, remote and on reserves.”

Sanche explained that in the 1990s there were low rates of infection, which increased in the mid-2000s as Saskatchewan became more prosperous and injection drug use became a risk factor. Instances of infection rose steadily until 2012 and improved temporarily between 2012 and 2014, with improved addictions services. Sanche believes it was due to directly observed therapy and the availability of antiretroviral treatment, which hadn’t previously been widely available.

He said that while the decrease in new cases was encouraging to some, it proved to be deceiving.  

“We could see on the front line we’re not winning the battle,” Sanche explained. “We were trying at that point to raise the alarm still and say look, this is an encouraging trend but what we’re seeing suggests we’re seeing a tip of the iceberg, and there’s still an iceberg out there that’s yet to be discovered.”

Skinner, an infectious disease specialist in Regina, attributes the rise of HIV and Hepatitis C infection rates among the province’s on-reserve population to two factors – testing accessibility and disease transmission through injected drug use.

To help combat this epidemic, Skinner and his team have developed a mobile outreach clinic to provide HIV point-of-care testing and treatment to First Nations communities. A team of primary care and specialist physicians provide integrated care with other health care professionals.

Skinner stressed the clinic is a collaboration with First Nations leadership, Health Canada, clinicians and the province. He noted that the communities take pride in the program and had input in developing it. 

“Everything that we’ve developed is community-led, in partnership with First Nations leadership - chiefs, elders, council, and health directors,” explained Skinner.

The local testing has replaced the need to drive hours to the nearest town or city, increasing the likelihood patients will get tested. Nurses can draw blood remotely – at a patient’s house or roadside – and will provide case management.

Skinner also noted that technology has played a big part in remote presence, pointing to cell phones and Tele-health as key components in managing treatment. Participants in the program now are given a cell phone to receive text reminders, he explained, something that wouldn’t have been possible 10 years ago, when cell phone use was uncommon among this population.

There are wider benefits to the model they’ve set up beyond the immediacy of testing and care.

“This system can be used as a basis for chronic disease management for First Nations,” said Skinner. “Not just HIV or Hep C, but diabetes (which) greatly trumps those epidemics in all of those communities.”

The mobile health unit is already seeing success with increased HIV status awareness. Their statistics show 42 per cent of people tested in these clinics were unaware of their HIV status. Currently, the mobile outreach clinic is at 10 sites serving 24 First Nations communities.