1 in 5 Canadians infected with HIV doesn't know it

One in five Canadians infected with HIV doesn't know it, so federal scientists are looking for ways to make testing more accessible.

"The behaviours associated with HIV transmission are highly stigmatized, and that can result in individuals in certain populations not wanting to come forward and be tested," says Paul Sandstrom, director of the National HIV and Retrovirology Laboratory in Winnipeg.

"We can't just be sitting back and waiting for a sample to arrive in the laboratory … We've had to come up with new strategies where we can engage the community and individuals within the community — essentially take the laboratory outside of the laboratory."

On World AIDS Day, Dec. 1, the Public Health Agency of Canada (PHAC) says there's a new HIV infection in Canada every three hours.

According to the World Health Organization (WHO), nearly two million people were newly infected with HIV in 2016. In the same year, about one million people died of AIDS-related illness.

There were approximately 36.7 million people living with HIV at the end of last year.

CBC News recently got an exclusive tour of PHAC's state-of-the-art Level 2 laboratory in Winnipeg.

The researchers involved discussed how they are contributing to the United Nation's goal to end the AIDS epidemic globally by 2030. That includes the following targets for 2020:

• 90 per cent of all people living with HIV will know their HIV status.
• 90 per cent of all people with diagnosed HIV infection will receive sustained antiretroviral therapy.
• 90 per cent of all people receiving antiretroviral therapy will have viral suppression.

The UN says too many people are being left behind, including young women and girls, sex workers, prisoners, gay men, transgender people and those who inject drugs.

And it's not just the case in sub-Saharan Africa.

"It remains a problem domestically here in Canada. The epidemic is not over. There are still people at risk. There are still populations that are more vulnerable in Canada. There are still people who are undiagnosed," Sandstrom says. 

"It's trying to engage the community in a culturally sensitive way. Trying to normalize the testing to some extent so all individuals are not only provided with the opportunity to be tested, there's uptake to the testing because it's not necessarily associated with a particular behaviour."

One of PHAC's projects involves training people in remote communities to collect blood in culturally appropriate ways, using a non-invasive technique known as dry blood spot collection.

It involves pricking the end of a finger and smearing a drop of blood on each of five circles on a card.

Once the blood is dry, it's considered non-infectious and can be mailed to the lab.

"You do not have to be a nurse to use this technique, and you do not have to be trained in taking blood through a needle," says John Kim, head of the National HIV Reference Services Lab.

Teaching community workers

Kim's team is teaching community health care workers from First Nations communities how to collect the blood and to train others to do the same.

"Even if there is a second person involved in collecting the blood, no one knows the test results. … It gives time for the individual to get ready whether it's negative or positive. … Especially in a remote area where everyone knows everyone else, stigma can be a huge factor in not wanting to get tested," Kim says.

"In order for this intervention to work, all we need to do is identify one individual that is positive for HIV or hepatitis C that would not have accessed the health care system. That's success."

In some cases, though, public health workers and patients want faster results so they can start treatment quickly, especially if the patient is transitory or homeless.

So PHAC researchers are also piloting new diagnostic technology just a bit bigger than a toaster that can be sent to clinics and needle-exchange or safe-injection sites in big cities and remote communities.

It's simple to operate, works off a car battery or solar power and is sturdy enough to use in places that couldn't support the sophisticated machinery used in most labs.

"Our goal is to really take the machines and diagnostics out of the lab and move it into the populations that are affected by HIV the most," says Blake Ball, head of the national lab for HIV immunology.

Results in an hour

For example, more than one million babies are born to HIV-positive mothers in Africa, many of whom travel for days to give birth.

"With these devices, we can test the blood of the baby for the presence of the HIV virus, know within an hour if the baby is infected or not. … If the baby is treated appropriately right away, that baby is more than likely going to have a long and healthy life," Ball says.

Ball is evaluating the new technology and coming up with a plan to deploy it.

"We have a couple of pilot projects about to start in the next couple of months, engaging with communities to find out how they will work in the Canadian setting," he says.

Those two projects work toward the first of the UN's three goals. Research in Winnipeg targets the other goals.

Paul McLaren, a research scientist who uses cutting-edge sequencing technology to map the genome of the virus and the patient, works with sociologists to come up with effective public health strategies.

"If [an infected person is] taking their medication inconsistently or not all the time, then the virus can change and modify its genome to escape a particular therapy. And when that happens, it has a tendency to make a person very, very sick. So what we do is some surveillance … with the goal of switching people on to different therapies," McLaren says.

Using biological and behavioural data, scientists can find out the likely mode of transmission, which will inform not only the patient's treatment plan, but also the public health strategy.

Maybe we should be increasing our needle exchange programs in one region, or increasing our education about safe sex and condom use in another region.— Researcher Paul McLaren

"Statistics tell us in places like British Columbia, the epidemic is primarily in men who have sex with men. In Saskatchewan, it's primarily in injection drug users, and in Manitoba, in fact, it's heterosexual transmissions," he says.

"Once we have that information … we can target our intervention. Maybe we should be increasing our needle exchange programs in one region, or increasing our education about safe sex and condom use in another region."

While the Winnipeg lab doesn't develop new HIV drugs, it does study biological factors that alter effectiveness of existing ones.

For example, research scientist Adam Burgener studies reproductive health factors in young women that are important for HIV infection risk.

He recently studied 688 women in South Africa in a clinical trial that tested a vaginal gel containing the drug tenofovir as a form of protection against HIV.

The clinical trial showed the drug had a 39 per cent success rate in preventing HIV in high-risk women if applied before and after sex.

Different women, different strategies

Burgener found the drug was even more protective, 61 per cent, in women who had the vaginal bacterium Lactobacillus. However, a different bacteria, Gardnerella — found in almost half of the women in the study — broke down the active form of the drug, making it ineffective to protect against HIV.

This showed for the first time that bacteria can affect HIV prevention drugs, and that certain strategies may not work for all women.

"We're really interested in women's health and how this pertains to HIV infectious disease," Burgener says.

"Globally, there are 1,000 new infections every day in women, and we really want to understand the biology of how this is occurring so we can design better prevention options against HIV."

'We welcome any initiative'

The approach is being applauded by some Indigenous leaders, who say there are ongoing problems of poor access, stigma, discrimination, and gaps in service and funding.

"Specifically on HIV/AIDS, we welcome any initiative that works with us on the ground in the communities to address the taboos and stigmas, and bring to our people what they need," says Sheila North Wilson, Grand Chief of Manitoba Keewatinowi Okimakanak (MKO), which represents 30 First Nations in Northern Manitoba.

"Our people need help and they deserve proper care. 'Boots on the ground,' one of our leaders said. It's one thing to know the problem, it's another to act. We need action." 

MKO and the University of Manitoba have applied for funding for HIV/AIDS research through the Canadian Institutes of Health Research.

The proposal says First Nations in northern Manitoba are not involved in the planning and implementation of UNAIDS 90-90-90 targets. It goes on to say that rapid point-of-care tests for diagnosis and treatment can make a positive difference in disease outcome and transmission, but interventions have to be culturally appropriate.

"We hypothesize that intervention programs for HIV diagnosis and treatment that are responsive and respect First Nations culture and local environment will increase testing and linkage to care," the proposal adds.

Global AIDS statistics

• There were approximately 36.7 million people living with HIV/AIDS at the end of 2016. Of these, 2.1 million were under age 15.
• An estimated 1.8 million individuals became newly infected with HIV in 2016 — about 5,000 new infections per day. This includes 160,000 children under 15. Most of these children live in sub-Saharan Africa and were infected by their HIV-positive mothers during pregnancy, childbirth or breastfeeding.
• Only 60 per cent of people with HIV know their status. The others, over 14 million people, need to access testing. 
• As of July, 20.9 million people living with HIV were accessing antiretroviral therapy, up from 15.8 million in June 2015, 7.5 million in 2010, and less than one million in 2000.
• One million people died from AIDS-related illnesses in 2016, bringing the number of deaths since the start of the epidemic to 35 million.

Source: UNAIDS