In the mid-1990s, Saskatchewan had the lowest incidence of both HIV and AIDS in the country. To put it mildly, things have changed. The rise in the number of new cases since the early 2000s has been dramatic—catapulting from 26 in 2002 to 200 seven years later. Last year Saskatchewan physicians called on the provincial government to declare a public health state of emergency over the high number of people diagnosed with HIV, especially in Indigenous communities, where rates have become comparable to those in some African countries. The Prairie province now has the highest prevalence of HIV in Canada, at almost two and a-half times the national average, or 14.5 cases per 100,000 people.

Since the province started reporting HIV cases in 1985, more than 2,200 cases have been identified, the bulk of them (73 per cent) diagnosed in the past 10 years. Between 2007 and 2016, 1,608 have been reported, tripling the 463 cases found in the previous decade. The number of new cases since 2007 peaked in 2009 at 200, and reached its decade-low in 2014 (112). “I think that was seen as evidence that the problem was solved, says Dr. Stephen Sanche, the head of the infectious diseases department of the Saskatoon Health Region and one of the experts to raise the alarm last year. “But those of us on the front lines could see that this was far from over.” Indeed, in 2016, the number of new diagnoses bumped back up to 170—a six per cent increase over the previous year.

What is clearly an emergency, Saskatchewan physicians say, has not been treated as such by the provincial government. “It seems to be going in the wrong direction,” says Dr. Kris Stewart, a physician who specializes in HIV care. “The humanitarian consequence of this is profound.” Stewart expects the incidence of infection in 2017 to be similar to that of 2016.

The key driver of this spike has been injection drug use. According to a 2016 report from Saskatchewan’s ministry of health, cases have shifted from urban centres to rural and remote areas. In 2007, Regina and Saskatoon made up nearly 75 per cent of all new HIV cases, but by last year that share had been sliced in half (35 per cent). Part of the cities’ success in recent years, Sanche says, has been creating better access to addictions services in cities, and linking HIV therapy to methadone—a drug used to treat opioid addictions. But these services are scarce in rural environments. The result, Stewart and Sanche say, is people being diagnosed later in their lives when it’s more difficult to return to normal health.

“We need to have a centrally developed and coordinated strategy with a clinical lead, who has access to a budget and who can look at the province and direct resources to where we need it,” Stewart says. Patients who are on treatment, Stewart reassures, have a near-zero risk of passing on HIV.

That’s not to say the challenges in urban areas have gone away. At Sanctum, Saskatchewan’s first hospice for people living with HIV/AIDS, there is a growing demand for services. The 10-bed facility in Saskatoon operates on referrals and almost always has patients waiting in line to get in. “If we opened up to the community, we would have a never-ending wait-list,” says Katelyn Roberts, the executive director. There needs to be more funding, she notes, for addiction and housing services: “Somebody living with HIV without support and who’s homeless in our community will die within five years.”

Saskatchewan’s annual budget to support HIV services and programs has gone almost unchanged since 2010. Between 2011-12 and 2015-16, the budget remained firmly at $3,956,000. For Sanche, it’s a clear disconnect from what they could be doing and what they are actually doing: “We know what needs to be done, we just haven’t been given the tools to do so.”

The Saskatchewan Ministry of Health says it did not declare a public health state of emergency in 2016 because there are already legislated provisions guiding health authorities to prevent the spread of HIV. In a statement to Maclean’s, the ministry said declaring a public health emergency “would not result in any additional measures under the Public Health Act, 1994, that would assist in addressing this blood-borne disease, nor would it result in any changes to the current plan to address HIV in the province.”

For Indigenous communities, the HIV crisis has been particularly devastating. Dr. Ibrihim Khan, Health Canada’s regional medical health officer responsible for Saskatchewan First Nations, says there are 108 cases of HIV per 100,000 for Indigenous people living on southern reserves. “The rates are alarmingly high, but the work is incredible and there’s always the evidence that it’s working to reduce the rates,” Khan says.

Still, in 2016, out of the 170 new cases in Saskatchewan, 79 per cent identified as Indigenous—only slightly down from 81 per cent a year earlier. Three First Nations communities (Cote, Key and Keeseekoose) in southern Saskatchewan are experiencing an HIV outbreak, in a region that had an eight-fold increase in HIV cases in 2016.

To tackle the crisis, the federal government’s newly formed Indigenous Services Canada has established 23 HIV testing sites, 19 harm reduction programs and 13 mobile nursing teams in Saskatchewan First Nations. “The program’s aim is to have zero new HIV diagnosis in the future, hopefully by 2020,” Khan says, noting that there are plans to add these services to more communities next year.

Others are less optimistic, given the latest numbers and distance these communities are from health-care hubs in Regina or Saskatoon. “The people that are most affected don’t have a strong political voice,” Stewart says. For him, the reluctance to declare the situation a humanitarian emergency perpetuates the idea that nothing can be done about HIV, thus deterring those infected from seeking treatment out of fear of social isolation. “HIV really suffers from the kind of stigma that existed in the world in the mid-80s,” he says. “It still exists here in Saskatchewan.”