COMPLEX AND UNIQUE HIV/AIDS EPIDEMIC AMONG ABORIGINAL CANADIANS

Opportunistic infections that were the hallmark of the early days of
the AIDS epidemic in Canada -- PCP, MAC, CMV and meningitis -- are
conditions that nurse Doreen Littlejohn sees regularly at the
Vancouver Native Health Society.

These infections -- Pneumocystis carinii pneumonia, Mycobacterium
avium complex and cytomegalovirus -- are rarely seen now among, for
example, male homosexuals who still make up the majority of Canadians
living with HIV, observes Mark Tyndall, an HIV/AIDS researcher at the
British Columbia Centre of Excellence in HIV/AIDS.

But among the population served by Littlejohn, people are routinely
diagnosed late, when their CD4 counts are low and their viral load
high. "We try to stabilize them as much as possible," with primary
health care and other services, says Littlejohn who runs the
society's Positive Outlook Program, which sees up to 200 people a
day, 7 days a week. "Then we talk to them about starting a treatment regimen."

The unique and complex nature of the HIV/AIDS epidemic among
Aboriginal Canadians is reflected in statistics that show the
population has a far higher proportion of new HIV infections caused
by injection drug use (53%, compared to 14% among non-Aboriginals)
and among women (about 45% compared to 20%).

Meanwhile, researchers are warning that there is potential for
explosive outbreaks of HIV among young, injection drug using
Aboriginals. A study of drug-using Aboriginal youth in Vancouver and
Prince George has found high rates of hepatitis C infection (57% and
62%, respectively), which is also passed through needle sharing.
About half the youth, whose average age is 23, are injection drug
users, and the HIV prevalence among the entire group is now 8%.

Around the world there have been situations among illicit injection
drug users where HIV "suddenly goes from low to high prevalence -- to
30% to 40% -- in a year or 2" as happened in Vancouver's Downtown
Eastside in 1996 and 1997, says Dr. Martin Schechter, an
epidemiologist and co-investigator of the Cedar Project.

All the ingredients for such an outbreak exist in Prince George,
where the risks include more cocaine injection, which involves more
frequent needle use than heroin, and less access to care than in
Vancouver, warns principal investigator Patricia Spittal. About 50%
of the youth in the study group are female, and many are involved in
the sex trade, she said.

"This is more than a big city issue ... and man, this thing is
moving," notes Spittal. Proven harm reduction strategies -- such as
very accessible needle exchanges and mobile health care vans to help
sex workers -- need to be introduced in smaller centres, she argues.

Treating HIV among people with addiction problems and who may be
homeless or living in marginalized conditions is challenging.
Littlejohn's program offers what it calls "maximally assisted
therapy" (MAT), in which HIV medications are kept on site and
dispensed to clients at the centre. "We have to work with their
comfort level; MAT can be viewed as paternalistic. We try to address
all the determinants of health."

Spittal also sees some hope in the growing acceptance of
community-based research, where researchers work with the community,
as has been spearheaded by the Institute for Aboriginal Peoples'
Health. "The innovations are going to come at the community level,
that is how you are going to get better designed programs."