British Columbia, once the province with the highest rate of HIV infections in Canada, has become a model for prevention and treatment. A new study from the BC Centre for Excellence in HIV/AIDS confirms that people with HIV in the province are now living significantly longer due to advancements in treatment and harm reduction strategies. However, the study also highlights a growing disparity: while men with HIV have seen significant improvements in life expectancy, women have not benefited at the same rate. The findings raise questions about whether medical advancements have been equally accessible and which barriers continue to affect certain populations.
Two decades ago, Vancouver’s Downtown Eastside had one of the highest HIV infection rates in the developed world, driven by injection drug use, limited healthcare access, and homelessness. Today, BC reports historically low transmission rates, largely due to the widespread availability of antiretroviral therapy and harm reduction programs. However, recent data indicates that declines have been slower among Indigenous people and women, who now represent a disproportionate share of new infections. Researchers caution that maintaining BC’s progress will require adapting prevention strategies to address these ongoing disparities rather than relying solely on past treatment successes.
Understanding how BC moved from an HIV crisis to a global leader in prevention requires looking beyond medical advancements alone. The province’s response was shaped by shifting public health policies, legal battles over harm reduction, and evolving strategies in disease management. At the same time, the persistence of inequalities in HIV outcomes today raises critical questions: have the successes of the past left some populations behind, and what must be done to prevent new challenges from reversing decades of progress?
The Downtown Eastside’s HIV Crisis in the 1990s
By the mid-1990s, Vancouver’s Downtown Eastside had one of the highest HIV infection rates in the developed world, with transmission levels comparable to those seen in regions experiencing severe public health emergencies. The crisis was driven mainly by widespread injection drug use, a lack of harm reduction programs, and structural issues such as homelessness and inadequate healthcare access. At the height of the epidemic, approximately 19 percent of people who used injection drugs in the neighbourhood were living with HIV. This statistic underscored how rapidly the virus spread among the most vulnerable populations.
British Columbia’s public health response during the early years of the crisis was widely regarded as inadequate. Needle-sharing remained common due to the limited availability of sterile syringes, and existing programs were insufficient to slow the rate of new infections. At the same time, law enforcement crackdowns on drug use led to riskier injection practices, forcing individuals to use drugs in unsanitary and unsafe conditions. The absence of coordinated harm reduction efforts allowed HIV to spread unchecked, particularly among those experiencing homelessness or engaging in sex work.
Public health failures in the 1990s made it clear that BC’s HIV response needed drastic reform. As infection rates climbed, medical experts and frontline organizations pushed for a shift away from enforcement-driven strategies and toward a healthcare-first model. Dr. Julio Montaner and his team at the BC Centre for Excellence in HIV/AIDS argued that access to early treatment should be expanded, while community-led programs like the Portland Hotel Society sought to integrate housing with healthcare for those most at risk. These early advocacy efforts set the stage for a radical rethinking of HIV policy, which would later influence provincial and national health strategies.
How British Columbia Became a Global Leader in HIV Prevention
By the early 2000s, British Columbia took a new approach to HIV, shifting from reactive public health measures to a treatment-based strategy aimed at stopping transmission altogether. The previous focus on containment had failed to curb rising infections, particularly in Vancouver’s Downtown Eastside, prompting health officials to pursue a model that treated the virus as a medical and public health challenge. This shift resulted in broader access to highly active antiretroviral therapy (HAART), which research had shown could lower viral loads to undetectable levels, significantly reducing transmission.
A major step in this transformation came with the introduction of Treatment as Prevention (TasP), which linked expanded HAART access to broader public health goals. Under this model, early and consistent treatment became the centrepiece of British Columbia’s HIV strategy, reducing the overall prevalence of the virus in the population. Provincial health authorities integrated TasP into routine care, ensuring that more people living with HIV could access life-saving medications at no cost. This strategy not only reduced deaths and transmission rates but also positioned BC as a global leader in treatment-based HIV prevention.
Harm reduction initiatives provided additional support, though their implementation faced political resistance. Insite, North America’s first supervised injection site, opened in 2003 after years of legal and public debate. While its role in reducing HIV transmission was initially questioned, studies later confirmed that providing safer spaces for drug use helped prevent new infections by reducing needle sharing and increasing access to medical care. The combination of expanded treatment and harm reduction helped drive HIV rates in BC to historic lows, setting a model that was later studied and replicated internationally.
The Gender and Indigenous Disparity
Despite British Columbia’s success in reducing overall HIV infections, not all populations have benefited equally. Women living with HIV in the province have a significantly lower life expectancy than men despite receiving the same medical treatments. Indigenous people, particularly Indigenous women, are also disproportionately represented among new infections, accounting for nearly 30% of all recent HIV cases, even though they make up only 6% of the province’s population. This trend has persisted even as overall transmission rates decline. These disparities highlight systemic issues in healthcare access, social conditions, and the limitations of treatment-focused HIV strategies.
One explanation for the gender gap in life expectancy is that women with HIV often face additional health complications unrelated to the virus itself. Higher rates of poverty, unstable housing, and gender-based violence increase barriers to consistent medical care. Women are also more likely to be diagnosed at later stages of infection, delaying access to antiretroviral treatment. Indigenous women, in particular, experience even greater obstacles due to higher rates of injection drug use, limited healthcare access in remote communities, and socioeconomic instability that increases vulnerability to HIV transmission. The standard approach to HIV treatment assumes that once medication is made available, people will adhere to it consistently, but this assumption does not account for the challenges faced by women and Indigenous people in unstable living situations.
Some argue that these disparities are not failures of the medical system but rather a reflection of broader social inequities that extend beyond HIV treatment. Others counter that this view ignores gaps within the healthcare system itself. Medical outreach programs designed for men may not be as effective for women, particularly those who experience intimate partner violence or fear disclosing their status. Indigenous-led health initiatives have attempted to address these concerns by integrating culturally safe care models, but access remains inconsistent across the province. If British Columbia is to eliminate new HIV infections, addressing these systemic inequalities will be as important as continuing advancements in medical treatment.
The Current State of HIV in British Columbia
British Columbia has made significant progress in reducing new HIV infections, but recent data suggests that transmission rates may no longer be declining as sharply as before. The widespread use of antiretroviral therapy and harm reduction initiatives has driven cases to historic lows, yet public health officials remain cautious about declaring an end to the epidemic. A closer look at emerging trends reveals areas of concern, particularly among high-risk populations who continue to experience new infections at disproportionate rates.
One challenge is the number of undiagnosed cases, which remains an obstacle to complete disease control. While routine testing has expanded, some individuals—especially those in marginalized communities—continue to be diagnosed at later stages, limiting the effectiveness of early treatment. Additionally, despite the success of harm reduction strategies, shifts in drug use patterns and socioeconomic conditions may be influencing transmission in ways that are not yet fully understood. Some experts warn that as public awareness of HIV has decreased due to lower case numbers, there is a risk of complacency, particularly among younger populations who may not perceive the virus as a serious health threat.
There is also ongoing debate over whether British Columbia’s HIV response has focused too heavily on medical treatment at the expense of broader prevention efforts. While expanding access to antiretroviral therapy has proven effective, critics argue that social determinants of health—such as housing instability, mental health, and economic inequality—continue to drive transmission. If these factors are not addressed alongside medical intervention, public health officials may struggle to eliminate new infections entirely. The province’s achievements in HIV prevention are undeniable, but the question remains: is British Columbia on the verge of eradicating the virus, or have the limits of its current approach already been reached?
The People and Organizations Fighting HIV in BC
While British Columbia has made significant progress in controlling HIV, the work of reducing transmission and improving care is far from over. A network of healthcare providers, researchers, and community organizations continues to drive efforts in prevention, treatment, and advocacy. These groups play an essential role in reaching populations that remain at high risk, particularly those in remote areas or living with complex social challenges.
The BC Centre for Excellence in HIV/AIDS remains at the forefront of scientific advancements, conducting research that informs treatment strategies not only within the province but internationally. Its work in expanding the availability of pre-exposure prophylaxis (PrEP) has provided a preventive option for people at risk of contracting HIV, yet access remains inconsistent outside major urban centres. Organizations such as the Dr. Peter Centre integrate clinical care with housing and support services, recognizing that effective treatment often requires addressing broader health and social needs. Meanwhile, public health teams in Northern BC and on Vancouver Island continue to navigate the challenge of delivering HIV services in areas with fewer specialized healthcare providers.
Community-led initiatives also remain essential, particularly for Indigenous populations and people who use drugs. Indigenous-led health programs work to improve culturally safe care, bridging gaps in trust between communities and mainstream healthcare services. In the Downtown Eastside, outreach teams distribute harm reduction supplies while also facilitating connections to treatment. However, with shifting public health priorities and finite funding, the sustainability of these programs remains a concern. The organizations leading BC’s HIV response face an ongoing challenge: ensuring that progress is maintained while adapting to new risks and emerging health crises.
The Future of HIV in British Columbia
The province’s approach to HIV has transformed the province from a crisis zone to a global model of disease control. The expansion of antiretroviral therapy, harm reduction initiatives, and widespread testing has driven infection rates to record lows. Yet, a closer look at the current landscape reveals that progress is neither universal nor guaranteed to continue. The remaining challenges—disparities in treatment outcomes, gaps in prevention efforts, and shifting public health priorities—will determine if BC is truly working toward eliminating HIV or merely containing its spread.
Public health officials have long relied on the assumption that expanding treatment access will eventually eliminate HIV. While this approach has significantly lowered overall transmission rates, new infections remain concentrated in specific populations. Indigenous people and women continue to be overrepresented in recent cases, indicating that medical treatment alone has not closed the gap. Researchers have identified key barriers, including housing instability, limited mental health services, and healthcare shortages in remote areas. Some experts argue that addressing these factors is essential for further reducing infections, while others caution that shifting focus away from treatment-based prevention could undermine past progress.
HIV in British Columbia is no longer the crisis it once was, but the province has not yet reached the stage where it can declare victory. The steady decline in new infections is an achievement built on decades of medical advancement and public health reform, but the virus persists in places where treatment alone cannot reach. The real test of BC’s success will not be measured solely by how few new cases are recorded in the coming years, but by whether those who remain most at risk are finally included in the progress.
Monika is a dedicated Downtown Eastside activist and youth counsellor with extensive experience working alongside British Columbia and California community organizations. Passionate about harm reduction and youth empowerment, Monika’s advocacy focuses on creating impactful programs, offering a voice to those often overlooked.
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