ABSTRACT
Background: Saskatchewan, a Canadian Prairie province, faces a complicated HIV epidemic characterized by high rates of transmission due to injection drug use (IDU) and disproportionate representation of younger persons, women, and persons of Indigenous ethnicity. HIV incidence in Saskatchewan in 2021 was 19.7 per 100,000, 4.5 times higher than the Canadian average. Concurrently, during the COVID-19 pandemic, the recreational use of synthetic opioids such as fentanyl increased, leading to high numbers of overdose events & deaths. We characterized the difference in cascade of care outcomes & mortality amongst people with HIV (PWH) living in southern Saskatchewan during the COVID-19 pandemic. Method(s): We conducted a retrospective cohort study for all PWH cared for in the Infectious Diseases Clinic (IDC) at Regina General Hospital between December 31/19 and June 10/22. Age, sex, ethnicity & primary mode of HIV acquisition were collected from the IDC database, along with cascade of care & mortality data. Deaths, including most likely cause of death were characterized via individualized case review. Result(s): On December 31/19, IDC cared for 518 PWH. This increased to 585 by June 10/22. Amongst the current cohort, 245 (42%) were female, 163 (28%) were <= 35 years old, 306 (52%) were Indigenous, and 318 (54%) had acquired HIV through IDU. Cascade of care indicators worsened during the COVID-19 pandemic. 58.1% of the cohort were retained in care & 76.1% virally suppressed (HIV RNA <= 200 copies/mL) in December 2019, decreasing to 51.3% retained (p=0.02) & 68.8% suppressed (p=0.06) by June 2022. There were 80 deaths during the study period, representing 15.4% of the cohort from the end of 2019. Most deaths (49, 61.3%) were due to suspected or confirmed drug overdose. 10 (12.5%) additional deaths occurred due to complications from IDU (i.e., sepsis). No deaths were directly attributable to COVID-19. Most who died acquired HIV from IDU (69/80, 86%). Conclusion(s): We describe intersecting epidemics of HIV and IDU disproportionately affecting high-risk populations, leading to significant morbidity & mortality during the COVID-19 pandemic. Contributing factors may have included disruption of safe opioid supply and disrupted access to harm reduction services due to COVID-19. Comprehensive population-level harm reduction and addictions management strategies are urgently needed to reduce morbidity & mortality from drug use amongst PWH in Saskatchewan.
ABSTRACT
In this article, we suggest rethinking how to move forward in a way that better elucidates socio-economic and political factors driving inequities, and in turn points to more broad sweeping, deep-rooted changes necessary if pandemics in the future are finally going to be mitigated pre-emptively rather than reactively. To this end, we argue that a more comprehensive, flexible and incisive approach is necessary - a hermeneutic framework that focuses analytical attention and action on interventions upstream, on the multifaceted interrelations necessary before lives currently deemed disposable are lost. Unlike dominant public health and epidemiological approaches, that is, Social Determinants of Health and Syndemics, proven unlikely to fuel structural change or to enable pre-emptive response, we propose the framework of pathogenicity and apply it to urban contexts to answer questions concerning the relationship between microbes on the one hand, and on the other, the urban, social, political, ideological, global, scientific, economic and many other relations that galvanise these into pathogens. By employing pathogenicity in the context of two case studies in the US and Turkey, we shift emphasis away from tackling microbes to better understanding what makes those microbes, and even the interventions implemented to stop them, so destructive.