Leaving no one behind? An equity analysis of the HIV care cascade among a cohort of people living with HIV in Manitoba, Canada

BACKGROUND: Manitoba is a central Canadian province with annual rates of new HIV infections consistently higher than the Canadian average. National surveillance statistics and data from the provincial HIV care program suggest that epidemiological heterogeneity exists across Manitoba. New HIV cases are disproportionately reported among females, Indigenous-identifying individuals, and those with a history of injection drug use. Given the heterogeneity in acquisition, it is of interest to understand whether this translates into inequalities in HIV care across Manitoba. METHODS: A sample of 703 participants from a clinical cohort of people living with HIV in Manitoba, with data current to the end of 2017, was used to conduct cross-sectional, disaggregated analyses of the HIV care cascade to identify heterogeneity in service coverage and clinical outcomes among different groups receiving HIV care in Manitoba. Equiplots are used to identify and visualize inequalities across the cascade. Exploratory multivariable logistic regression models quantify associations between equity variables (age, sex, geography, ethnicity, immigration status, exposure category) and progression along the cascade. Adjusted odds ratios (AOR) and 95% confidence intervals (95%CI) are reported. RESULTS: Equity analyses highlight inequalities in engagement in and coverage of HIV-related health services among cohort participants. Equiplots illustrate that the proportion of participants in each cascade step is greater for those who are older, white, non-immigrants, and report no history of injection drug use. Compared to those living in Winnipeg, participants in eastern Manitoba have greater odds of achieving virologic suppression (AOR[95%CI] = 3.8[1.3–11.2]). The odds of Indigenous participants being virologically suppressed is half that of white participants (AOR[95%CI] = 0.5[0.3–0.7]), whereas African/Caribbean/Black participants are significantly less likely than white participants to be in care and retained in care (AOR[95%CI] = 0.3[0.2–0.7] and 0.4[0.2–0.9], respectively). CONCLUSIONS: Inequalities exist across the cascade for different groups of Manitobans living with HIV; equiplots are an innovative method for visualizing these inequalities. Alongside future research aiming to understand why inequalities exist across the cascade in Manitoba, our equity analyses can generate hypotheses and provide evidence to inform patient-centred care plans that meet the needs of diverse client subgroups and advocate for policy changes that facilitate more equitable HIV care across the province.