Introduction
Materials and Methods
Ontario’s Province-Wide Community-Based HIV Programs
Non-biomedical intervention | Target populations | Examples of Ontario’s community-based programs | Evidence of effectiveness in current literature |
---|---|---|---|
Individual-, group-, and community-level education, outreach, and community campaigns that promote risk-behaviour reduction | People living with HIV Gay, bisexual and other men who have sex with men Indigenous people African, Caribbean and Black Ontarians Women at-risk (who engage in activities with a high risk of exposure to HIV, or with priority populations) | Prevention/education activities targeted to high-risk populations (e.g., group workshops/presentations in varying locations and one-on-one education through outreach activities) Community campaigns such as the HIV Stigma campaign, Our Agenda, Keep It Alive for African, Caribbean and Black communities etc. | |
Promote HIV medication adherence | People living with HIV | Clinical counseling Case management Support sessions for HIV symptoms management, treatment/medication Adherence | Increase HIV medication adherence behaviour and reduce HIV viral loads among people living with HIV [11] |
Social support and social inclusion | People living with HIV People affected by HIV (e.g. family, friends, partners) People at risk for HIV | Clinical counseling Support sessions for disclosure, emotional well-being, harm reduction, physical health, employment services, relationships/social supports, financial counseling, housing, stigma/discrimination, employment services, wellness checks Bereavement services | A high level of social support is associated with fewer risky sexual behaviours [5] Support programs can achieve a high level of retention in care (91.4 %) over a 4-year follow-up [6] |
Needle and syringe programs, safer inhalation programs, harm reduction outreach programs, and community development for people who use drugs | Injection drug users / people who use drugs | Distribution of safer injection equipment: cookers, filters, needles, sharps containers, swabs, ties/tourniquets, vitamin C/acidifiers, water for injection, and safer inhalation equipment Harm reduction activities, outreach and education programs (e.g. safer injection, safer inhalation, and safer sex practices to reduce HIV risk and transmission) | Exposure to needle and syringe programs was associated with reduction of HIV transmission (pool effect size: 0.4, 95 % CI 0.22–0.81) [2] Community outreach programs for injection drug users were effective [4] |
Education and support for reduction of risky HIV transmission behaviour | People living with HIV Gay, bisexual and other men who have sex with men Indigenous people African, Caribbean and Black Ontarians People who use drugs Women at-risk (who engage in activities with a high risk of exposure to HIV, or with priority populations) | Prevention, education, and outreach activities | Education and support programs significantly reduced unprotected sex (OR 0.57, 95 % CI 0.40–0.73), and incidence of sexually transmitted disease (OR 0.20, 95 % CI 0.05–0.73) [3] Men living in geographic regions of Ontario with HIV prevention programming had unprotected homosexual intercourse with both casual and regular partners significantly less frequently [60] |
Mass media programs for HIV prevention | People living with HIV Gay, bisexual and other men who have sex with men Indigenous people African, Caribbean and Black Ontarians People who use drugs Women at-risk (who engage in activities with a high risk of exposure to HIV, or with priority populations) | Mass media campaigns, e.g. Keep It Alive, HIV Stigma, Our Agenda | Increases in condom use [effect size (d):0.25, 95 % CI 0.18–0.31], knowledge of HIV transmission (d: 0.30, 95 % CI 0.18–0.41), knowledge of HIV prevention (d: 0.39, 95 % CI 0.25–0.52) [7] |
Mass condom, and safer sex materials distribution | People living with HIV Gay, bisexual and other men who have sex with men Indigenous people African, Caribbean and Black Ontarians People who use drugs Women at-risk (who engage in activities with a high risk of exposure to HIV, or with priority populations) | Distribution of condoms, lubricant and dental dams | Increased condom use (OR 1.8, 95 % CI 1.51–2.17), condom acquisition (OR 5.4, 95 % CI 1.86–15.66), and reduced incidence of sexually transmitted disease (OR 0.69, 95 % CI 0.53–0.91) [10] |
Practical assistance programs (includes distribution of practical assistance items) | People living with HIV Gay, bisexual and other men who have sex with men Indigenous people African, Caribbean and Black Ontarians People who use drugs Women at-risk (who engage in activities with a high risk of exposure to HIV, or with priority populations) People affected by HIV | Practical assistance programs, e.g. access to food programs, access to complementary therapies, emergency financial assistance, assistance accessing provincial drug payment programs, child care subsidy, clothing, household items, help with transportation, assistance with tax, insurance, or legal information | Support program can achieve a high retention of care (91.4 %) over a 4-year follow-up [6] |
Linkage to HIV care, Ontario’s testing programs, HIV supportive case management, and clinical counseling | People living with HIV | Case management Support sessions that focus on connection to HIV care, retention in HIV care, HIV management, supporting clients to make/keep/or travel to medical appointments, referrals to HIV care, testing or treatment, or accompanying clients to medical appointments. Anonymous point-of-care testing as well as standard blood draw HIV testing—anonymous, nominal, non-nominal/coded Clinical counseling services | Case management and community engagement program increased likelihood of retaining in care (OR 4.13, 95 % CI 1.93–8.85) [12] Community-based approach increased uptake of HIV testing and counseling (RR 10.65, 95 % CI 6.27–18.08) and increased proportion of first-time testers (RR 1.23, 95 % CI 1.06–1.42) [55] Support programs can achieve a high retention of care (91.4 %) over a 4-year follow-up [6] |
Increase awareness of use of post-exposure prophylaxis (PEP) | People living with HIV Gay/bi/trans and other men who have sex with men | Education activities include group workshops/presentations and one-on-one education through outreach targeted to priority populations Support sessions provided to clients at Ontario’s community-based HIV organizations | Increased use of PEP for HIV by 42 % [62] |
Supportive housing | People living with HIV | HIV supportive housing programs across Ontario: Fife House & McEwan Housing and Support Services (Toronto), AIDS Niagara (St. Catherines), Bruce House (Ottawa), John Gordon Home-Regional HIV/AIDS Connection (London), and Abercrombie Place-ARCH (Guelph) | Homeless/ marginally-housed people living with HIV were associated with poorer HAART access/adherence or treatment outcomes [63] Housing status reduces needle sharing (OR 0.37, 95 % CI 0.15–0.81) and unprotected sex (OR 0.39, 95 % CI 0.18–0.84) [64] |
Data Sources and Analytic Framework
Sensitivity Analyses
Results
Year | Ontario | Comparatora
| New HIV infection cases | Total HIV infection averted (C) = (A) − (B) | |||
---|---|---|---|---|---|---|---|
HIV incidence (1) | HIV prevalence in previous year (2) | HIV transmission rateb (3) | HIV transmission rateb (4) | Comparator (A) = [(4) × (2)] ÷ 100 | Ontario (B) = [(3) × (2)] ÷ 100 | ||
1987 | 1546 | 1546 | 53.1 | 20.8 | 321.6 | 821.3 | 0.0 |
1988 | 1442 | 4352 | 33.1 | 20.8 | 905.3 | 1442.0 | 0.0 |
1989 | 1702 | 6054 | 28.1 | 20.8 | 1259.4 | 1702.0 | 0.0 |
1990 | 2062 | 8116 | 25.4 | 20.8 | 1688.3 | 2062.0 | 0.0 |
1991 | 1822 | 9938 | 18.3 | 20.8 | 2067.3 | 1822.0 | 245.3 |
1992 | 1797 | 11735 | 15.3 | 20.8 | 2441.1 | 1797.0 | 644.1 |
1993 | 1477 | 13212 | 11.2 | 20.8 | 2748.4 | 1477.0 | 1271.4 |
1994 | 1304 | 14516 | 9.0 | 20.8 | 3019.7 | 1304.0 | 1715.7 |
1995 | 1314 | 15830 | 8.3 | 20.8 | 3293.0 | 1314.0 | 1979.0 |
1996 | 1034 | 16864 | 6.1 | 20.8 | 3508.1 | 1034.0 | 2474.1 |
1997 | 924 | 17788 | 5.2 | 20.8 | 3700.3 | 924.0 | 2776.3 |
1998 | 953 | 18741 | 5.1 | 20.8 | 3898.6 | 953.0 | 2945.6 |
1999 | 889 | 19630 | 4.5 | 20.8 | 4083.5 | 889.0 | 3194.5 |
2000 | 886 | 20,516 | 4.5 | 20.8 | 4267.8 | 923.2 | 3344.6 |
2001 | 957 | 21,473 | 4.6 | 20.8 | 4466.9 | 987.8 | 3479.1 |
2002 | 1,132 | 22,605 | 5.2 | 20.8 | 4702.4 | 1175.5 | 3526.9 |
2003 | 1,164 | 23,769 | 4.8 | 20.8 | 4944.5 | 1140.9 | 3803.6 |
2004 | 1,085 | 24,854 | 4.9 | 20.8 | 5170.2 | 1217.8 | 3952.4 |
2005 | 1,106 | 25,960 | 4.4 | 20.8 | 5400.3 | 1142.2 | 4258.0 |
2006 | 1,132 | 27,092 | 4.3 | 20.8 | 5635.8 | 1165.0 | 4470.8 |
2007 | 1,049 | 28,141 | 3.9 | 20.8 | 5854.0 | 1097.5 | 4756.5 |
2008 | 1,102 | 29,243 | 3.9 | 20.8 | 6083.2 | 1140.5 | 4942.7 |
2009 | 999 | 30,242 | 3.4 | 20.8 | 6291.0 | 1028.2 | 5262.8 |
2010 | 1,023 | 31,265 | 3.3 | 20.8 | 6503.8 | 1023.0 | 5480.8 |
2011 | 946 | 32,211 | 2.9 | 20.8 | 6700.6 | 946.0 | 5754.6 |
Total | 99,055.1 | 30,628.9 | 70,278.9 |
Year | Savings in Canadian health care system by community-based programsa
| Investments in community-based HIV programs | |||
---|---|---|---|---|---|
AIDS Bureaub
| ACAPc
| Other governmentald
| Otherse
| ||
2005 | $ 213,833,757 | $ 12,644,074 | $ 2,534,540 | $ 8,118,491 | $ 10,222,525 |
2006 | $ 224,518,625 | $ 13,607,252 | $ 3,323,877 | $ 9,532,182 | $ 10,037,582 |
2007 | $ 238,864,805 | $ 13,830,988 | $ 2,441,225 | $ 9,948,038 | $ 9,904,051 |
2008 | $ 248,218,737 | $ 16,567,895 | $ 3,252,240 | $ 11,584,297 | $ 10,968,874 |
2009 | $ 264,291,987 | $ 17,698,104 | $ 3,796,024 | $ 12,058,316 | $ 7,962,258 |
2010 | $ 275,241,483 | $ 20,083,701 | $ 3,564,936 | $ 14,223,361 | $ 10,125,239 |
2011 | $ 288,990,894 | $ 20,338,042 | $ 3,859,085 | $ 13,106,427 | $ 9,719,275 |
Total | $ 1,753,960,288 | $ 114,770,056 | $ 22,771,927 | $ 78,571,112 | $ 68,939,804 |
Present value of total savings in Canadian health care system (2005–2011) (in 2011 dollars, discounted by 3 %)f (A) | $ 1,908,564,059 | ||||
Present value of investments in community-based HIV programs (2005–2011) (in 2011 dollars, discounted by 3 %)f (B) | $ 327,793,439 | ||||
Financial return on investment ratio (C) = [(A) − (B)]/(B) | 4.8 |