Tools for Access Curriculum: Newcomers by CTAC

Tools for Access Workshop Curriculum

Tools for overcoming treatment access barriers facing newcomers living with HIV and viral hepatitis co-infection in Canada

The following curriculum was developed using surveillance data collated by the Public Health Agency of Canada, peer-reviewed academic literature, grey literature, narrative accounts and information based on consultations with key stakeholders including community-based service providers and newcomers living with HIV and viral hepatitis co-infection. The intention of this Curriculum Outline is to inform the development of CTAC Tools for Access workshops to address barriers to treatment access among newcomers living with HIV or Viral Hepatitis co-infection in Canada. It is intended as a working document to be reviewed, discussed and revised by the Newcomers Working Group. For the purpose of this curriculum, barriers to treatment access should be considered in their holistic form, encompassing the range of treatment, care and support needs of newcomers living with HIV or HIV co-infection that are required to reach the most successful treatment experience possible.

Tools for overcoming treatment access barriers facing newcomers living with HIV and Viral Hepatitis Co-infection

Contents 1. Overview of People Living with HIV and Viral Hepatitis Co-Infection who are Newcomers to Canada............. 4 Epidemiology....................................................................................................................................................................................................4 2. Structural, Social and Personal Barriers to Treatment, Care and Support................................................................... 8 Migration, Immigration and Citizenship Status..................................................................................................................................8 Culture, Race and Gender..........................................................................................................................................................................10 Socio-economic Status............................................................................................................................................................................... 12 3. Impacts of HIV Stigma and Discrimination on Access to Treatment, Care and Support.......................................13 Intersections of Stigma Affecting Treatment Access for Newcomers living with HIV................................................. 13 4. Barriers to Holistic Treatment Access....................................................................................................................................15 5. Take Action: Tools, Solutions and Alternatives....................................................................................................................17 Works Cited........................................................................................................................................................................................19

Overview of People Living with HIV and Viral Hepatitis Co-Infection who are Newcomers to Canada

The first section of this curriculum provides general background information on demographic trends in HIV and co-infection among newcomers in Canada. Information is taken primarily from regional and local surveillance data collated and published by the Public Health Agency of Canada. Factors considered include sex and gender, ethnic and cultural background, age, modes of transmission, HIV prevalence and AIDS prevalence. For the purpose of this curriculum, newcomers include people who have recently immigrated to Canada and are living with HIV or Viral Hepatitis co-infection acquired in their home country or in Canada.

Epidemiology1 • T here are considerable challenges to painting an accurate epidemiological picture of HIV, AIDS and Viral Hepatitis among newcomers to Canada. As of 2002, Citizenship and Immigration Canada (CIC) has required HIV screening of all immigration applicants as a component to the Immigration Medical Examination (IME). This includes all applicants who are 15 years and older, as well as children with a known HIV positive mother or who have received blood or blood products abroad. • W hile HIV screening has resulted in a more accurate estimate of HIV prevalence among people who immigrated to Canada in 2002 or later, it does not depict how many newcomers to Canada acquired HIV after they arrived in Canada or the rates of HIV infection among people who came to Canada prior to 2002.2 • R egional data used to develop estimates in national HIV surveillance is not specific to immigration status in every province or territory. In Ontario and Quebec, positive tests reports are not recorded by ethnicity or country of origin, which compromises national estimates given that the largest portion of people living with HIV in Canada reside in these provinces.

• N otwithstanding limitations in data collection, national surveillance data show that people from countries where HIV is endemic, specifically people from African and Caribbean countries, are disproportionately affected by HIV and AIDS in Canada. • A n HIV-endemic country is defined as a country that has an adult prevalence (ages 15-49) of HIV that is 1.0% or greater and one of the following3:

- 50% or more of HIV cases that are heterosexually transmitted;

– Male-to-female ratio that is 2:1 or less; or

– HIV prevalence greater than or equal to 2% among women obtaining prenatal care

• I n 2009, 574 positive test reports were reported from CIC. Of this total, 341 (59.4%) were born in Africa and the Middle East; 178 (31%) in the Americas; 46 (8%) in Asia; and 9 (1.6%) in Europe.

1 (Public Health Agency of Canada, 2010B) (Public Health Agency of Canada, 2010C) (Public Health Agency of Canada, 2009) 2 (www.cic.gc.ca, 2012) 3 (Public Health Agency of Canada, 2010B)

Tools for overcoming treatment access barriers facing newcomers living with HIV and Viral Hepatitis Co-infection

Proportion (%) of HIV-positive tests received through IME and geographic location of birth of applicant, January 15, 2002 to December 31, 2006 (n=597)

Africa and the Middle East (417 - 70%) Americas (131 - 22%) Other (49 - 8%)

Source: (Public Health Agency of Canada, 2009)

• N ational HIV surveillance includes information on people who are from countries where HIV is endemic. The HIV-endemic exposure subcategory was estimated to account for around 7,050 (5,200 – 8,800) of the estimated 58,000 (48,000 – 68,000) people living with HIV in Canada in 2005. Approximately 16% (400 to 700) of new infections in Canada were attributed to people in the HIV-endemic exposure category. Infections in this population are 12.6% times higher than infections in the general Canadian population.

• I njection drug use is not believed to be a primary source of transmission among people from newcomer communities or Black people in Canada. While there is a low prevalence of the spread of HIV among newcomers through injection drug use, Black men who have sex with men who use drugs are over represented in surveillance reports.

• I t is important to highlight that Black people have the highest proportion of HIV acquired through heterosexual contact (86.8%), of which 76.3% are believed to be people from countries where HIV is endemic. Black women are more likely to acquire HIV through heterosexual contact than black men (56.8% vs. 43.2%).

Number and proportion of reported HIV cases by exposure category and race/ethnicity Toronto (1980-2004, n=945) and Ottawa (1983-2004, n=300) Toronto

Ottawa

HIV-endemic - Black 528 (55.9%)

HIV-endemic - Black 243 (81.0%)

IDU - Black 15 (1.6%)

IDU - Black 5 (1.7%)

MSM-IDU - Black 9 (0.95%)

MSM-IDU - Black 2 (0.67%)

MSM - Black 200 (21.2%)

MSM - Black 23 (7.7%)

Other - Black 193 (20.4%)

Other - Black 27 (9.0%)

Source: (Public Health Agency of Canada, 2009)

• Y oung people from countries where HIV is endemic account for a substantial proportion of HIV and AIDS cases at the national level. Black young people living in Canada are overrepresented in national surveillance reports. • A mong reported AIDS cases, people from countries where HIV is endemic is the highest in Ontario and Quebec. However, people from countries where HIV is endemic make up a greater proportion of the national distribution of AIDS cases in Quebec (55.3%) than in Ontario (36.1%). There is evidence that this is related to the large immigrant population of Haitian origin – a country known to be heavily affected

by HIV and AIDS. It should also be noted that many people from French speaking African and Middle Eastern countries where HIV is endemic migrate to Quebec. This suggests a disproportionate burden of barriers to testing and treatment access among people from countries where HIV is endemic who live in Quebec.

Tools for overcoming treatment access barriers facing newcomers living with HIV and Viral Hepatitis Co-infection

Number of reported AIDS cases by province/territory and national proportional distribution (%) of total AIDS cases for the HIV-endemic exposure subcategory, cumulative to December 31, 2006 (n=1248)

Yk, NT, & NV AIDs cases: 0 National proportion: 0%

BC AIDs cases: 37 National proportion: 3.1%

NB, Ns, pE, NL AIDs cases: 14 National proportion: 1.2%

sk AIDs cases: 10 National proportion: 0.8%

AB AIDs cases: 33 National proportion: 2.6%

MB AIDs cases: 13 National proportion: 1.0%

QC AIDs cases: 690 National proportion: 55.3% oN AIDs cases: 451 National proportion: 36.1%

Source: (Public Health Agency of Canada, 2009)

â&#x20AC;˘ A study utilizing data from cohorts in Ontario and British Columbia that compared HIV risk-taking behaviour of young foreign-born men who have sex with men and Canadian-born men who have sex with men found that those born outside Canada had an elevated risk of HIV infection.4 Qualitative evidence on health behaviours provided by a sample of Black men who have sex with men in Toronto suggests that this population is highly affected by HIV. 5

â&#x20AC;˘ C hronic Hepatitis B infection is much lower in Canada than in Asia, Africa, Eastern Europe and Latin America. Similarly, people from subtropical countries (including South Asia, North Africa and Central America) are disproportionately vulnerable to Hepatitis C infection.6

4 (George C. A., 2007) 5 (George C. H., 2008) 6 (Public Health Agency of Canada, 2008)

Structural, Social and Personal Barriers to Treatment, Care and Support

Section 2 of this curriculum explores the specific structural, social and personal barriers preventing newcomers to Canada who are living with HIV or HIV/Hepatitis C co-infection from accessing treatment, care and support. Social determinants of health, including gender, culture and race are highlighted as influences that can sometimes create challenges to treatment access. Homophobia, racism and sexism are discussed as factors causing various barriers to treatment access for people from foreign countries. The curriculum also outlines the relationships between discriminatory laws and legislation against newcomers and potential newcomers and the relevance of this relationship to holistic treatment access. Migration, Immigration and Citizenship Status • M any people living with HIV attempting to migrate to Canada do so anticipating a better life. Sometimes people wish to come to Canada under the assumption they will have better prospects managing their HIV illness. Migration patterns of people living with HIV have been linked to the effects of war and conflict, including sexual violence, globalization, environmental disasters and human rights abuse (notably homophobia-driven violence and discrimination against gay, lesbian and transgendered people). Migrating to Canada has become common for people, particularly for those living in lower-income countries where resources and political will to address such issues are inadequate. Likewise, migration has also been associated with lack of economic opportunity and global reductions in public spending on health.7 • O ne’s citizenship status in Canada (Canadian citizen, permanent resident, temporary resident, immigrant, refugee, or asylum seeker) has a direct impact on the ability to access publically provided health care and affordable treatment.

7 8 9 10

• C itizenship status directly influences social determinants of health through legislative barriers imposed on newcomers by governmental bodies. Examples of such legislative challenges are laws and regulations preventing newcomers from accessing housing, health insurance, employment opportunities and training, schooling and childcare services.8 For people living with HIV, the impact of these restrictions is magnified. • A ccess to treatment, care and support for newcomers living with HIV can be affected by mandatory HIV screening of all immigration applicants to Canada. It has been argued that the IME, which includes HIV testing, has generated a false perception that there is less risk of HIV infection in Canada, leading to increased risk-taking behaviours among newcomers.9 There is evidence that Caribbean young people are disproportionally represented among HIV positive test reports in this population. • T he IME may be the first time one learns of their HIV infection. There have been accounts of stressful and harmful testing and diagnosis experiences. Immigration medical doctors have been criticized for lacking knowledge, training and sensitivity around best practices and application of human rights in HIV testing and counselling.10

(Interagency Coalition on AIDS and Development, 2004) (www.cic.gc.ca, 2012) (Omorodion, 2007) (Committee for Accessible AIDS Treatment, 2006) (Bisaillon, 2010)

Tools for overcoming treatment access barriers facing newcomers living with HIV and Viral Hepatitis Co-infection

• W hile CIC contends that HIV screening in immigration processes help to link newcomers to health services, many stakeholders view the process as a discriminatory practice. There is belief that HIV screening in immigration processes prevents people living with HIV from coming to Canada, as well as causes barriers to accessing treatment, care and support. This issue has resulted in hardship for many families, especially in circumstances where the process can prevent families from staying together or reuniting.11 • T here is a lack of information on the success of HIV screening in linking newly diagnosed people with care. The number of people who have been deemed ‘inadmissible’ based on a positive test report is not reported. • D iagnosis with HIV accompanies the critical decision of whom to disclose to. Upon arrival to Canada, a newly diagnosed person may experience challenges with respect to disclosing their HIV status to family and friends in Canada and abroad, consequently affecting the ability to integrate and reunify with family in Canada. • P arents who are new to Canada often have difficulty sharing and accessing information from schools. Due to recent incidents involving the Toronto District School Board (TDSB), the “Don’t Ask, Don’t Tell” policy was developed with respect to immigration status information. This was a direct result of the actions of the Canadian Border Services Agency, where children at schools were detained in efforts to apprehend their non-status parents.12 • D epending on citizenship status, many newcomers to Canada are not awarded the health insurance necessary to cover the costs of basic healthcare, let alone the burdensome costs attributed to HIV treatment. Ineligibility for provincial assistance for drug

11 12 13 14 15

coverage is a direct barrier to treatment access for newcomers with HIV, especially given the high costs of HIV therapies in Canada. • T he Ontario Health Insurance Plan (OHIP) is not available to people with temporary status in Canada, making affordable treatment, care and support services for many immigrant, refugee and non-status people living with HIV inaccessible. Exclusion from OHIP also results in exclusion from the Trillium Drug Program (TDP), the provincial program in Ontario that assists in covering high drugs costs, including HIV medications, for many people.13 • As legislation does not permit newcomers from accessing provincial health coverage, many people living with HIV who are new to Canada often seek services from community health centres. In such community-based organizations, such as AIDS service organizations, costs associated with treatment are partially subsidized. Newcomers accessing health services are able to omit confidential information regarding their health, including HIV status. Ability to omit such information was developed as a result of many immigrants fearing being ‘discovered’ as HIV positive by immigration service providers through information sharing. • T he Interim Federal Health (IFH) program is responsible for providing essential health care and treatment services to refugee claimants until the pre-removal risk assessment is completed.14 Unfortunately, IFH eligibility is highly limited and excludes failed refugee claimants who apply for permanent residence based on humanitarian and compassionate grounds. People who hold Temporary Resident Permits are not eligible for IFH. Furthermore, eligibility for IFH can and does expire, leaving the recipient with health and financial costs while they reapply and await approval.15

(Committee for Accessible AIDS Treatment, 2006) (www.cic.gc.ca, 2012) (Committee for Accessible AIDS Treatment, 2006) (Committee for Accessible AIDS Treatment, 2006) (Committee for Accessible AIDS Treatment, 2006) (Committee for Accessible AIDS Treatment, 2006; Committee for Accessible AIDS Treatment, 2001)

Culture, Race and Gender • C ultural norms define gender roles of men and women, girls and boys and the expected social interactions between them. Cultural traditions and beliefs can also dictate the way society treats people who differ from the perceived cultural norms. • C ultural norms drive stigma and discrimination against people living with HIV. Stigma of HIV may have roots in culturally-based perceptions of HIV and associations with promiscuity, mortality and/or of HIV as a “gay disease”. Although these beliefs are prevalent among many cultures, manifestations and outcomes of stigma may be different among communities of differing cultural backgrounds. Culturally-based HIV-related stigma and discrimination may cause people from various cultural backgrounds to deny risk factors, avoid HIV testing, conceal their HIV status and avoid accessing health services.16 • G ender inequities generate imbalances in power dynamics between men and women, impacting women’s ability to access the treatment, care and support. Gender norms and behaviours influence health behaviours, including treatment access and personal health management of HIV illness for both men and women.17 • G ender norms surrounding masculinity, or what societal ideologies define as how a man should behave, may lead men from seeking health services and supports, including seeking HIV testing, treatment, care and support services available, for fear of being portrayed as weak and feminine.18

• W omen’s delegated social role as the primary caregiver in the family, influenced by cultural norms and expectations, can negatively affect treatment access and adherence, as well as overall health management. The woman as the primary caregiver in the family negatively impacts the health of women, as it often results in women prioritizing the health of other family members at the expense of their own health. At the same time, responsibilities associated with motherhood for women living with HIV are magnified as poor health can limit the ability of women to care for their families. Women may avoid HIV testing or accessing services out of fear that their confidentiality will be jeopardized and their families will suffer the social consequences as a result. That is, women may be apprehensive in seeking support for HIV out of fear for themselves and fear that their families may face deportation and/or social exclusion as a result.19 • G ender-based violence, particularly sexual violence against women, is a known health challenge among newcomer communities in Canada. Sexual violence negatively affects treatment adherence and access to care and support services for women living with HIV or co-infected with Viral Hepatitis. Reports of repeated violence (sexual and physical) with a positive test report for women suggest that the incidence of violence against HIV-positive women in Canada is widespread. Physical injury, emotional scars and threats of further violence can limit women’s ability to adhere to treatment, seek health services and support, or escape vulnerable situations, negatively impacting overall health.20

The World Health Organization defines gender as “what a society believes about the appropriate roles, duties, rights, responsibilities, accepted behaviours, opportunities and status of women and men in relation to one another.” Gender relationships are experienced within the social environment we live in and are rooted in cultural norms, beliefs and traditions. (The World Health Organization 2012)

16 (Public Health Agency of Canada, 2009) (Lawson, 2006) 17 (Joint United Nations Program on HIV/AIDS, 2010) 18 (Interagency Coalition on AIDS and Development, 2011) 19 (Greene, 2009) (Public Health Agency of Canada, 2012) 20 (Public Health Agency of Canada, 2012)

Tools for overcoming treatment access barriers facing newcomers living with HIV and Viral Hepatitis Co-infection

UNAIDS describes homophobia as intolerance and contempt for those who have identities and orientations other than heterosexual ones. It is an aversion, hatred, fear, prejudice or discrimination against homosexual men, bisexual people, transgender people, transvestites, lesbians and transsexuals. Homophobia confers a monopoly of normality on heterosexuality, thus generating and encouraging contempt for those who diverge from the reference model. (Joint United Nations Program on HIV/AIDS, 2010)

• N ewcomer women are known to be at high risk of gender-based violence due to cultural norms and customs that grant men power privileges over women within marriage and in the community at large. For instance, Black women, women who are immigrants to Canada and women living with HIV, are all subject to higher risk of violence compared to women in the general public.21 These types of abusive intimate partner relationships can prevent women from accessing health services. • S ome women who are new to Canada may face violence as a result of clashing cultural norms, especially in cases where women gain increased rights and autonomy not customary in their country of origin. This power struggle can cause a backlash and further contribute to violent behaviour and brutality against women. It is important to recognize that higher rates of poverty and racism can increase a woman’s vulnerability to become a victim of violence. For example, Black women, who often experience higher rates of impoverishment and racial discrimination, are also more in danger of suffering from violent relationships.22 • M any women in newcomer communities experience barriers in terms of health service access that stem from cultural practice. This is mainly due to the fact that some women feel that they should not reveal certain information about themselves to providers within the mainstream healthcare system. Cultural practices, such as female genital cutting and vaginal drying for increased friction during sexual intercourse, can be difficult to discuss with providers who

may stigmatize or discriminate against these practices. As a result, these women may feel forced to seek health support from providers who do not have adequate medical knowledge, or may avoid attending to health issues altogether.23 • H omophobic discrimination is prominent in many newcomer communities in Canada. Colonization, rooted in European Christian doctrines, imposed social values, laws and legislations that induced intolerance of gay and lesbian relationships. Consequently, many cultural communities originating from countries that were formally colonized have held on to discriminatory legislation and prejudicial attitudes toward gay people. Homophobic discrimination, as a result, has caused many men and women to conceal their sexual orientation and activities from healthcare providers, family and loved ones. The pressure to withhold sexuality can negatively impact access to health and social supports essential in managing health, including HIV illness. • H omophobia affects men and women differently and sometimes results in violent consequences for both. The impacts of homophobia, including social rejection, isolation, abandonment and vulnerability to violence, have been the driving forces behind the decision to attempt to immigrate to Canada in some foreign countries.24

21 (Lawson, 2006) 22 (Hyman, 2006) 23 (Public Health Agency of Canada, 2009) (CTAC, 2012) 24 (George C. H., 2008) (Interagency Coalition on AIDS and Development, 2011) (Public Health Agency of Canada, 2009)

• R acism is a significant determinant of health affecting newcomers to Canada, particularly newcomers of black ethnic origin.25 According to findings from Statistics Canada, Black people are more likely to report discriminatory practices by others due to their ethnicity, culture, race, skin colour, language, accent or religion.”26 Racism has been linked to other known determinants of health, including disparities in access to housing, education and employment. Similarly, racism has resulted in social exclusion, such as civic participation of racial minorities. acism intersects with other forms of prejudice, • R including gender and socio-economic status that result in multiple barriers to health services accessibility. For people who are living with HIV and Viral Hepatitis co-infection and who are racial minorities in Canada, the layers of stigma and discrimination can result in isolation, exclusion and overall lowered health status.

Socio-economic Status • H IV illness along with related structural, social and personal health barriers to employment opportunities can negatively impact income potential and thereby the newcomer’s ability to send money to family outside of Canada. For many newcomers, sending financial support home is a critical social responsibility. Inability to fulfill this obligation can have damaging cultural, social and personal ramifications for newcomers living with HIV, including loss of social support. 27 • E ducational achievement and access to education is a key determinant of health that has implications for treatment success among people living with HIV. Newcomers to Canada often have educational qualifications that are not recognized in Canada. Many newcomers are prevented from finding employment

that makes use of their existing knowledge and skills and are often forced to accept employment in sectors not as well paid as employment that utilizes their existing qualifications. Low-income creates barriers to affordable holistic treatment access, including the need to support highly active antiretroviral therapy (HAART) with nutritious food and safe housing.28 • A ccess to housing is a critical determinant of health that has been independently associated with treatment access among people living with HIV.29 Affordable housing is a challenge many newcomers in Canada face due to often limited financial resources. Furthermore, many newcomers will not have the resources and status required to obtain housing, such as referral from a previous landlord, credit cheques, proof of employment, or first and last month’s rent. • A lthough applications to initiatives, such as the RentGeared-to-Income (RGI) housing, are available to immigrant applicants and refugee claimants, these programs have been difficult to access for many. Current legislation, for example, stipulates that newcomers who possess Temporary Resident Permits are not eligible to apply for RGI housing. Similarly, the current waiting period for RGI housing in Ontario is approximately 10 years, an unfeasible and unusable option for many. • A lthough reporting domestic violence can grant priority RGI housing placement, reporting abuse may have a negative effect on immigration sponsorship and application for permanent residence. Accordingly, many people living with HIV may feel pressured to continue to remain in abusive relationships in order to be eligible for immigration.30

25 (Tharao, 2001) 26 (Statistics Canada, 2003) 27 Committee for Accessible AIDS Treatment, 2006) (Interagency Coalition on AIDS and Development, 2004) (Public Health Agency of Canada, 2009) 28 (Public Health Agency of Canada, 2009) 29 (Ontario HIV/AIDS Treatment Network, 2012) 30 (Committee for Accessible AIDS Treatment, 2006)

Tools for overcoming treatment access barriers facing newcomers living with HIV and Viral Hepatitis Co-infection

Impacts of HIV Stigma and Discrimination on Access to Treatment, Care, and Support

HIV-related stigma and discrimination is at the root of many barriers to accessing holistic treatment, care and support for people living with HIV and Viral Hepatitis co-infection. People living with HIV face severe stigma and discrimination as a result of societal beliefs, attitudes and behaviors regarding HIV and AIDS. Newcomers to Canada face specific forms of stigma and discrimination that may be rooted in their culture or community, or may result from existing prejudices in Canadian society. This section provides an overview of stigma and discrimination as it impacts holistic treatment access for newcomers.

Intersections of Stigma Affecting Treatment Access for Newcomers Living with HIV homelessness and unstable housing

immigration status

employment status

mental health

sexual preference

HIV and HIV/Hepatitis C Co-infection

culture, gender and race

“HIV-related stigma refers to the negative beliefs, feelings and attitudes towards people living with HIV and/or associated with HIV. Thus, HIV-related stigma may affect those suspected of being infected with HIV; those who are related to someone living with HIV; or those most at risk of HIV infection, such as people who inject drugs, sex workers, men who have sex with men and transgender people.” “HIV-related discrimination refers to the unfair and unjust treatment (act or omission) of an individual based on his or her real or perceived HIV status. Though HIV-related stigma often leads to discrimination, it is important to note that even if a person feels stigma towards another, s/he can decide not to act in a way that is unfair or discriminatory. Conversely, a person may discriminate against another without personally holding stigmatising beliefs, for example, where discrimination is mandated by law.” (UNAIDS, 2010)

Stigma and discrimination against HIV affects access to treatment, care and support for newcomers living with HIV or HIV/Hepatitis co-infection in the following ways: • I mpels people to withhold HIV and Viral Hepatitis co-infection status, along with other important general health information from providers due to fear of violence, discrimination and stigmatization and/or fear of its bearing on the immigration process. • A ssumptions of HIV as a “gay disease” prevents newcomers from disclosing their status to providers and potential family, peer or community-level supports. General public unawareness, ignorant and biased prejudicial attitudes inhibits people from seeking critical social support networks. The lack or absence of social support is not only necessary for effective HIV and Viral Hepatitis co-infection management, but may also play a negative role in one’s mental health status. • C ulturally influenced stigma can lead to community rejection and result in isolation from settlement services provided at a community level. Community rejection can also lead to isolation from traditional sources of support, including involvement with religious groups, community forums and cultural/ Diaspora events. Social isolation not only increases withdrawal from the community, but also fortifies existing social inequities and inequalities.

ontributes to gender-based violence against wom• C en. Physical injury, emotional scarring and/or threats of further violence can limit the ability to adhere to treatment, seek health services and supports, or escape vulnerable and violent circumstances and relationships. Women who are victimized through violence often fear reporting abuse. This is compounded by the need to stay silent regarding the violence occurring in order to preserve their status in the immigration process. Failure to seek and adhere to treatment, however, can have detrimental consequences on overall health. • I solates and excludes newcomers living with HIV from participating in the development of research, policy and programs designed for people living with HIV. This is primarily due to the fact that newcomers are reluctant to disclose their HIV or Viral Hepatitis co-infection status due to fears of compromising their migration status, as well as fear of being identified by other members of their cultural communities. Failure to include newcomers living with HIV from participating in research and policy development could potentially lead to research that is not reflective of the needs of that particular population, as well as hinder efforts to produce research and develop programs that support best-practices.

Tools for overcoming treatment access barriers facing newcomers living with HIV and Viral Hepatitis Co-infection

Barriers to Holistic Treatment Access

The following section of the curriculum provides a summary overview of the barriers, including social, structural and personal barriers, preventing newcomers living with HIV or Viral Hepatitis co-infection from accessing holistic treatment, care and support services required to achieve the best treatment experience possible. • H IV diagnosis through the Immigration Medical Examination (IME) may not provide adequate counselling or comprehensive treatment information, including treatment options and decisions of when to initiate treatment, as well as retaining a continuum quality of care.

he burdens and responsibilities associated with • T the overall immigration process lead newcomers living with HIV and Viral Hepatitis to prioritize immigration and settlement duties at the expense of health management. • N on-citizen status can prevent access to financial coverage for treatment and a range of care and support services required to achieve successful treatment outcomes, as well as to maintain an overall satisfactory psychological, emotional and physiological health state. • T he socio-economic status of newcomers can be negatively affected by legislative barriers. Regulations preventing service access to non-citizens, including lack of health coverage and inability to find housing, could create further and greater financial constraints for newcomers. Financial hardship, inaccessible housing, employment opportunities and childcare can all impact the willingness and ability of people to actively prioritize and manage their health. • T he burden of single parenthood and associated low-income and poverty limits resources needed to ensure successful treatment outcomes for many people new to Canada, specifically women. Women, who are often the primary caregivers in their families, typically prioritize the needs and health of other members in the family over their own.

• O ften, newcomers are required to settle for poor working conditions, including being employed in more than one job, high demanding and physically straining jobs, working unstable and unpredictable long hours and employed in work where there is no private insurance coverage. Locations and operating hours of services do not often accommodate the needs of new Canadian immigrants. Consequently, newcomers must prioritize standard working hours for navigating immigration services at the expense giving primacy to their health. At the same time, language barriers make it increasingly difficult for newcomers to understand the full range of treatment options available. • T reatment side effects, including side effects on mental health and physical appearance, have deterred some newcomer women from accessing treatment for not only fear of being identified as HIV-positive, but also due to the desire to maintain physic and appearance. Narrative accounts of African women, for example, suggest the loss of fatty tissue in the buttocks deters treatment uptake. ue to fear of disclosing HIV and Viral Hepatitis • D co-infection status, many newcomers have difficulty accessing social support networks. In many cultures, voluntarily and openly disclosing HIV status may result in complete social isolation and expulsion from the community. As newcomers, people often identify with those from the same cultural communities; however, in order to maintain these relationships and due to fear of abandonment, many are compelled to hide their HIV status and fear to seek treatment and support services.

• L ack of cultural competence in care, particularly the ability to help women compliment traditional medicines with HAART, has proven to be a barrier to holistic treatment access for women. That is, many traditional healing practices are often viewed as ineffective and counterproductive to Western medical treatment approaches. Such ideologies and beliefs hinder newcomers in being able to choose alternative treatment options, thus inhibiting holistic models of care. • C ultural practices that might be considered harmful, such as female genital cutting and vaginal drying for sexual intercourse purposes, are often withheld from providers and lead to suboptimal care. • L ack of confidentiality in health services or perceived lack of confidentiality acts as a barrier to treatment, as well as regular care and support services. This is particularly the case for gay men and men who have sex with men who come from cultural backgrounds with strong intolerance for same sex relationships. The fear of others in the community finding out the individual’s HIV status often deters them from seeking necessary care.

• R acial stereotyping and discriminatory practices by health services toward newcomers, specifically newcomers who are visible minorities, contributes to avoidance of health services. Racism still exists within the healthcare system and such racial discrimination could lead to differential treatment with regards to accessing health services for newcomers and those belonging to cultural and ethnic minority groups. Newcomers may feel that they are not being fairly and equitably treated and therefore, may be reluctant to pursue or continue treatment. ewcomers may avoid services that they feel they • N do not identity with, including existing ASOs that are tailored toward specific populations, such as gay men, people who use drugs, Aboriginal people, or commercial sex workers. New Canadian immigrants may avoid services that they feel are not reflective of their needs.

Tools for overcoming treatment access barriers facing newcomers living with HIV and Viral Hepatitis Co-infection

Take Action: Tools, Solutions and Alternatives

Below is a list of actions you can take as a person living with HIV or Viral Hepatitis co-infection and as a service provider, as a researcher or policymaker, or as an allied member of the community. Actions • E liminate biases, ignorance and discriminatory practices within the healthcare setting, including racial stigma, gender bias and cultural discrimination. Ensure that healthcare providers and other staff members are sensitized to HIV and newcomers who are living with HIV and Viral Hepatitis co-infection. Educating and training providers and other allied health members on compassionate and culturally sensitive care is fundamental. In addition, members who engage in discriminatory and racially-offensive behaviour should be held accountable.

• A dvocate and support greater access to programs and services that address the needs and realities of newcomers. This includes having services with convenient hours of operation, available translation services and transportation assistance. Services should assist newcomers with settling into Canada by providing guidance and support to the steps they would need to take in order to access basic necessities, such as accessible housing, employment, affordable childcare services and access to health services. • G reater supportive services addressing access to housing is required. Organizations, stakeholders, service providers and the general public should mobilize themselves and advocate that the development of an effective housing strategy is given priority on political agendas.

• P romote holistic approaches to health. Health care providers should be educated on cultural and traditional healing and treatment options other than mainstream medicine. This initiative could be supported through incentivized continuing medical education conferences and events. • P rovide legal and social supports to newcomer women who are living with HIV and are victims of violence and abuse. Set policies that promote transparency by ensuring women who provide disclosure of abuse are not going to compromise their status in the immigration process. • O rganizations should develop inclusionary frameworks that support the need for rights-based and non-judgemental approaches towards newcomers living with HIV. These frameworks should be developed with a social determinants health approach in mind. Social and legal support should be readily available for newcomers who are victims of discrimination and/or who are denied treatment. • E mployment services that assist newcomers with training, skills development and employment assistance should be effortlessly available to newcomers, especially since individuals who fall into lower income brackets and socio-economic statuses tend to experience poorer access to treatment.

• E ncourage newcomers to take part and get involved in designing services for new immigrants in Canada. This will help develop programs and services that are reflective of the needs of that particular community and promote best practice and evidence-based information.

• L eading Together: Canada Takes Action on HIV/AIDS outlines a national strategy to HIV/AIDS in Canada. One of its key mandates highlights the importance of community involvement, as well as appropriate ethnocultural group services. In addition to the development of culturally sensitive programs and services, tracking the responses of governments on all levels is important. This involves the development of surveillance and evaluation tools that assess the progress of such programs and services. • P rograms that support negotiating disclosure of HIV should be available to newcomers. Such programs should be designed to assist people in navigating through the disclosure process, such as providing guidance and strategies to individuals preparing to disclose their status. At the same time, follow-up services should be made available post-disclosure to offer any additional support or counselling if necessary.

• I n addition to cultural differences, gender marginalization may make newcomer women even more susceptible to discriminatory and stigmatizing practices. Services and programs need to be developed with gender-equitable policies and formulated with tools and strategies of how gender-based barriers will be overcome. Existing organizations, in addition, must re-evaluate the ability or their organizations to facilitate the needs of women, including childcare services, rape and sexual violence counselling services and workshops that assist with positive body and self imaging. • R emove legislative barriers that inhibit newcomers from accessing health insurance necessary to cover the costs of basic healthcare. Those with temporary status in Canada should have access to treatment, care and support to services required. At the same time, programs, such as the Interim Federal Health (IFH) program should be inclusive of refugee claimants who apply for permanent residence based on humanitarian and compassionate grounds.

Tools for overcoming treatment access barriers facing newcomers living with HIV and Viral Hepatitis Co-infection

Bibliography AIDS Committee of Toronto. (2008). HIV+25 Survey Asks: Where are we in Canada twenty-five years after discovery of the virus? Toronto, Canada: AIDS Committee of Toronto. Retrieved from http://www.actoronto. org/home.nsf/pages/act.docs.0740/$file/HIV+25%20 Survey.pdf Bisaillon, L. (2010). Human rights consequences of mandatory HIV screening policy of newcomers to Canada. Health and Human Rights, 12(2). Canadian Coalition for Drug Policy. (2012). Retrieved September 20, 2012, from drugpolicy.ca Canadian Working Group on HIV and Rehabilitation. (2011). E-Module for Evidence Informed HIV-rehabilitation module . Retrieved from http://www.hivandrehab. ca/EN/information/care_providers/documents/CWGHR_E-moduleEvidence-InformedHIVRehabilitationfinal.pdf CATIE. (2009). Managing Your Health: a guide for people living with HIV. Toronto, Canada: CATIE. Retrieved from http://www.catie.ca/en/practical-guides/managing-your-health-guide-people-living-hiv Committee for Accessible AIDS Treatment. (2001). Committee for Accessible AIDS TreatmentAction Research Report: Improving Access to Legal Services & Health-Care For People Living With HIV/ AIDS Who are Immigrants, Refugees or Without Status. . Toronto, Canada. Committee for Accessible AIDS Treatment. (2006). Status, Access & Health Disparities: A Literature Review of Relevant Policies and Programs To Improve Access to Services. Toronto, Canada: CAAT. Deering, K. S. (2011). The street cost of drugs and drug use patterns: relationships with sex work income in an urban Canadian setting. 118(2-3), 430–436. George, C. A. (2007). HIV and ethnicity in Canada: is the HIV risk-taking behaviour of young foreign-born MSM similar to Canadian born MSM? AIDS Care, 1, 9-16.

George, C. H. (2008). MABWANA: WHO ARE THE BLACK MEN WHO HAVE SEX WITH MEN IN TORONTO? CAHR , Abstract:(P232). Greene, S. T. (2009). Under My Umbrella”: The housing experiences of HIV positive parents who live with and care. Arch Womens Mental Health, 13(3), 223-232. Hyman, I. F. (2006). The Association Between Length of Stay in Canada and Intimate Partner Violence Among Immigrant Women. Research and Practice, 96(4), 654659. Interagency Coalition on AIDS and Development. (2004). Fact Sheet: International Migration and HIV/ AIDS. Ottawa, Canada: Interagency Coalition on AIDS and Development. Interagency Coalition on AIDS and Development. (2011). ONE BLOOD: Youth & HIV in the Caribbean. Retrieved September 24, 2012, from http://www.accho.ca/pdf/ One_Bloord_Fact_Sheet_Eng_Final.pdf Joint United Nations Program on HIV/AIDS. (2010). UNAIDS OUTLOOK Report. Retrieved from http://data.unaids.org/pub/Report/2009/jc1796_outlook_en.pdf Lawson, E. G. (2006). HIV/AIDS Stigma, Denial, Fear and Discrimination: Experiences and Responses of People from African and Caribbean Communities in Toronto. Toronto, Canada: The African and Caribbean Council on HIV/AIDS in Ontario. Retrieved from http://www.accho. ca/pdf/hiv_stigma_report.pdf McKeown I, R. S. (2006). Sexual violence and dislocation in women’s acquisition of HIV in Manitoba. Research Bulletin: Time to Deliver on Gender and HIV/ AIDS. 5. Omorodion, F. G. (2007). HIV vulnerability and sexual risk among African youth in Windsor, Canada. Culture, Health & Sexuality, 9(4), 429-37. Ontario HIV/AIDS Treatment Network. (2012). Housing status and the health of people living with HIV/AIDS: A systematic review. Toronto, Canada.

Palepu, A. T. (2004). Initiating highly active antiretroviral therapy and continuity of HIV care: the impact of incarceration. Antiretroviral Therapy , 9, 9:713–719. Prisoners HIV/AIDS Support Action Network . (n.d.). Retrieved from www.pasan.org Public Health Agency of Canada . (2012). Population-Specific HIV/AIDS Status Report: Women. Ottawa, Canada. Public Health Agency of Canada. (2008). Canadian Guidelines on Sexually Transmitted Infections. Ottawa, Canada: Public Health Agency of Canada. Public Health Agency of Canada. (2009). Population-Specific HIV/AIDS Status Report: People from Countries where HIV is Endemic - Black people of African and Caribbean descent living in Canada. Ottawa, Canada: Public Health Agency of Canada. Public Health Agency of Canada. (2009A). Population Specific HIV/AIDS Status Reports: Aboriginal People. Ottawa, Canada. Public Health Agency of Canada. (2010A). At a Glance - HIV and AIDS in Canada: Surveillance Report to December 31st, 2010. Retrieved from http://www.phac-aspc.gc.ca/aids-sida/publication/survreport/2009/dec/1eng.php#table1 Public Health Agency of Canada. (2010B). HIV and AIDS in Canada. Surveillance Report to December 31, 2009. Ottawa, Canada: Public Health Agency of Canada. Public Health Agency of Canada. (2010C). HIV/AIDS Epi Updates - July 2010. Ottawa, Canada. Public Health Agency of Canada. (2010D). Population Specific HIV/AIDS Status Report: People from countries where HIV is endemic. Ottawa, Canada.

S Parashar, A. P. (2011). P5-S4.06 Sticking to it: the effect of maximally assisted therapy on antiretroviral treatment adherence among a cohort of unstably housed people living with HIV in BC, Canada. Sexually Transmitted Infections, 87(1), A324. Small, W. K. (2006). Impacts of intensified police activity on injection drug users: Evidence from an ethnographic investigation. Journal of Drug Policy , 17(2), 85–95. Statistics Canada. (2003). Ethnic Diversity Survey: Portrait of a multicultural society. . Ottawa: Minister of Industry. Statistics Canada. (2010). Measuring violence against women: Statistical trends 2006. Ottawa, Canada. doi: Catalogue no. 85-570- XIE Steffanie A. Strathdee, A. P. (1998). Barriers to Use of Free Antiretroviral Therapy in Injection Drug Users. JAMA, 280(6), 547-549. Retrieved from http://jama.jamanetwork.com/article.aspx?articleid=187834 Tharao, E. M. (2001). Black Women and HIVAIDS: Contextualizing their Realities. Canadian Womens Studies, 2(21), 72-80. UNAIDS. (2010). Non-discrimination in HIV responses. Joint United Nations Project on HIV/AIDS. Urban Health Research Institute. (Accessed September, 2012). Vancouver Injection Drug Users Study. Vancouver, Canada. Retrieved from http://uhri.cfenet.ubc.ca/ content/view/35/57/ www.caan.ca. (n.d.). www.CATIE.ca. (n.d.). www.cic.gc.ca. (2012).

Public Health Agency of Canada. (2012). Population-Specific HIV/AIDS Status Report: Women. Ottawa, Canada.

Tools for overcoming treatment access barriers facing newcomers living with HIV and Viral Hepatitis Co-infection

CTAC is Canadaâ&#x20AC;&#x2122;s national civil society organization addressing access to treatment, care and support for people living with HIV. CTAC meaningfully engages community members, service providers, policymakers and researchers to identify, develop and implement policy and program solutions. ÂŠ 2013, CTAC All rights reserved. This document is available at www.ctac.ca Permission to reproduce This document is copyrighted. It may be reprinted and distributed in its entirety for non-commercial purposes without prior permission, but permission must be obtained to edit or otherwise alter its content. The following credit must appear on any reprint: This information was provided by CTAC. For more information, contact CTAC at 1-877-237-2822 or www.ctac.ca