Rates of new HIV diagnoses among Indigenous peoples in Canada, Australia, New Zealand, and the United States: 2009–2017 : AIDS

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Rates of new HIV diagnoses among Indigenous peoples in Canada, Australia, New Zealand, and the United States: 2009–2017

Koehn, Katrinaa,b; Cassidy-Matthews, Chenoaa,c; Pearce, Margod,e; Aspin, Clivef; Pruden, Harland; Ward, Jamesg,h; Mullen, Maramai; Hogg, Robert S.a,b; Nicholson, Valeriea

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AIDS 35(10):p 1683-1687, August 1, 2021. | DOI: 10.1097/QAD.0000000000002977

Abstract

Introduction

Indigenous peoples of Canada, Australia, New Zealand, and the USA are highly diverse, yet share similar relationships with land, community, and understandings of wellness. Nekultimuk [Mi’kmaq (Canada): Nekultimuk means ‘I know’, referring to collective knowledge that comes from ancestors]; ehara taku toa i te takitahi, he toa takitini kē (Māori (New Zealand): Ehara taku toa i te takitahi, he toa takitini kē translates to strength that is not in being alone, rather strength as many’ [1]; or kanyini [Pitjantjatjara (Australia): Kanyini refers to the connectedness of tjukurrpa (knowledge of creation or Dreaming), ngura (place), walytja (‘kinship’) and kurunpa (‘spirit’) [2]) are examples of concepts used by different nations to describe the strength Indigenous peoples draw from knowledge that spans generations. These regions are connected through colonial policies of genocide employed to eradicate or assimilate Indigenous populations and cultures, including forced displacement from land, prohibition of ceremonies, residential, and day school systems in Canada and the USA, and Stolen Generations in Australia [3]. Enduring colonialism creates far-reaching sociostructural inequities for Indigenous peoples [4,5], including disproportionate impacts from health challenges like HIV [6].

Despite similar colonial experiences, few cross-national comparisons assessing HIV diagnoses among Indigenous peoples have been conducted. The studies that exist focus on differences between Indigenous and non-Indigenous peoples [6,7] and attribute elevated rates of HIV among Indigenous peoples to intergenerational trauma [4] and lack of culturally safer healthcare services [6]. Further, it is thought that increased rates of HIV testing occur because of perceptions that Indigenous peoples are ‘at-risk’ [4]. Although such comparisons between Indigenous and non-Indigenous populations in a region are useful in some contexts, measuring the health of Indigenous peoples using non-Indigenous populations as a benchmark perpetuates the othering of Indigenous people, a definition of health that centers whiteness, and the narrative that Indigenous people suffer a health deficit in settler states. One alternative to this comparison is to examine divergences between Indigenous peoples at the international level. Such divergences may indicate progress towards equity, reconciliation (reconciliation in this context is used broadly to describe different national efforts to take responsibility for enduring colonialism and make reparations for the harms perpetrated against Indigenous peoples) and HIV de-stigmatization within healthcare systems [8,9], and could inform policy direction and development within nations. We compared rates and trends of HIV diagnoses among Indigenous peoples in Canada, Australia, New Zealand, and the USA between 2009 and 2017 using publicly available HIV surveillance data.

Methods

Data sources

Details of data sources employed in this descriptive study can be found in Table S1, https://links.lww.com/QAD/C192. Indigenous peoples in this analysis include First Nations, Inuit, Métis, and Other Indigenous Nonspecified (Canada); Aboriginal and Torres Strait Islanders (Australia); American Indian, Alaska Native, Native Hawaiian, and Other Pacific Islanders (USA); and Māori (New Zealand). All countries had mandatory HIV reporting over the study period except New Zealand, which only had mandatory reporting since January 2017. Information on Indigenous identity is collected through HIV notification forms. In Canada, the provinces of British Columbia and Quebec do not report ethnicity to the national surveillance body; we have supplemented our data with provincial-level British Columbia reports, and excluded Quebec, which constitutes 11% of Indigenous peoples in Canada.

National census data was used for population denominators. Canada and Australia have separate questions asking whether a person identifies with their respective Indigenous groups, whereas the USA and New Zealand include standard ethnicity questions (i.e. the Indigenous identifier is in the same list as the other ethnicities, instead of as a separate question). For consistency, we used nonmutually exclusive population counts (i.e. a person could identify as Indigenous in addition to other ethnicities). In Canada, where intercensal estimates are not publicly available, we assumed a linear population increase between census years.

Analysis

We calculated annual estimates and 95% confidence intervals (CI) of rates per 100 000 of HIV diagnoses for Indigenous peoples overall and for Indigenous women and men. Estimated annual percentage change (EAPC) between 2009 and 2017 was calculated using Poisson regression with no covariates and logarithms of population denominators as offsets [10]. All analyses were conducted with RStudio, version 1.2.1335 (R Foundation for Statistical Computing, Vienna, Austria).

Results

Table 1 and Fig. 1 show the rate per 100 000 for HIV diagnoses among the total and sex-stratified Indigenous population in each country. As of 2017, rates of HIV were highest in Canada (16.22, 95% CI: 14.30--18.33) and lowest in New Zealand (1.36, 95% CI: 0.65--2.50). Australia had a rate of 3.81 (95% CI: 2.59--5.40) and the USA 3.22 (95% CI: 2.85--3.63).

Table 1 - HIV case rate per 100 000 and estimated annual percentage change among Indigenous peoples in Canada, Australia, USA, and New Zealand (2009-2017).
2009 2010 2011 2012 2013 2014 2015 2016 2017 EAPC (95% CI)
Canadaa , b
 Total CI 30.06 (27.01--33.35) 24.84 (22.12--27.80) 25.98 (23.24--28.95) 19.23 (16.93--21.76) 16.94 (14.82--19.29) 14.81 (12.86--16.97) 15.44 (13.48--17.60) 17.71 (15.64--19.98) 16.22 (14.30--18.33) −7.92d (−9.34 to −6.49)
 Men CI 34.46 (29.82--39.61) 26.97 (22.95--31.48) 30.07 (25.88--34.74) 23.03 (19.45--27.08) 20.28 (16.98--24.03) 16.67 (13.74--20.04) 17.44 (14.48--20.82) 19.12 (16.07--22.59) 19.95 (16.94--23.34) −7.62d (−9.51 to −5.69)
 Women CI 25.89 (22.00--30.27) 22.82 (19.23--26.88) 22.11 (18.63--26.04) 15.64 (12.79--18.94) 13.80 (11.18--16.85) 13.05 (10.55--15.97) 13.56 (11.05--16.48) 16.38 (13.64--19.50) 12.59 (10.26--15.30) −8.33d (−10.45 to −6.17)
Australiaa
 Total CI 3.49 (2.23--5.19) 3.12 (1.96--4.73) 3.33 (2.14--4.96) 4.48 (3.09--6.30) 3.46 (2.26--5.07) 4.30 (2.96--6.04) 4.98 (3.54--6.81) 5.76 (4.22--7.69) 3.81 (2.59--5.40) 5.10d (0.39--10.08)
 Men CI 6.12 (3.79--9.36) 4.27 (2.39--7.05) 5.02 (2.97--7.93) 7.36 (4.85--10.71) 5.87 (3.68--8.89) 6.54 (4.23--9.65) 8.96 (6.24--12.47) 10.29 (7.38--13.96) 5.65 (3.58--8.48) 5.91d (0.67--11.50)
 Women CI 0.87 (0.18--2.54) 1.98 (0.80--4.08) 1.66 (0.61--3.61) 1.63 (0.60--3.54) 1.06 (0.29--2.72) 1.82 (0.73--3.75) 1.02 (0.28, 2.61) 1.00 (0.27--2.56) 1.72 (0.69--3.54) 0.81 (−11.13 to 10.76)
USAa , c
 Total CI 5.36 (4.68--6.12) 4.18 (3.71--4.69) 3.80 (3.37--4.26) 3.96 (3.53--4.43) 3.62 (3.21--4.07) 3.50 (3.10--3.93) 3.54 (3.15--3.98) 3.53 (3.14--3.96) 3.22 (2.85--3.63) −4.25d (−5.75 to −2.73)
 Men CI 7.88 (6.72--9.19) 6.45 (5.63--7.36) 6.07 (5.31--6.90) 6.47 (5.69--7.32) 5.63 (4.91--6.42) 5.49 (4.79--6.27) 5.50 (4.80--6.27) 5.77 (5.06--6.55) 5.06 (4.40--5.79) −3.75d (−5.45 to −2.02)
 Women CI 2.82 (2.15--3.64) 1.93 (1.50--2.45) 1.54 (1.17--1.99) 1.44 (1.09--1.87) 1.62 (1.25--2.07) 1.42 (1.08--1.84) 1.55 (1.19, 1.98) 1.31 (0.98--1.71) 1.36 (1.03--1.76) −6.32d (−9.48 to −3.05)
New Zealanda
 Total CI 1.83 (0.95--3.20) 2.25 (1.26--3.72) 1.63 (0.81--2.91) 1.17 (0.50--2.30) 1.44 (0.69--2.66) 3.28 (2.08--4.92) 2.53 (1.50--3.99) 2.49 (1.47--3.93) 1.36 (0.65--2.50) 2.23 (−4.48 to 9.47)
 Men CI 2.81 (1.29--5.34) 4.61 (2.58--7.61) 3.03 (1.46--5.58) 1.50 (0.49--3.50) 2.37 (1.02--4.68) 6.15 (3.80--9.39) 4.61 (2.63--7.48) 4.82 (2.81--7.71) 2.23 (0.96--4.40) 2.79 (−4.42 to 10.61)
 Women CI 0.90 (0.18--2.62) 0.00 (0.00--1.08) 0.29 (0.01--1.61) 0.85 (0.18--2.50) 0.56 (0.07--2.03) 0.56 (0.07--2.01) 0.55 (0.07--1.98) 0.27 (0.01--1.50) 0.53 (0.06--1.92) −1.40 (−18.63 to 19.49)
aGroups included in this analysis: First Nations, Inuit, Metis, and Other Indigenous Nonspecified (Canada); Aboriginal and Torres Strait Islanders (Australia); American Indian, Alaska Native, Native Hawaiian and Other Pacific Islanders (USA); and Māori (New Zealand).
bCanada HIV cases and population denominators exclude Quebec as they do not report data on Indigenous status.
cUSA cases and population denominators exclude California, Delaware, Hawaii, Maryland, Massachusetts, Montana, Oregon, Rhode Island, Vermont, and Washington for 2009 and Hawaii, Maryland, Massachusetts, and Vermont for 2010. CDC reporting is absent for these states as they did not have mature mandatory reporting systems in place at the time of the annual surveillance report.
dStatistically significant at 5% alpha level – confidence interval does not cross zero.

F1
Fig. 1:
HIV case rate per 100 000 (95% confidence interval) among Indigenous peoples, men and women in Canada, Australia, USA, and New Zealand (2009--2017)a,b.

The EAPC of HIV diagnoses between 2009 and 2017 can be found in Table 1. In Canada, HIV diagnosis rates decreased among Indigenous peoples (−7.92 EAPC, 95% CI: −9.34 to −6.49), men (−7.62 EAPC, 95% CI: −9.51 to −5.69), and women (−8.33 EAPC, 95% CI: −10.45 to −6.17). In Australia, rates increased among Indigenous peoples (5.10 EAPC, 95% CI: 0.39--10.08) and men (5.91 EAPC, 95% CI: 0.67--11.50) but did not change significantly among women. In the USA, rates decreased among Indigenous peoples (−4.25 EAPC, 95% CI: −5.75 to −2.73), men (−3.75 EAPC, 95% CI: −5.45 to −2.02) and women (−6.32 EAPC, 95% CI: −9.48 to −3.05). In New Zealand, no significant trends over time were observed.

Discussion

Our study revealed elevated but decreasing rates of HIV diagnoses among Indigenous peoples in Canada compared to the USA, Australia, and New Zealand. Past research shows how reconciliation efforts impact the health of Indigenous peoples [1,8], and Canada's trailing progress may indicate challenges implementing the Truth and Reconciliation Commission (TRC) Calls to Action to redress harms done by Canada's Indian Residential School system [11]. Despite the relatively elevated rates among Indigenous people in Canada, our analysis found a conservative estimate compared with past studies [6,7]. We included individuals who self-report their status rather than limiting the population estimate to those who are considered ‘Indians’ by Registered/Treaty status within the Indian Act (1876) [12], in order to include those who are legally restricted from acquiring government status and align closer to self-reporting standards in other countries. Our analysis also estimated conservative USA diagnosis rates compared with what is reported by the USA CDC [10] as we included those who reported American Indian/Alaska Native or Native Hawaiian/Other Pacific Islander alone or in combination, regardless of Hispanic origin. Similarly, this population estimate was chosen to improve comparability to countries where individuals can report Indigenous ethnicity in addition to other ethnic backgrounds.

Consistent with recent studies, our analysis revealed an increasing rate of HIV diagnoses among the total Indigenous population and Indigenous men in Australia [13]. A 2018 commentary on Australian national surveillance trends attributed this increase to sociocultural determinants of health, poorer outcomes in all aspects of the HIV diagnosis and treatment cascade and both lower and later uptake of preexposure prophylaxis, and elevated heterosexual rates of transmission [13]. In the USA, associations between racial/sexual discrimination and unprotected sex, and between-community participation and protected sex have been demonstrated among American Indian/Alaska Native MSM [14]. Further research is needed to determine driving factors of differential trends in HIV diagnoses worldwide. Associations between racial/sexual discrimination and unprotected sex and between-community participation and protected sex have been demonstrated among American Indian/Alaska Native MSM in the USA, which may also be relevant in the Australian context [15].

Overall, further research is needed to determine what factors are driving differential trends in HIV diagnoses in these four countries. In conducting this analysis, we found a large amount of incomplete data on HIV among Indigenous peoples in Canada. Indeed, a 2013 review article of HIV and STI surveillance among Indigenous peoples worldwide highlighted the urgent need for more reliable and comprehensive data [14]. We recommend that efforts are made to collect and standardize robust data on Indigenous peoples worldwide. Without such data, changes in the epidemic may occur before Indigenous-led positive action can be taken, and ongoing work of Indigenous communities in preventing HIV may be overlooked at the population-level [9].

Limitations

Our results are impacted by country-level variation in census classifications, HIV surveillance methods, and reporting completeness. For example, in 2017, 50.8% of Canadian HIV data on ethnicity was missing, likely underestimating the rate of HIV diagnoses among Indigenous peoples observed in this study [16]. A 2013 review of HIV and STI surveillance among Indigenous peoples globally highlighted the urgent need for more reliable and comprehensive data worldwide [14]. Additionally, we were unable to calculate age-adjusted rates, as publicly available data on age at diagnosis was limited.

Cross-national comparisons risk overgeneralizing the experiences of Indigenous peoples; however, a strength of this analysis is demonstrating the differential impact of HIV in four countries with similar colonial experiences. We recommend that efforts are made to collect and standardize robust data on Indigenous peoples worldwide. Without such data, changes in the epidemic may occur before Indigenous-led positive action can be taken, and ongoing HIV prevention work of Indigenous communities may be overlooked at the population-level.

Acknowledgements

Funding: R.S.H. is supported by a Canadian Institutes of Health Research Foundation Award.

M.E.P., K.K., R.S.H., and V.N. conceptualized the initial study design. K.K. and M.P. conducted the analyses. K.K., C.C.M., and M.E.P. drafted the initial manuscript. C.A., H.P., J.W., and M.M. provided critical revisions for subsequent drafts. R.S.H. and V.N. provided research supervision and mentorship. R.S.H. is funded by a Canadian Institutes for Health Research Foundation Grant.

Conflicts of interest

There are no conflicts of interest.

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Keywords:

global indigenous health; HIV diagnosis; indigenous health; population health; surveillance

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