Findings among Indigenous participants of the Tracks survey of people who inject drugs in Canada, Phase 4, 2017–2019

Background: The Tracks survey of people who inject drugs (PWID) collected data in 14 sentinel sites across Canada (2017–2019). These findings describe the prevalence of human immunodeficiency virus (HIV), hepatitis C and associated risk behaviours among Indigenous participants. Methods: Information regarding socio-demographics, social determinants of health, use of prevention services and testing, drug use, risk behaviours, and HIV and hepatitis C testing, care and treatment was collected through interviewer-administered questionnaires. Biological samples were tested for HIV, hepatitis C antibodies and hepatitis C ribonucleic acid (RNA). Descriptive statistics were calculated and reviewed by an Indigenous-led advisory group using the Two-Eyed Seeing approach. Results: Of the 2,383 participants, 997 were Indigenous (82.9% First Nations, 14.9% Métis, 2.2% Inuit). Over half (54.5%) were cisgender male and the average age was 38.9 years. A large proportion (84.0%) reported their mental health as “fair to excellent”. High proportions experienced stigma and discrimination (90.2%) and physical, sexual and/or emotional abuse in childhood (87.5%) or with a sexual partner (78.6%). Use of a needle/syringe distribution program (90.5%) and testing for HIV (87.9%) and hepatitis C (87.8%) were high. Prevalence of HIV was 15.4% (78.2% were aware of infection status) and 36.4% were hepatitis C RNA-positive (49.4% were aware of infection status). Conclusion: High rates of HIV and hepatitis C were identified. Challenges in access to and maintenance of HIV and hepatitis C care and treatment were noted. This information informs harm reduction strategies, including the need to scale-up awareness of prophylaxis in a culturally relevant manner. Affiliations 1 Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, Ottawa, ON 2 Canadian Aboriginal AIDS Network, Halifax, NS 3 Pauktuutit Inuit Women of Canada, Ottawa, ON 4 National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, MB *Correspondence: jill.tarasuk@canada.ca Suggested citation: Tarasuk J, Sullivan M, Bush D, Hui C, Morris M, Starlight T, Cholette F, Jonah L, Bryson M, Paquette D, Masching R. Findings among Indigenous participants of the Tracks survey of people who inject drugs in Canada, Phase 4, 2017–2019. Can Commun Dis Rep 2021;47(1):37–46. https://doi.org/10.14745/ccdr.v47i01a07


Introduction
In Canada, Indigenous peoples represent 4.9% of the total Canadian population (1); however, they are disproportionately affected by human immunodeficiency virus (HIV) and hepatitis C infections. In 2016, it was estimated that 11.3% of new HIV infections in Canada were among Indigenous peoples (2) and newly diagnosed hepatitis C infections among First Nations people living on reserve were three-fold higher compared with new diagnoses in the overall Canadian population (3). National case-based HIV surveillance for 2017 found that 68.1% of cases attributed to people who inject drugs (PWID) reported Indigenous ethnicity, among the 49.3% of reported HIV cases with available ethnicity data (4).

SURVEY
The Public Health Agency of Canada (PHAC), in collaboration with provincial, territorial and local public health partners, monitors trends in the prevalence of HIV and hepatitis C and associated risk factors in key populations, such as PWID, through the Tracks Surveillance Systems. The Tracks survey of PWID (formerly I-Track) involves repeated cross-sectional surveys at selected sites across Canada. This national integrated bio-behavioural surveillance system was first implemented in 2003-2005 (Phase 1) in seven sentinel sites. This was followed by three subsequent data collection periods, including the most recent survey, Phase 4 (2017-2019), in 14 sentinel sites.
Information about risk practices and health-seeking behaviours among the populations most at risk for HIV, including Indigenous PWID, is necessary to better understand the factors driving transmission (5). The objective of this report is to present national surveillance findings among Indigenous participants from Phase 4 of the Tracks survey of PWID in Canada, conducted between January 1, 2017 and May 9, 2019, at participating sentinel sites in Canada. Findings include socio-demographic characteristics, social determinants of health, use of sexually transmitted and blood-borne infection (STBBI) prevention services and testing, drug use and experiences with overdoses, sexual risk behaviours, the HIV and hepatitis C care cascade, and prevalence and awareness of infection status.

Data source and sampling methods
The data presented in this report are from Phase 4 of the Tracks survey of PWID in Canada. The Tracks survey of PWID makes use of venue-based sampling, in which participants are recruited from settings in which they are likely to gather, most often, but not limited to, where STBBI-related prevention, testing and treatment services are provided including needle and syringe distribution programs. Individuals who had injected drugs six months prior to recruitment and who met the minimum age to provide consent, which was determined at each site according to local research ethics requirements, were eligible to participate in the survey. Eligible and consenting participants completed an interviewer-administered questionnaire and provided a biological sample in the form of a dried blood spot specimen (or oral fluid exudate in the Surveillance des maladies infectieuses chez les utilisateurs de drogues par injection (SurvUDI) network sites).
The surveillance protocol and questionnaire were approved by the Health Canada/PHAC Research Ethics Board, and by local research ethics boards at each sentinel site where required. The same sampling and recruitment strategies and core questionnaire, with minor revisions to question wording, were used across all four phases to ensure comparability over time. Survey methods, sentinel site selection, questionnaire details and laboratory testing algorithms are described elsewhere (6).

Interviewer-administered questionnaire and biological sample
The Tracks PWID questionnaire collects information about socio-demographic characteristics, social determinants of health, use of health and prevention services (including testing), drug use and injecting behaviours, sexual behaviours and care and treatment for HIV and hepatitis C. The questionnaire is interviewer-administered and takes approximately 30 minutes to complete.
Dried blood spot samples were tested for HIV (antibody and antigen) and hepatitis C (antibody and ribonucleic acid; RNA). Participants were not informed of their laboratory test results because no identifying information was collected to ensure participant anonymity. Sentinel sites were asked to provide on-site testing (e.g. point of care testing, full phlebotomy) during recruitment times so that participants who were not aware of their status could get tested, should they wish. Where on-site testing was not feasible, participants were referred to local testing sites and/or health care services.

Analysis
A partnership between the Canadian Aboriginal AIDS Network (CAAN), PHAC and an advisory group comprised of a representative from Pauktuutit Inuit Women of Canada, and people with lived and/or living experience of injection drug use, HIV and/or hepatitis C was formed. Using the Two-Eyed Seeing approach, where both Indigenous and Western worldviews were respected, the advisory group met regularly over a six-month period to review and interpret the survey findings. In addition to writing this article, the advisory group identified key findings and themes that resonated with community priorities for action and prepared complementary culturally relevant infographics targeted for community use. These infographics focused on indicators related to access to harm reduction and health care services including HIV and hepatitis C care and treatment and preexposure prophylaxis (PrEP) and will be released by CAAN at later date.
Descriptive statistics for selected indicators were computed with SAS Enterprise Guide 7.1. Small cell counts were assessed to determine the risk of identifying individual participants and were presented where there was no risk of reidentification, as per PHAC's Directive for the collection, use and dissemination of information relating to public health (unpublished document, PHAC, 2013). Participants who responded as "not stated", "don't know" or "refused" were excluded from the denominator of each indicator analysis.  Table 2). Four sentinel sites-three in the prairies and one in western Ontario-comprised over 60% of all Indigenous participants, while the proportion of Indigenous participants in the other sentinel sites was between 1% and 7%.

SURVEY
The average age was 38.9 years. The largest proportion of participants were between the ages of 25 to 39 years (46.5%), with a lower proportion between the ages of 40 to 54 years (36.6%), and smaller proportions of participants younger than 25 years (8.0%) or 55 years or older (8.9%).
Just over half (54.5%) identified their gender as cisgender male, 42.9% identified as cisgender female, 1.4% as transfeminine (i.e. those assigned male at birth who identified with either female or a non-binary gender) and 1.2% as transmasculine (i.e. those assigned female at birth who identified with either male or a non-binary gender). A large proportion reported their sexual orientation as heterosexual or straight (85.7%) and smaller proportions identified as bisexual (9.2%), gay or lesbian (2.6%), Two-spirit (1.7%) or other (0.8%).

Social determinants of health
Among the Phase 4 Indigenous participants, over half (57.9%) completed some high school or less, 26.4% completed high school and 15.8% completed more than high school ( Table 3).
Within the six months prior to the interview, participants most commonly reported being unemployed (70.3%) and/or on social assistance (66.7%) and/or on disability assistance (33.6%). A large proportion (83.7%) experienced financial strain (i.e. difficulty making ends meet) in the 12 months prior to the interview.
Two-thirds (66.2%) of participants reported living in unstable housing in the six months prior to the interview. This included living in a hotel or motel room, rooming or boarding house, shelter or hostel, transition or halfway house, psychiatric institution or drug treatment facility, public place or correctional facility. Overall, 75.2% had ever been incarcerated and 26.1% had been incarcerated in the 12 months prior to the interview.
Most participants (84.0%) reported their mental health as "fair to excellent" with a smaller proportion (16.0%) reporting poor mental health status. Among Indigenous participants, 23.7% had been placed in a residential school and 89.8% had a family member who had been placed in a residential school.
The majority of participants experienced stigma and discrimination (related to racial or cultural background, hepatitis C status, HIV status, sexual orientation, use of drugs or alcohol or sex work) in their lifetime (90.2%) and in the 12 months prior to the interview (84.6%). Large proportions of participants had also experienced physical, sexual and/or emotional abuse in childhood (87.5%) or with a sexual partner (78.6%).

Access to primary health care and use of prevention services and testing
Participants were asked questions about access to primary health care and use of harm reduction and STBBI prevention services, as well as testing patterns for HIV and hepatitis C ( Table 4).
Overall, nearly three-quarters (72.2%) of participants had access to primary health care and a slightly smaller proportion (63.9%) had a regular primary healthcare provider. In the 12 months prior to the interview, one-quarter of participants (25.1%) used health services that included Indigenous health or healing practices such as a Traditional Healer, a Community Elder, the Hope for Wellness Help Line (8) or other Indigenous-specific health services. Mental health counselling services were used by 28.5% of participants in the 12 months prior to the interview.  Family member placed in a residential school c 687 89.8 Use of harm reduction and STBBI prevention services in the 12 months prior to interview varied depending on the service in question ( Table 4). The majority of participants (90.5%) reported using a needle and syringe distribution program with a small proportion (9.9%) using a supervised injection or consumption site. Less than half of participants (43.6%) used methadone, suboxone or other opioid substitution therapy and just over one-quarter of participants (27.2%) used treatment services for drug or alcohol use in the 12 months prior to the interview. In the same period, 48.9% reported using a condom distribution program and 54.2% received STBBI prevention counselling. A large proportion of participants reported having ever tested for HIV (87.9%) and hepatitis C (87.8%) ( Table 4).
Only a small proportion of participants were aware of oral HIV PrEP (11.5%) and non-occupational postexposure prophylaxis (nPEP) for HIV (10.8%) ( Table 4). In the 12 months prior the interview, 45.7% of participants avoided healthcare services and among those who had never been tested for HIV and those who self-reported being HIV-negative, 23.1% avoided getting tested for HIV because of stigma and discrimination (defined as fear of or concern about or experienced stigma or discrimination by staff or neighbours, fear of or concern someone may learn they inject drugs, fear of or concern about or experienced violence, fear of or concern about or experienced police harassment or arrest).

Injecting behaviours
The average age participants reported first injecting drugs was 24.5 years. Less the half of all participants (40.5%) reported injecting daily in the month prior to the interview and just over half (53.5%) reported injecting in a public space in the six months prior to the interview. Overall, 93.1% of participants used a sterile needle and syringe at last injection. In the six months prior to the interview, 10.0% of participants had injected with used needles and/or syringes, of whom the majority (85.0%) borrowed needles and/or syringes from people who they knew well (e.g. family, friends or sex partners). Just under one-half (45.7%) injected with used injection equipment other than needles and/or syringes, such as water, filters, cookers, tourniquets, swabs or acidifiers in the six months prior to the interview. Among those who borrowed used injection equipment (other than needles and/or syringes), the majority (85.9%) reported borrowing from people they knew well (family, friends or sex partners). More than half of participants (58.3%) borrowed used non-injection drug paraphernalia such as straws, dollar bills or pipes in the six months prior to the interview ( Table 5).

Sexual risk behaviours
Among participants who had ever had sex, 35.4% had two or more sexual partners in the six months prior to the interview ( Table 7). Among participants who had a regular sex partner, inconsistent condom use was reported by 85.6% during vaginal and/or anal sex. Among participants who had a casual sex partner, inconsistent condom use was reported by 57.6% during vaginal and/or anal sex. A small proportion (16.0%) had engaged in transactional sex at least once, among whom, 26.3% had condomless sex at last transactional sex (Table 7). Most participants (81.6%) reported substance use before or during sex ( Table 7).

HIV and hepatitis C prevalence and awareness
Among Indigenous participants who provided a biological sample of sufficient quantity for testing (n=879), 15.4% tested positive for HIV, among whom 78.2% were aware of their HIV-positive status (  a Proportion of participants who responded to each individual question varied. Information was missing or not collected for 2% to 14% of the sexual risk behaviour indicators b Among participants who had ever had sex c Inconsistent condom use defined as not always using a condom (i.e. never, sometimes or frequently). This question was not asked at the London site d This question was not asked at the SurvUDI network sites a Proportion of participants who responded to each individual question varied. Information was missing or not collected for 1% to 2% for these indicators except for drugs used at last overdose where information was missing or not collected for 10% to 15% of these indicators b Participants recorded all drugs (that they had injected, consumed or used at last overdose) for non-medicinal purposes in the six months prior to interview. The most commonly reported drugs among all participants are presented. Responses are non-mutually exclusive c This question was not asked at the SurvUDI network and London sites d Among participants who had heard of overdose kits e This question was not asked at the SurvUDI network sites f Among participants who overdosed in the past six months and who provided a response

Discussion
The establishment of an Indigenous-led advisory group was fundamentally important and necessary in the analysis and interpretation of the surveillance findings focusing on Indigenous participants. The team composition and use of the Two-Eyed Seeing approach respected both Indigenous and Western world views while fostering meaningful engagement from diverse stakeholders, including Indigenous people with lived and/or living experience of injection drug use. The collaborative nature of the advisory group is a step towards reconciliation.
A large proportion of Indigenous participants (84.0%) reported fair to excellent mental health-a finding that stands out compared with proportions reported for other survey indicators associated with poor mental health: childhood and sexual partner abuse (87.5% and 78.6%, respectively); family member placed in a residential school (89.8%); incarceration (75.2%); unstable housing (66.2%); and ever experienced stigma and discrimination (90.2%). High levels of reported mental health wellness may be a reflection of the resiliency of Indigenous peoples within the individual and collective experience of trauma.
Regarding prevention indicators, high rates of lifetime testing for HIV and hepatitis C were noted (87.9% and 87.8%, respectively) and the majority of participants (90.5%) had used the services of a needle and syringe distribution program and reported safe injecting practices (93.1% reported using a clean needle and syringe at last injection). Use of other harm reduction services was notably lower: opioid-substitution therapy (43.6%); drug treatment services (27.2%); condom distribution program (48.9%); or receipt of STBBI counselling (54.2%). While the use Abbreviations: ART, anti-retroviral therapy; HCV, hepatitis C virus; HIV, human immunodeficiency virus; RNA, ribonucleic acid a Proportion of participants who responded to each individual question varied. Information was missing or not collected for less than 1% of these indicators except for adherence to ART (20%) and self-reported undetectable HIV viral load (26%) b Among participants who provided a biological sample of sufficient quantity for HIV testing (n=879) c HIV and hepatitis C testing algorithms are provided in Appendix 1 d Among participants who tested positive for HIV antibodies and who reported their HIV diagnosis. Participants who reported that their last HIV test result was positive and who were found to be HIV positive based on testing of the biological specimen provided at the time of interview were classified as being aware of their HIV-positive status e Defined as under the care of a doctor or health care provider for HIV-related services at the time of the interview (in the six months prior to the interview in the SurvUDI network and London sites) f This question was not asked at the SurvUDI network and London sites. The denominator also excludes participants with missing data g Among participants currently on ART at the time of the interview. This question was not asked at the SurvUDI network sites. The denominator also excludes participants with missing data h Among participants who provided a biological sample of sufficient quantity for HCV antibody testing (n=863) i Among participants who provided a biological sample of sufficient quantity for HCV antibody and RNA testing (n=696). HCV RNA testing was not conducted at the SurvUDI network sites j Among participants who tested HCV RNA positive and who reported their current hepatitis C status. Participants who reported being currently infected with hepatitis C and who were hepatitis C RNA positive based on testing of the biological specimen provided at the time of interview were classified as being aware of their hepatitis C RNA-positive status k Defined as under the care of a health care provider for hepatitis C-related services at the time of the interview. The denominator excludes participants with missing data l Denominator excludes participants with missing data m Among participants who provided a biological sample of sufficient quantity for testing for both HIV antibodies and HCV RNA testing. The HCV RNA testing was not conducted at the SurvUDI network sites Currently taking hepatitis C treatment l 7 5.8 HIV and hepatitis C co-infection m HIV-positive and hepatitis C RNA positive 42 6.0 SURVEY of a supervised injection or consumption site in the 12 months prior to the interview was low (9.9%), it should be noted that this service is not available uniformly across Canada. Awareness of PrEP and nPEP was low (11.5% and 10.8%, respectively). Most participants had heard of naloxone kits (83.3%). The lower reported proportions that reported carrying an overdose kit (33.8%) speaks to the ongoing need for scaling up naloxone kit distribution.
Among Indigenous participants of the Tracks survey of PWID, HIV seroprevalence (15.4%), lifetime exposure to hepatitis C (65.8%) and current hepatitis C infection (36.4%) were high. These findings corroborate results from other regional studies that underscore how injection drug use and HIV and hepatitis C disproportionately impact Indigenous peoples and communities across Canada (9)(10)(11)(12)

Moving forward
Indigenous peoples and communities are resourceful and resilient. Connection to culture, land, and ceremony has helped Indigenous peoples to understand health and respond individually and collectively to historical and ongoing trauma such as colonialism and residential school experiences. As Indigenous peoples and communities face ongoing health issues such as HIV and hepatitis C infections, the burden of the opioid crisis and other drug-related overdose deaths further emphasize the ongoing need for access to culturally relevant prevention and treatment services including increased distribution of naloxone overdose kits. Prevention interventions are warranted such as comprehensive STBBI sexual health education including increasing awareness and access to PrEP and nPEP among HIV-negative individuals at high risk for infection to lower their risk of becoming infected (13). Ongoing engagement in the interpretation of surveillance findings among Indigenous participants through Indigenous-specific networks, traditional healers and community-based approaches can also contribute to the resilience of Indigenous peoples and communities.

Strengths and limitations
This national integrated bio-behavioural surveillance system provides information on HIV and hepatitis C among PWID from sites across the country for use at the local, provincial and federal levels to inform and guide public health interventions in this population. The Tracks survey of PWID uses non-probabilitybased sampling; therefore, findings are not representative of all Indigenous PWID at any given site or in Canada. Small numbers of participants who identified as Métis and Inuit, as well as those whose gender identity was transmasculine or transfeminine, precluded specific sub-group analyses to examine associations with other socio-demographic characteristics and indicators.
With the exception of the laboratory results, these findings were based on interviewer-administered questionnaires and selfreported data and it is possible that certain risk behaviours were over-or underrepresented.

Conclusion
The shared efforts of the Indigenous-led advisory group facilitated community leadership and collaborative analysis of the Tracks survey of PWID. This collaboration resulted in the development of knowledge products that will disseminate the Indigenous-specific results contextualized to be most relevant for uptake by stakeholders in diverse settings. These surveillance findings signal the challenges in access to and maintenance of effective HIV and hepatitis C care and treatment among Indigenous PWID in Canada. This information is especially important to inform harm reduction strategies and Indigenousspecific STBBI prevention and treatment services in Canada. Further examination of the barriers and facilitators to the access and use of STBBI and harm reduction prevention and treatment services is warranted.

Funding
The Tracks survey of people who inject drugs in Canada is supported by Public Health Agency of Canada, with in-kind contributions provided by regional and local health authorities and community-based organizations.

HIV testing algorithms
For non-SurvUDI sites, HIV status was initially determined by screening dried blood spot specimens using the Bio-Rad GS HIV Combo Ag/Ab assay followed by confirmatory testing using the Roche COBAS AmpliPrep/COBAS Taqman