n any given night, more than half a million people in the United States 1 and more than 35 000 in Canada 2 experience homelessness. Homelessness has always been associated with poor health outcomes, 3 but its risks to health have only been heightened by coronavirus disease 2019 (COVID-19), with consequences extending to the broader community. People experiencing homelessness are at increased risk of acquiring severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections and spreading the virus to others. 4,5 Many people experiencing homelessness stay in congregate living settings such as shelters, where it is difficult to practise social distancing. Others live rough, on the street or in encampments, and do not have access to basic hygiene supplies or showering facilities. In any of these scenarios, selfisolation is not possible. People who experience homelessness also have higher rates of chronic conditions such as diabetes and hypertension, which puts them at increased risk of complications if they acquire the infection. 3,6 Recent data from Boston suggest that people experiencing homelessness have a higher prevalence of SARS-CoV-2 positivity 7 and more severe

Our findings can inform new interventions that focus on employment as a social determinant of health. Although hiring a dedicated employment specialist may not be feasible for most primary care organizations, pathways using existing resources with links to external agencies can be created. As precarious work becomes more common, helping patients engage in safe and productive employment could improve health, access to health care, and well-being.

Background Financial strain is a key social determinant of health. As primary care organizations begin to explore ways to address social determinants, peer-to-peer interventions hold promise. Objective Our objective was to evaluate a peer-to-peer intervention focussed on financial empowerment delivered in primary care, in partnership with a social enterprise. Methods This intervention was hosted by a large primary care organization in Toronto, Canada. Participants were recruited within the organization and from local services. We organized three separate groups who met over 10 weekly in-person, facilitated sessions: millennials (age 19–29) no longer in school, precariously employed adults (age 30–55) and older adults near retirement (age 55–64). We applied principles of adult education and peer-to-peer learning. We administered surveys at intake, at exit and at 3 months after the intervention, and conducted three focus groups. Results Fifty-nine people took part. At 3 months, participants had sustained higher rates of optimism about their financial situation (54% improved from baseline), their degree of control (55% improved) and stress around finances (50% improved). In focus groups, participants reported greater understanding of their finances, that they were not alone in struggling with finances, and that it was useful to meet with others. One group continued to meet for several months after the intervention. Conclusions In this study, a peer-to-peer intervention helped address a key social determinant of health, likely through reducing stigma, providing group support and creating a space to discuss solutions. Primary care can host these interventions and help engage potential participants.

Objectives: Efforts to contain the COVID-19 pandemic should take into account worsening health inequities. While many public health experts have commented on inequities, no analysis has yet synthesized recommendations into a guideline for practitioners. The objective of this rapid review was to identify the areas of greatest concern and synthesize recommendations.Methods: We conducted a rapid systematic review (PROSPERO: CRD42020178131). We searched Ovid MEDLINE, Embase, PsycINFO, CINAHL and Cochrane Central Register of Controlled Trials databases from December 1, 2019 to April 27, 2020. We included English language peer-reviewed commentaries, editorials, and opinion pieces that addressed the social determinants of health in the context of COVID-19.Results: 338 articles met our criteria. Authors represented 81 countries. Income, housing, mental health, age and occupation were the most discussed social determinants of health. We categorized recommendations into primordial, primary, secondary and tertiary prevention that spoke to the social determinants of COVID-19 and equity.Conclusion: These recommendations can assist efforts to contain COVID-19 and reduce health inequities during the pandemic. Using these recommendations, public health practitioners could support a more equitable pandemic response.Systematic Review Registration: PROSPERO, CRD42020178131.

Background Effective treatment has extended the life expectancy and reduced disability in people living with HIV (PLWH). However, previous research has found 45–65% of working-age PLWH were unemployed compared to 5–10% in the general public of North America and Europe. We examined the barriers to gaining employment among PLWH. Methods Thirty-five in-depth interviews were conducted in person or over the phone with PLWH living in Toronto or Ottawa. This included PLWH who were unemployed but actively seeking employment, as well as PLWH who had successfully gained employment through an agency that specifically supported PLWH funded by the AIDS Committee of Toronto. Interviews were conducted between February 2019 and March 2020. All interviews were audio-recorded, transcribed and analyzed using thematic analysis. Results The majority of participants were between the ages of 40–55 and identified as male. Participants shared many common barriers when describing their attempts to attain or maintain employment. Although varying in employment status at the time of the study, consistent barriers included experiencing HIV stigma in workplaces, challenges overcoming mental health illnesses, and difficulties in navigating social assistance and unemployment insurance programs when pursuing a return to work. Conclusions PLWH face significant barriers when attempting to engage with employment opportunities. Health providers and organizations can do more to support campaigns to end HIV stigma, to support individuals in pursuing employment, and to advocate for policy change that supports reentry into the workforce for PLHA.

Background: Antivirals for the treatment of hepatitis C virus (HCV) infection are effective, but many patients remain untreated and treatment is not yet routine in primary care. We evaluated the characteristics of patients who engaged in HCV treatment, and clinician perspectives on the barriers and facilitators to treatment. Methods: Our mixed-method, parallel-design study was conducted at a multisite primary care centre in downtown Toronto. In a retrospective chart review, we searched records from 2011 to 2017 to collect quantitative data, including HCV infection status and HCV treatment status. To contextualize the data, we conducted in-depth interviews with select physicians between Aug. 1 and Nov. 1, 2017, and analyzed the transcripts using content analysis. Results: Of the 40 381 charts reviewed, 727 patients (1.8%, 95% confidence interval [CI] 1.7%-1.9%) were infected with HCV, and 542 (74.6%) had HCV infection requiring treatment. Of those, 255 patients (47.0%) had engaged in treatment. Patients who had engaged in treatment were more likely to be male (odds ratio [OR] 1.63, 95% CI 1.10-2.42), older (OR 1.04 per year increase in age, 95% CI 1.02-1.05) and housed (OR 2.2, 95% CI 1.36-3.75), and they were more likely not to have engaged in injection drug use (OR 1.87, 95% CI 1.33-2.63). Based on interviews with 8 physicians, treatment barriers included a lack of knowledge about HCV treatment, concerns that patients would not adhere to medications and challenges related to medication access. Facilitators of treatment included access to specialist consultation, pharmacist support and primary care treatment guidelines. Common themes that emerged in both quantitative and qualitative components were the roles of unstable housing and intravenous drug use as barriers to engaging in and completing treatment. Interpretation: Our study captured provider-identified barriers to HCV care and the key factors related to retention in HCV care, including gender, age, housing status and experience with drug use. Successful primary-care-led HCV treatment programs may incorporate specialist and pharmacy support and focus on younger, female, underhoused populations and people who use drugs.

Hwang reports grants from the Canadian Institutes of Health Research and participation on the data safety monitoring board for a study on smoking cessation. He has roles with the board of directors of Good Shepherd Ministries, the research committee of the National Health Care for the Homeless Council and with Inner City Health Associates. No other competing interests were declared. This article has been peer reviewed.

Among those visiting a testing centre in Toronto, ON, between March and April 2020, people experiencing homelessness ( n = 214) were more likely to test positive for COVID-19 compared with those not experiencing homelessness ( n = 1,836) even after adjustment for age, sex and medical co-morbidity (15.4% vs. 6.7%, p < 0.001; odds ratio [OR] 2.41, 95% confidence interval [CI: 1.51, 3.76], p < 0.001).