Author: Samira Prasad

From The Conversation, co-authored by Dr. Darrell Tan

One year ago, the United States approved a new injectable drug that prevents HIV.

After successful clinical trials, long-acting cabotegravir was found to be almost 100 per cent effective at preventing HIV. It was approved in the U.S. on Dec. 20, 2021, for use as HIV pre-exposure prophylaxis (PrEP). This approval means that eligible individuals can now receive this medication every eight weeks to prevent sexually-acquired HIV infection.

However this new drug, which would help address some of the ongoing challenges with HIV prevention for those who remain at high risk, is still not available in Canada.

HIV in Canada

The number of new HIV infections has not changed much over the past couple of decades and approximately 13 per cent of people living with HIV in Canada are undiagnosed. This demonstrates the need for more HIV prevention strategies.

While long-acting injectable PrEP is new, oral PrEP — a pill taken either daily or around sexual activity — was approved in the U.S. back in 2012. Canada only approved oral PrEP in 2016. And we are once again falling behind the U.S. on making injectable PrEP available here.

Oral PrEP already reduces the risk of HIV by almost 100 per cent when taken consistently, but recent clinical trials show that injectable PrEP is even more effective. The main advantage of injectable PrEP is that going for injections every two months is a lot easier to remember than taking pills every day, or taking pills before and after sexual activity. The switch from oral pills to injectable shots means that individuals can more easily maintain adherence, which impacts the overall effectiveness of PrEP as HIV prevention.

From CBC Toronto

Virtual-care clinics may be adding pressure to the overwhelmed health-care system, the Ontario Medical Association said Thursday, even as some patients and doctors say they are vital alternatives to an otherwise necessary visit to an emergency room.

The OMA comments come as pediatric hospitals, emergency departments and the overall health-care system are struggling to meet the demands of a triple-threat of respiratory syncytial virus, the seasonal flu and COVID-19.

“Virtual-only walk-in clinics may actually be resulting in more churn, more cost to our system,” said Dr. Tara Kiran, a family physician at Toronto’s St. Michael Hospital and senior author of a preliminary study that compared patients who visited their own family doctors virtually with people who visited a virtual-only clinic.

The preprint study, which has not been peer reviewed, found that virtual walk-in patients are twice as likely to visit an emergency department within 30 days due to a lack of continuity of care.

However, some patients and doctors are lamenting a reduction in virtual care options as doctors leave the platforms after the province and the OMA reached an agreement to reduce fees paid to doctors for virtual visits, effective Dec. 1.

From the CBC article

According to the Ontario College of Family Physicians, 1.8 million residents in the province don’t have a family doctor — a number it says could reach three million by 2025 if current trends persist. 

About 1.7 million people have a physician over the age of 65, said Dr. Jobin Varughese, the college’s president-elect 

“So, unfortunately, as tragic as it is to say ‘Thank you for all of your service, but continue to work,’ [even older doctors like Dr. Bell] may become a little bit more common than one or two cases,” Varughese said. 

Dr. Tara Kiran, a family doctor and researcher at St. Michael’s Hospital, which is part of the Unity Health Toronto network, said there is a worrying trend of fewer Ontario medical students choosing to enter family practice, and there are several potential reasons why. 

Those include a fear of working alone at clinics not staffed by teams, lower pay and perceived stature, and a significant amount of time spent on paperwork instead of interacting with patients. 

“The paperwork in primary care is horrendous,” Bell said. “Wednesday is a day off, but [they] tend to be paperwork days.”

Bell and Kiran also cite a backlog in medical services created by the COVID-19 pandemic, which puts “a huge increase in pressure on us,” he said.

Kiran co-authored a recent study showing many family doctors retired early in the pandemic, whereas Bell says he’ll stay on at the Sharbot Lake clinic until they find the right person to replace him. 

“Well, kudos to Dr. Bell for his commitment to his practice and to the town,” Kiran said, adding it’s not uncommon for some family doctors to work into their old age. 

“It’s a profession that we train a long time for and it becomes a big part of our identity.”

From CityNews

Every night in Toronto, an average of 187 people seeking warmth and safety are turned away from the shelter system, raising renewed concerns about how the City will help its most vulnerable residents trying to survive the winter outdoors.

“We personally see people every day in our emergency department and in our hospital wards who are homeless and for whom we can’t find a shelter bed for,” said Dr. Stephen Hwang with the MAP Centre for Urban Health Solutions at St. Michael’s Hospital.

He told CityNews a rising number of people are turning up at the already overcrowded emergency department, not because they have a medical problem but simply because they need a place to get out of the cold.

Hwang, whose research focuses on ending homelessness and improving the health of those who live outside, said social workers will spend hours calling the City’s central intake office to find spots inside shelters. But very few leave the emergency department with somewhere to go.

“I’m afraid we’re going to see people dying from hypothermia, literally freezing to death on the street,” Hwang said.

According to the City, the shelter system is currently accommodating approximately 8,200 people nightly. That’s 1,600 more than this time last year, and more than they’ve ever had.

At the same time, the City is closing temporary shelter sites opened during the pandemic. Some residents at the Novotel allege they were evicted last month as the City prepares to close the leased hotel by the end of the year. The move impacts 251 unhoused people.

As Hwang explained, people are in encampments because there is not enough safe shelter space for them.

While the City vows outreach staff hand out blankets, sleeping bags and warm clothing in the wintertime, people are not offered safer alternatives to propane heat, raising the risk of frostbite or the danger of fire.

From the National Observer article

When unhoused people in Toronto run out of options, they turn to the city’s overcrowded emergency departments for shelter.

The result is a collision of two crises, emergency department overcrowding and homelessness, that will risk lives, physicians, social workers and advocates for unhoused people say.

“We are going to see higher rates of people dying and more severe health impacts. For example, people are going to experience frostbite and people are going to have more amputations,” said Jesse Jenkinson, a postdoctoral fellow at the MAP Centre for Urban Health Solutions at St. Michael’s Hospital’s Li Ka Shing Institute.

Emergency department overcrowding is at a critical level, according to experts. A wave of respiratory illnesses, including COVID-19, has swamped ERs already struggling with hospital bed-block and nursing shortages. At the same time, the city is closing temporary hotel shelters opened during the first year of the COVID-19 pandemic to aid social distancing.

Some of the hotel occupants are being placed in permanent housing. But others are left to join the shelter bed queue and when those are full, some turn to emergency departments to stay warm. The triad of too little affordable housing and too few temporary shelter spaces and social services further adds to the strain.

Sylvia Gomes, an emergency department social worker at the University Health Network’s Toronto Western Hospital, along with her colleagues have been sounding the alarm since August.

People without homes come to the ER for shelter and warmth, but when social workers try to help them, there are no shelter beds available, she said.

“We are having tremendous difficulty in the emergency department supporting unhoused people and in ensuring that they leave to a place where they are warm and safe,” said Dr. Aaron Orkin, an emergency physician at St. Joseph’s Hospital and the population health director for Inner City Health Associates.

Shelter beds are allocated through a 24/7 city-operated telephone-based service that refers people to dormitory-style congregate shelters and other overnight accommodations. Congregate shelters sleep up to 20 people per room.

City data shows the number of calls to central intake continues to climb. In January, there were 411 calls to central intake; the numbers mounted to 749 in October.

The data also shows that in October, an average of 186 unhoused people per day went unmatched. This is almost eight times the rate in October 2021 rates. Gomes believes that’s a conservative estimate. Many people don’t call because they can’t tolerate the conditions in congregate shelters or have given up because they know they won’t find a spot.

Between January and October, 3,418 people were moved out of the shelter system to permanent housing, according to an email from the City of Toronto’s Shelter, Support and Housing Administration (SSHA).

Despite that, there is a rising demand for shelter beds, said Milton Barrera, project director of homelessness initiatives and prevention services at SSHA. “People are getting evicted from their rentals,” he said. “There are also more refugees.”

According to a November briefing by Gordon Tanner, SSHA general manager, 27 per cent of those currently in shelters are refugees, with 60 to 90 new people accessing the shelter system each week.

Meanwhile, the city is continuing to relocate people from the temporary hotel shelter beds that housed 2,500 people, sleeping one or two per room. Two sites with about 225 residents closed in the spring, another site with 250 beds will shutter by the end of this month and one is being converted to permanent affordable and supportive homes.

The SSHA’s stated goal is to find permanent housing for all former hotel residents, but Barrera admits there is not enough to go around.

According to city data, at one site alone, 251 people are losing their temporary hotel rooms and it is projected only 48 will find permanent housing. The remaining 203 will be out on the street and forced to seek shelter elsewhere.

Not all of the hotel bed closures are within the city’s control, according to Dr. Stephen Hwang, an internal medicine physician at St. Michael’s Hospital and the director of the MAP Centre for Urban Health Solutions. “Many owners are not willing to renew their leases,” he said. Most signed leases with the city during the pandemic when hotel occupancy was low and are now resuming their pre-pandemic businesses.

By Marlene Leung, Unity Health Toronto

In an office in downtown Toronto, a dedicated team of Unity Health researchers is using math to tackle some of the world’s most pressing health problems, including COVID-19, Ebola, HIV and human mpox (monkeypox).

The Research Group in Mathematical Modeling and Program Science develops and uses math models to better understand, analyze and predict epidemics. Housed within the MAP Centre for Urban Health Solutions and led by principal investigator Dr. Sharmistha Mishra, the lab includes data scientists, mathematical modelers, epidemiologists, biostatisticians, graduate students and research associates. Together, they use math and data to understand the factors driving infectious disease transmission in the hopes of helping to craft more tailored, impactful solutions.

Grounding the lab is a deep commitment to public health, equity and scientific inquiry, says Mishra, who is also a MAP scientist and infectious disease physician at Unity Health. This means taking nothing for granted about viruses, human behavior, and the structural factors that could be fueling disease transmission, she said.

“Our models are really part of the science that serves communities… we approach our modeling with that lens,” she said. “We challenge and interrogate assumptions that go into what we think we understand about epidemics.”

From the Toronto Star article

A fiery explosion beneath a Toronto bridge, which burned hot under the nighttime sky after propane tanks left in an encampment burst, is raising fears about how to keep the city’s homeless population safely warm this winter — particularly amid a growing squeeze on the shelter system.

The explosion took place late Saturday on Nov. 26. Officials didn’t know how the fire started, describing the setting as an empty encampment. No known injuries were sustained, and though transportation officers were dispatched to be sure, the bridge didn’t appear to suffer damage.

But the fiery scene illustrates a looming tension in Toronto. When winter sets in, those facing homelessness outdoors find ways to stay warm and stave off frostbite, in many cases involving propane heat that city and fire officials have labelled as dangerous. Those officials have urged people to come inside instead — but this year, that’s an especially tough task, with more than 180 people on average turned away each day in October after calling the shelter intake line.

And while a coroner’s inquest years ago recommended the city offer people safer heating sources in the wintertime — as a way to prevent death — it’s a suggestion that hasn’t been heeded.

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When people try to survive the winter outdoors, they often turns up in the St. Michael’s Hospital emergency room. Last winter, hospital staff reported a rising number of people arriving in search of shelter and help for cold-weather injuries. At least one person died of hypothermia.

“Every time someone dies of hypothermia, it’s unnecessary,” said Dr. Carolyn Snider, the hospital’s chief of emergency medicine. She suggested more advanced planning for when warming centres open based on forecasts of extreme weather, to give those staying on Toronto’s streets more notice. While the ER tries its best to hand out wool socks, hats, gloves and jackets to patients staying outdoors, she said places to properly warm up were critical.

By Jennifer Stranges, Unity Health Toronto

For more than two decades, St. Michael’s Hospital has led the way in HIV care and is now home to Ontario’s largest HIV program in Ontario, serving 1,700 patients.

It is also where you’ll find two dynamic healthcare leaders who have been here since the beginning. Dr. Gordon Arbess launched his career as a family doctor drawn to helping patients experiencing this deadly disease. Back then, he was also referring patients to Dr. Sean Rourke, a young neuropsychologist and scientist trying to understand and improve promising new treatments. “We bombarded Sean in those early days!” Dr. Arbess laughs.   

Today, Dr. Arbess is the Clinical Director of the HIV/AIDS program with the St. Michael’s Academic Family Health Team. Dr. Sean Rourke is a Scientist with MAP Centre for Urban Health Solutions and the Director of REACH Nexus, a national research group working on how to address HIV, Hepatitis C and other sexually transmitted and blood-borne infections.

We spoke with Arbess and Rourke about their long histories serving people with HIV and AIDS, how far treatment has come — and what still needs to be done.

Tell me about yourself and why HIV/AIDS is an area you’ve focused your career on.

Arbess: I’m a primary care physician at St. Michael’s and I initially started my career at the Wellesley Hospital before it merged with St. Mike’s. I fell into this area because I did medical school at Queen’s University and while there, I met an individual who was single-handedly going into the community and penitentiaries to treat people living with HIV and Hepatitis C – I was really intrigued. When I moved to Toronto and did my residency with Wellesley Hospital, I was drawn to the work. When the hospital merged with St. Michael’s – a Catholic hospital – there were concerns among those of us doing this work about what that would mean. But it panned out beautifully and we’ve always felt well supported. I feel fortunate to be doing this type of work. It’s extremely rewarding work and it touches on all facets of humankind.

Rourke: I’m a neuropsychologist by training and a scientist, but I see myself more as a social entrepreneur now. I have a similar path to the start of my career as Gord – I started at the Wellesley-St. Michael’s Hospital. It was my first job and I’m still here! 1995 was a critical juncture in HIV because combination therapy was coming online. There was a lot of optimism that those therapies would ‘solve everything’. The concern at the time in my area of expertise was if the medications would eliminate dementia, and they have, but they haven’t eliminated this milder condition. So I was recruited to set up a clinical research program to explore the brain and cognitive health, and that’s how I started to work with Gord over 25 years ago.

St. Michael’s is a place with incredible, extraordinary people who are so committed, and like Gord said, to have the hospital behind the work we do on the clinical side, research, education – it makes our lives busy, we’re always over-extended – but it’s a real pleasure to be in a place where you get so much support. Today my work is about this: there are so many solutions, now it’s about getting them to people.

From Starbucks Canada

The impact of AIDS is felt around the globe in communities and homes near and far. An estimated 38.4 million people worldwide are living with HIV as of the end of 2021 and 650,000 000 people died from AIDS-related illnesses in that same year, according to the UNAIDS. Progress is being made, but still four decades into the HIV response, inequalities persist for the most basic services like testing and treatment. 

This is why the Starbucks Canada Pride, Black, Pan-Asian and Indigenous Partner Networks are teaming up with MAP Centre for Urban Health Solutions, and I-AM.health, a first-in-Canada national program to raise awareness and action on HIV self-testing. Starbucks partners (employees) can visit I-AM.health/StarbucksPN to know their status and get access to free and completely anonymous HIV self-testing. 

“It is so special to collectively come together as Partner Networks, a vast and diverse representation of the Starbucks partner population, to raise awareness and action about HIV self-testing that is free and confidential, while also encouraging our partners to take their health into their own hands with such an incredible program like I’m Ready to Know. With World Aids Day around the corner, we wanted to show solidarity and demonstrate how our partners are united with the cause.” 

-Steven Snyder, co-chair of Canada Pride Partner Network

From the Canadian Medical Association Journal press release

A modelling study to explore optimal allocation of vaccines against monkeypox virus (MPXV) provides a road map for public health to maximize the impact of a limited supply of vaccines. The article, published in CMAJ (Canadian Medical Association Journal) https://www.cmaj.ca/lookup/doi/10.1503/cmaj.221232, confirms that prioritizing vaccines to larger networks with more initial infections and greater potential for spread is best.

“We hope that these insights can be applied by policy-makers across diverse and dynamic epidemic contexts across Canada and beyond to maximize infections averted early in an epidemic with limited vaccine supply,” says Dr. Sharmistha Mishra, MAP Centre for Urban Health Solutions, Unity Health Toronto.

As of November 4, 2022, there were 1444 cases of MPXV in Canada, disproportionately among gay, bisexual and other men who have sex with men (GBMSM). A very limited supply of smallpox vaccines is available and is being prioritized to populations experiencing disproportionate risks.

Researchers modelled two hypothetical cities as interconnected networks with a combined GBMSM community size of 100 000. The team then varied the characteristics of the two cities across a range of plausible settings and simulated roll-out of 5000 vaccine doses shortly after the first detected case of MPXV.

They found that the strongest factors for optimal vaccine allocation between the cities were the relative reproduction number (epidemic potential) in each city, share of initial cases, and city (or network) size. If a larger city had greater epidemic potential and most of the initial cases, it was best to allocate the majority of vaccines to that city. The team varied the reproduction number with a single parameter, but they highlight how many factors could influence local epidemic potential, including the density and characteristics of the sexual network, access to prevention and care, and the underlying social and structural contexts that shape both sexual networks and access.

“Under our modelling assumptions, we found that vaccines could generally avert more infections when prioritized to a larger network, a network with more initial infections and a network with greater epidemic potential,” writes Jesse Knight, lead author and PhD candidate at the University of Toronto and MAP Centre for Urban Health Solutions, Unity Health Toronto. “Our findings further highlight the importance of global vaccine equity in responding to outbreaks, and also in preventing them in the first place,” he says.

The study emphasizes the interconnectedness of regions and that a population-level perspective is necessary.

“Strategic prioritization of a limited vaccine supply by network-level risk factors can maximize infections averted over short time horizons in the context of an emerging epidemic, such as the current global MPXV outbreak,” conclude the authors.