Towards anti-colonial approaches in social work: Enhancing culturally safe HIV care for Indigenous communities in Manitoba and Saskatchewan

Abstract

The social work profession, with historical ties to colonial harm, must adopt decolonizing and anti-colonial approaches to promote culturally safe HIV care for Indigenous communities. This study examines how the COVID-19 pandemic disrupted health and social services throughout Manitoba and Saskatchewan, significantly limiting access to essential services and traditional practices for Indigenous peoples living with HIV. Using a Two-Eyed Seeing approach, this study integrates Indigenous and Western research approaches. Community-based participatory research and Indigenous Storywork comprised the overall research design. An Indigenous Elder, a cultural knowledge holder, and a community guiding circle of Indigenous peoples living with HIV helped guide the project. Qualitative interviews were conducted with 51 participants, recruited through community organizations, social media, and peer networks. The pandemic's impact on health, access to services, and ceremonies were explored. Data was analyzed using thematic analysis grounded in Indigenous Storywork principles. The pandemic significantly impacted traditional ceremonies, vital for the spiritual and communal well-being of Indigenous peoples living with HIV. Participants displayed resilience by adapting spiritual practices amidst restrictions. Social workers and other service providers acknowledged the crucial role of ceremonies in offering spiritual and cultural connection but showed varying levels of knowledge in connecting Indigenous clients to ceremonial practices, some facing organizational and systemic barriers. This study advocates for a systemic shift in social work to adopt decolonizing and anti-colonial practices that integrate Indigenous knowledge, ceremonies, and medicines. Such an approach advances culturally safe HIV care that respects Indigenous sovereignty, promotes wholistic well-being, and actively addresses structural colonial violence.

Introduction

Social work as a profession has an enduring history of contributing to the harmful effects of colonization; incorporating decolonizing and anti-colonial methods is of vital importance for social workers practicing in the fields of HIV/AIDS and health. The significance of the need for this work is further amplified within the context of a dual pandemic – HIV and COVID-19 – in Manitoba and Saskatchewan Canada, where Indigenous peoples are disproportionately represented among new HIV diagnoses (Challacombe, 2024). Currently, while stressing the importance of a wholistic and person-centered model in social work provision, our health and social care systems are largely based off a Western medical model which frequently pathologizes Indigenous lives (Lavallee and Poole, 2010). Internalized colonial ideas still exist within individuals and our health and social care systems, and these hinder the need for Indigenous ways of knowing and sovereignty to flourish (Krusz et al., 2020). Within the health and social care system in Canada, there has been long-standing systemic anti-Indigenous racism stemming from the history of settler colonialism and abuse (e.g., residential schools, the Sixties Scoop) within this country. The harm often caused by this phenomenon can predispose people to physical, mental, and sexual health inequities (PHAC, 2021; Ristock et al., 2010; Southern Chiefs Organization, 2021). Increasing HIV diagnoses among Indigenous peoples in Manitoba and Saskatchewan, two prairie provinces in Canada, underscores this reality.

Indigenous-led HIV/AIDS organizations have brought forward peer defined meaningful provisions to care for decades, noting the need for relational-based care, Indigenous representation among care providers, and connection to traditional wellness practices (Reading et al., 2013). Understanding the role of ceremony and culture for Indigenous Peoples living with HIV (IPLH) in Manitoba and Saskatchewan during the initial years of the COVID-19 pandemic (2020-2022), along with service providers’ comfort and awareness in connecting these elements to care, offers insights for social workers to enhance their support for IPLH. With the rising rates of HIV among Indigenous peoples in Manitoba and Saskatchewan (Challacombe, 2024), a culturally responsive approach is urgently needed in HIV care. Social workers play a key role in healthcare systems and contribute to the overall well-being of individuals and communities. Given social workers’ responsibility to familiarize themselves with the communities they serve, a comprehensive understanding of Indigenous ways of knowing, doing, and being is crucial in working with IPLH. The purpose of this paper is to equip social workers with the tools and knowledges of enhancing culturally safe care for IPLH in Manitoba and Saskatchewan through decolonizing and anti-colonial approaches.

Literature review

Saskatchewan and Manitoba, two Canadian prairie provinces, make up only approximately 6.6% of the country’s population (Statistics Canada, 2024), yet respectively have the highest rates of HIV with nearly three times the national diagnosis rate (Public Health Agency of Canada, 2023). The COVID-19 pandemic had a significant impact on how health and social services were delivered throughout Manitoba and Saskatchewan. Provincial wide states of emergency were called in Saskatchewan and Manitoba on March 18 and 20, 2020 respectively and lasted until July 11, 2021, and October 21, 2021, respectively. Altered public health orders resulted in physical distancing, prolonged periods of social isolation, and restricted access to health and social services. During this time HIV numbers steadily increased across the country with Manitoba and Saskatchewan having a combined new diagnosis rate twice as high as all other Canadian provinces (Public Health Agency of Canada, 2023). Indigenous peoples are disproportionally represented within these growing numbers and have an infection rate nearly 4 times higher than non-Indigenous peoples (Challacombe, 2024). Given these numbers and the historical and ongoing oppression caused by colonialism across Turtle Island (Canada), it is not surprising that Saskatchewan and Manitoba also have the highest population proportion of Indigenous peoples than any other province (Government of Alberta, 2023). The need for more culturally relevant care is clear in light of these disparities.

The HIV care cascade references the connection to care and subsequent outcomes following an HIV diagnosis. For a variety of systemic reasons, such as those previously mentioned, individuals fall off this continuum of care and are unable to progress to an achievable viral suppression (Hosein, 2022; Mbuagbaw, 2024;). The COVID-19 pandemic has significantly impacted IPLH and the HIV care cascade throughout Manitoba and Saskatchewan (Larcombe et al., 2023 & Souleymanov et al., 2024). Although there were substantial changes to services throughout the COVID-19 pandemic, Indigenous agencies adapted service delivery to retain culturally relevant components including, delivery of items such as beading to homes as well as providing community with tablets for online smudging and sharing circles (Christianson, 2024; Watson et al., 2022). The availability of cultural practices of those seeking it was an important aspect of overall health and well-being for Indigenous peoples throughout the COVID-19 pandemic (Souleymanov et al., 2024). Decolonizing the HIV care cascade through the direct implementation of culturally relevant practices along with the centering of Indigenous voices is a necessary component of enhancing the health and well-being of IPLH (Hillier et al., 2020). This concept can encourage social workers to think how to create spaces where Indigenous communities are heard and respected, as well as opportunities for the appreciation of diverse ways of knowing within healthcare, and culturally relevant systems (Larcombe et al., 2020). Indigenous peoples and those with lived experience have knowledge and teachings that must be incorporated into the provision of care for IPLH.

There have been several peer-based research projects conducted across Turtle Island grounded in Indigenous knowledges which provide culturally relevant care and pathways to support for IPLH. One of which includes the Community-Based Research Centre’s medicine bundle pilot which initially provided Indigenous peoples in British Columbia, later expanded to across Canada, with medicine bundles containing both traditional medicines and safer sex resources as a more wholistic approach to sexuality (Kulkarni, 2022). Another example includes the educational campaign called Strong Medicine (developed with and for IPLH) which weaves together Indigenous culture and Western knowledges of HIV treatment and testing (CATIE, 2024). Importantly, the call for culturally relevant care for IPLH has been present among Indigenous led organization such as CAAN (Communities, Alliances & Networks) formerly known as Canadian Aboriginal AIDS Network, since the beginning of the AIDS epidemic in Canada in the late twentieth century (CAAN, 2024).

Some scholars also provided a model of Indigenous-led, community-based research that addresses the health and wellbeing of Indigenous women living with HIV in Canada (Peltier et al., 2020). This study by Peltier and colleagues (2020) underscored the need for service delivery models that align with Indigenous ways of knowing, as opposed to Western frameworks, offering a template for anti-colonial service provision that advances both culturally congruent HIV care and broader reconciliation goals. Their study highlighted the importance of Indigenous-led approaches in dismantling colonial health structures and supports the movement toward self-determined, culturally respectful service delivery. Additionally, a study out of California in the United States of America conducted by Masotti et al. (2023), using the Cultural Connectedness Scale in Canada, found that the incorporation of culture into health and social services for Indigenous peoples was a predictor for better mental and physical health days. Masotti et al. (2023) draw the conclusion that for Indigenous peoples, culture is a social determinant of health and just as the loss of it is a risk factor, “strengthening, reconnecting, or reclaiming is protective on multiple levels” (p. 2). A similar understanding of the role of culture within HIV prevention was brought forward by Wilson et al. (2016) who highlight the voices of Indigenous youth and their perspectives on focusing on HIV prevention through cultural teachings focusing on aspects such as respect and balanced living; teachings they attributed as commonly being done through connections with Elders.

Some non-profit organizations in Saskatchewan and Manitoba have taken it upon themselves to offer culturally relevant programming to IPLH, though not yet formally incorporated into the HIV care models. The Mino Pimatisiwin Sexual Wellness lodge at Ka Ni Kanichihk in Winnipeg, Manitoba partners with health clinics and front-line workers to address the prevention and treatment of HIV and STBBIs while simultaneously offering traditional medicines and guidance in traditional healing through elders, grandmothers, and aunties (Ka Ni Kanichihk Inc., 2024). A Place of Hope, through All Nations Hope Network, located in Regina, Saskatchewan offers a wide range of social and health programming supports to IPLH. A safe space as well connection to Elders and ceremony is also incorporated into programming (All Nations Hope Network, 2024). These adaptations and community-driven approaches underscore the urgent need for a structured framework in HIV care that not only recognizes but centers cultural safety and Indigenous knowledges.

The First Nations Health Authority (2024) describes cultural safety as “an outcome based on respectful engagement that recognizes and strives to address power imbalances inherent in the health care system. It results in an environment free of racism and discrimination, where people feel safe when receiving health care”. Access to culturally safe services throughout the HIV care cascade is imperative for IPLH and is done through client-provider relationship, building on existing support systems, and addressing other health and wellness concerns aside from HIV (Jongbloed et al., 2019; Skov et al., 2024). Social workers within the HIV care cascade are positioned to help bridge connections for IPLH into the health and social care systems and should utilize the knowledge shared by those with lived experience and connections to resources in community to help facilitate culturally safe care for IPLH accessing health and social services.

Theoretical framework

Western dominance in knowledge systems often conditions both knowing and doing, resulting in entrenched perspectives that shape practice (Bainbridge et al., 2015). Within the field of social work, ethical responsibilities—particularly those tied to social justice, competence, and commitments to Truth and Reconciliation (Canadian Association of Social Work, 2024)—demand accountability to decolonial and anti-colonial frameworks. Health scholars highlight that these approaches are necessary to dismantle the power imbalances in health systems that perpetuate settler violence, which continues to harm IPLH (Lawrence and Hirsch, 2020). Decolonizing approaches involve critically examining and resisting the colonial structures that pervade Western knowledge systems. Linda Tuhiwai Smith (2021) articulates that decolonizing methods do not aim to abandon Western knowledge entirely; rather, they create a framework that interrogates colonial societal constructs while ensuring space for diverse worldviews. Decolonial practices in Indigenous health and HIV can guide mainstream agencies in shifting towards culturally responsive services that honor Indigenous worldviews (Haynes et al., 2021; Hillier et al., 2020; Reading and Nowgesic, 2002). This shift encourages a critical perspective on the assumptions underlying mainstream health systems and practices and opens pathways for alternative ways of delivering healthcare.

Anti-colonialism, distinct from decolonizing approaches, goes beyond inclusion and critique to center Indigenous knowledge and resist ongoing colonial power dynamics. It emphasizes Indigenous leadership in addressing healthcare injustices and the prioritization of Indigenous values and knowledge systems as central pillars, not merely as complementary perspectives. Anti-colonialism situates itself as a social, cultural, and political stance against colonialism’s ongoing harms (Hart, 2009). When formulating the structure of an anti-colonial approach in social work, it is pivotal that Indigenous knowledge is centered, methods are rooted in spirituality, and key concepts such as respect, wholeness, relationality, balance, and mino-pimatisiwin (the good life) are honored (Hart, 2009).

To address Indigenous health injustices effectively, deconstruct biased perspectives, and ensure cultural safety in practice, social workers can adopt decolonizing or anti-colonial approaches in their practice and research (Gray et al., 2013; Haynes et al., 2021). Such approaches are essential for disrupting the entrenched patterns of structural violence that affect IPLH within healthcare systems. Structural violence, as articulated by Farmer (1999), refers to the social and institutional structures that inhibit individuals’ ability to reach their full potential, disproportionately impacting marginalized communities. For IPLH, structural violence manifests as systemic barriers to equitable healthcare, rooted in colonialism and reinforced by social and economic inequalities that extend far beyond the medical aspects of HIV.

Farmer (1999) argues that diseases like HIV are not simply medical issues; they are profoundly shaped by broader structural determinants. This perspective is critical to understanding the unique challenges IPLH face, particularly highlighted during the COVID-19 pandemic when limited healthcare access and harm reduction resources intensified existing inequities. Farmer’s (1999) framework reveals the disconnect between the healthcare needs of IPLH and the structural realities of healthcare delivery, emphasizing the necessity of a social work response that goes beyond clinical care to address systemic colonial barriers.

For social workers, this requires a return to the structural roots of their practice, actively engaging in efforts to dismantle colonial violence and create spaces that honor and center Indigenous sovereignty and knowledges. By integrating decolonial and anti-colonial frameworks, social workers can help to dismantle oppressive structures, foster meaningful access to resources and supports, and promote the health and well-being of IPLH in a way that aligns with the core ethical principles of social justice and cultural safety.

Methodology

The Gigii-Bapiimin project was developed through ongoing community consultation which identified the need to better understand the impacts of the COVID-19 pandemic on the health and well-being of First Nations, Métis, and Inuit people in Manitoba and Saskatchewan, two prairie provinces in Canada. Community partners included: Two-Spirited people of Manitoba, Ka Ni Kanichihk, FEAST Centre for STBBI Research, Waniska Centre for STBBI Inequities, Communities Alliance and Networks, Nine Circles Community Health Centre, Village Lab at the University of Manitoba, Manitoba Harm Reduction Network, and the Manitoba HIV/STBBI Collective Impact Network. The goal of the study was to enhance the knowledge surrounding these impacts and generate recommendations for change to inform post-pandemic services and alleviate inequities for future pandemics. A wide range of topics were explored throughout each interview regarding the impacts of COVID-19 for Indigenous peoples in Manitoba and Saskatchewan. For the purpose of this paper, further analysis was conducted with a focus specifically on access to ceremony, impact on spiritual health and well-being, impact on service access and delivery, and impact on social health.

This study incorporated etuaptmumk, Two-Eyed Seeing, a concept developed by Mi’Kmaw elder Albert Marshall. Two-Eyed Seeing is used as a guiding principle as a way of incorporating aspects of both Indigenous and western worldviews. The incorporation of both ways of knowing is achieved through the development of trust, respect, and collaboration as well as an understanding and acceptance of the strengths each worldview brings (Marsh et al., 2015; Marshall et al., 2015). With this approach, the study combined more western approaches such as community-based participatory research and thematic analysis while incorporating an Indigenous methodology through Indigenous Storywork, a framework developed by Jo-Ann Archibald in collaboration with Indigenous Elders, storytellers, and cultural knowledge holders which consists of seven principles - respect, responsibility, reverence, reciprocity, holism, interrelatedness, and synergy (Archibald, 2021). Given this incorporation, Kovach’s (2021) thematic analysis strategies for Indigenous methodologies was also utilized. This method ensured the seven principles of Indigenous Storywork were centered throughout the analysis process and allowed for a more cyclical approach to analysis more consistent with an Indigenous worldview.

By incorporating community-based participatory research the study ensured community members directly impacted by this issue were actively involved throughout the entirety of the project. A community guiding circle (CGC) consisting of 13 Indigenous people living with HIV in Manitoba and Saskatchewan was formed to help direct the project from the ground up. The majority of CGC members identified as either women or Two-Spirit individuals, with many having lived with HIV for an extended period, while some were more recently diagnosed (within the last five years). The CGC members represented a broad geographic spread across Manitoba and Saskatchewan. Many had lived experience of substance use. Many had disabilities, with some managing multiple conditions in addition to HIV.

The CGC met ten times throughout the duration of the study either in-person or virtually. The CGC assisted with developing research questions, participant recruitment, data analysis via member checking, and generating knowledge transfer exchange ideas for findings. Capacity building for CGC members varied and involved paid employment, conference presentations, research skill development, access to knowledge keepers and cultural teachings and ceremony, as well as multidisciplinary and multi-sector collaborative teamwork. The CGC’s involvement was imperative to ensuring the study along with its findings and knowledge dissemination were aligned with the needs and vision of the community.

Two-Eyed Seeing was integrated with the development of ethical space, a concept Ermine (2007) conceptualized to enhance two-eyed seeing within research activities, creating opportunities for dialogue and sharing of ideas using ethical, reflexive, and decolonizing approaches. One way in which we strove to develop ethical space was with the involvement of an Indigenous Elder and cultural knowledge holder who grounded the work within Indigenous ways of knowing, doing, and being. Elder Albert McLeod lives in Winnipeg, Manitoba and has over thirty years of experience in HIV education for Indigenous peoples. Kookum Gayle Pruden is a two-spirit jingle dress dancer with a strong connection to culture and is Vice Chair of the Canadian Aboriginal AIDS Network Board of Directors. Another key element of the creation of ethical space was community engagement directed by the CBPR approach that was utilized as well as relational accountability. Relationships were honoured throughout the research by ensuring the First Nations principals of ownership, control, access, and possession were followed (First Nations Information Governance Centre, 2024). Furthermore, several sharing circles were held to develop relationship between academics and community members. Elder Albert and Kookum Gayle worked alongside the project offering teachings and conducting ceremony to ground the work in Indigenous knowledges and philosophies. Upholding the seven principles of Indigenous Storywork – respect, responsibility, reciprocity, reverence, holism, interrelatedness, and synergy - outlined by Archibald (2008) also helped build relationality and establish ethical space. Each facet of the research design melded together to create an overall methodology.

Participant recruitment

Participants were recruited using printed flyers, social media, and peer recruiters. Eligibility of those with lived experience included: self-identify as First Nations, Inuit, or Métis, be 18 years of age or older, and be living with HIV in Manitoba or Saskatchewan. Eligibility of service providers included: Provide services to IPLH, be 18 years of age or older, work in Manitoba or Saskatchewan. Ethics approval was obtained by the University of Manitoba Research Board of Ethics (Protocol #: HE2022-0188). Signed consent was obtained from each participant prior to the commencement of individual interviews.

Data collection and analysis

Stories were gathered from participants using semi-structured interviews as a guide to help facilitate conversation. Questions such as: what were your experiences when accessing ceremony throughout the COVID-19 pandemic, what helped you get through the pandemic, how have you dealt/coped with the COVID-19 pandemic, and how do you feel COVID-19 impacted you physically, emotionally, mentally, and spiritually were explored within each interview as well as personal experiences of receiving or providing services during this time, were asked. Indigenous Storywork (Archibald, 2008) remained at the forefront of data collection and analysis which strived to incorporate the seven principles previously outlined.

Thematic analysis (Braun and Clarke, 2006) with strategies for Indigenous methodologies (Kovach, 2021) were used to identify common themes throughout each story. Using MAXQDA data analysis software, a deductive approach was initially utilized to organize the data from the larger study and highlight areas pertaining to service access and delivery including traditional ceremonies. Wanting to maintain the wholistic understanding of each story, this deductive process was not narrowed to just specific questions relevant to the research question. Stories were analyzed in full and sectioned into segments pertaining to the focus of this paper. From there a more inductive approach was used, generating initial codes within those sections such as impacts on ceremony, loss of community, and ceremony access. Identifying relationships among initial codes helped to develop initial themes which included the significance of ceremony for those with lived experience, the varying knowledge and comfortability of Indigenous culture among service providers, and the varying degree of the incorporation of Indigenous culture and ceremony into practice with IPLH.

Initial themes were shared in circle with the CGC and Elder Albert and Kookum Gayle. As many of the CGC had also participated in the study, this process served as a form of member checking for the data. The analysis process was shared along with initial coding and themes and helped to ensure that initial themes identified were aligned with the meaning of stories shared by community. This process also provided additional insights shared by the CGC to incorporate into our reflexive process when finalizing themes. As themes were finalized, a more wholistic story was revealed and is discussed in detail in the upcoming findings section.

Sample characteristics

The sample (N = 57) included those with lived experience in both Saskatchewan (n = 24) and Manitoba (n = 21) as well as those who provided services and/or advocacy for IPLH in Saskatchewan (n = 5) and Manitoba (n = 10). Aside from three individuals who self-identified as Métis, participants with lived experience self-identified as First Nations. Each of these individuals accessed services in either Regina, Saskatchewan or Winnipeg, Manitoba. Of the total number of participants with lived experience, 8 identified as men while all others identified as women. There were 36 participants with lived experience who identified previous or current experience with substance use. Participants who provided services/advocacy practiced in a variety of health and social service settings with five identifying as social workers. There were four service providers who self-identified as either First Nations or Métis. Service provider participants were slightly more gender diverse with ten women, two men, and two non-binary folks; one service provider having not been asked about gender identity.

Findings

Access to ceremony and cultural programming were key to the wholistic health for Indigenous peoples living with HIV who participated in this study. Restricted access to ceremonies, cultural activities, and community supports during the COVID-19 pandemic negatively affected the overall wellbeing of IPLH. Analysis of the stories shared by participants identified three key thematic areas: the role of ceremony for IPLH during the COVID-19 pandemic – service user/lived experience perspectives, service providers knowledge of Indigenous ceremonies and practices, and the role of agencies in connecting community members to ceremony.

The role of ceremony for Indigenous peoples living with HIV during the COVID-19 pandemic: Service user/lived experience perspectives

The pandemic significantly impacted communities’ spiritual practices and access to ceremonial spaces, underlining the essential role these practices play in their lives. The limitations in accessing ceremonies were starkly evident. Many participants felt a profound sense of loss due to the suspension of communal ceremonies. One participant emphasized the importance of these gatherings, stating, “Yes. Sweats, pipe ceremonies, Sun Dance, singing. We had a lot of that. During the pandemic, we didn’t have any of that” (Donna). This quote underscores the loss felt by many participants due to the suspension of these shared spiritual activities during the pandemic that were vital to community connection and support. Another participant added, “Weren’t able to no because the amount of people that were allowed so that was pretty hard” (Kevin), pointing to the restrictions that prevented communal gatherings. This quote illustrates the absence of shared spiritual activities that were vital to community connection and support.

Restrictions also led participants to adapt their practices individually. For instance, one participant shared:

I did my best to maintain spirituality. I prayed a lot still. I did still a lot of Smudging. But it was really hard because I couldn’t go to ceremonies, I couldn’t go to Sweats I couldn’t access what I normally accessed. (Kate)

This respondent highlights the challenges faced in maintaining spiritual practices when traditional communal ceremonies were inaccessible. Another participant shared similar struggles: “We didn’t have that. We would smudge for each other… That’s what we were down to. I’m going to smudge for my home and I’m going to smudge for my family’s homes” (Sharon). These quotes underscore the resilience of participants in finding alternative ways to sustain their spirituality despite limitations on communal gatherings. Participants also reflected on the long-term impacts of the pandemic on their spiritual practices. One participant noted:

Even after the pandemic... things have changed dynamics have changed... I’m still praying I’m still Smudging... but me... being a full-time worker I’m just like okay... I’m trying to balance it. (Kate)

These findings illustrate the ongoing struggle to integrate traditional practices in post-pandemic life. Some participants found alternative ways to connect with their spirituality and ceremonies. One respondent mentioned, “I couldn’t... go to Sweats... I do it at home anyway and stuff like that” (Tim), highlighting a shift toward personal spiritual practices. Despite these challenges, some participants found solace in personal spiritual practices: “The only ceremony that I was able to do during the pandemic was smudging my home pretty much and drinking the medicines my nephews made” (Nadine). This adaptation underscores the resilience and flexibility in maintaining spiritual connections.

Finally, for some, ceremonial participation came to a complete halt during COVID-19. One participant reflected, “I never did through the COVID no” (Susan), capturing the stark absence of these practices in certain lives. These experiences reflect the profound spiritual disruptions that many IPLH faced and reveal both the strength and adaptability they drew upon to preserve their connections to ceremony in challenging times.

Service providers’ knowledge of Indigenous ceremonies and practices

This section focused on the knowledge of Indigenous ceremonies among service providers, as well as the perspectives of service providers on the role of ceremony in the health and well-being of IPLH during the COVID-19 pandemic. The findings underscore the significant role that ceremony plays in the lives of communities and the challenges faced due to the pandemic, from the perspective of service providers (who were both settlers and Indigenous peoples). Overall, the findings in this section reveal that ceremonies play a crucial role in the health and well-being of IPHAs by providing spiritual nourishment, cultural connection, and community support. The COVID-19 pandemic posed significant challenges to accessing these vital cultural practices, highlighting the need for more inclusive and accessible health services that encompass the spiritual and cultural dimensions of health for IPLH. This sentiment is echoed by Gigii-Bapiimin Indigenous Elder Albert McLeod who noted “this generation is very in tune with a traditional healing knowledge, and it is kind of a requirement or expectation in working with Indigenous peoples living with HIV”.

One service provider highlighted the importance of ceremonies as a means of cultural and spiritual reconnection, noting, “I think it plays a huge role. I think it gives you a reconnection to your culture, a spiritual connection that you don’t have otherwise” (Kristin). The role of ceremony in holistic health was emphasized by another respondent:

Ceremony plays a huge role. If you’re connected to Creator, higher power, to the land, connect to everybody, and then you’re doing Ceremonies, I think it’s really feeding your spirit and then it connects to everything in your wellbeing. (Amanda).

Another service provider expressed limited personal knowledge of ceremonies but highlighted their importance:

I keep learning about … like I’m a white man so I stay quiet during ceremony and just kind of watch and learn. I do ask questions, but I usually wait till after or before. But I’ve also noticed a lot of the people that I’ve done any kind of ceremonies with they’re also learning too. And I’ve also learned to not just assume that every Indigenous person knows about ceremony. It’s 70% Indigenous, there’s only two of us that are white, so it’s an Indigenous-led agency that’s all about bringing culture and tradition back to Indigenous youth and kin. So I’ve been learning a lot... I always get invited out to do it so I like it. I would say my knowledge isn’t good on ceremonies, like I don’t know a lot about them, but I am aware of how I’m supposed to act at most of them and how meaningful they are. (Bill)

Service providers observed the limited access to cultural practices during COVID-19: “A lot of the sort of cultural practices weren’t available during COVID… I think that when people are in crisis mode, services tend to revert back to the singular focus on physical health” (Mark). The significance of ceremony in fostering community and overcoming the effects of colonization was also highlighted: “Ceremony is important for everybody in their culture… the colonization of Indigenous peoples obviously has stripped that away… it’s really imperative for folks to get reconnected” (Cynthia). This sentiment is aligned with a more wholistic approach, in that the incorporation of more spiritual components is essential to overall well-being.

The role of agencies in connecting community members to ceremonies

The findings in this section highlight (from the perspective of service providers) the role of various organizations in connecting IPLH to Indigenous ceremonies. The responses from service providers offer a rich understanding of the diverse approaches and challenges in facilitating these vital cultural connections. The findings reveal a diverse range of experiences and approaches in integrating Indigenous ceremonial practices into healthcare services for these communities during the COVID-19 pandemic. Overall, the findings reveal a varied landscape in how organizations engage in connecting community members to Indigenous ceremonies. While some providers and organizations actively facilitate these connections, others acknowledge limitations and challenges, particularly in the context of the COVID-19 pandemic. These data underscore the importance of, and the need for increased awareness and integration of these practices in healthcare services.

Regarding organizational roles, one respondent noted: “We don’t do any connecting to ceremony. I don’t feel that’s an appropriate role for me as white healthcare provider” (Bill), highlighting the nuanced understanding of cultural sensitivity and the boundaries of their professional role. Another respondent stated: “For me I’m a big advocate for any Indigenous people I work with or help. I’m a big advocate for trying to connect them to things especially when it comes to ceremony and culture” (Kristin), highlighting their proactive role in bridging this connection. However, some organizations faced challenges in this regard, particularly during the pandemic. A provider noted, “I would say that my organization’s role… is not something that is really done especially widely in Manitoba in the healthcare system in general” (Mark), reflecting the limited scope of ceremonial connections within their organizational structure. In contrast, another service provider described a more integrative approach: “So now like with the Wellness Wheel we have that two-eyed seeing approach so we’re always you know like the Western way and the Ceremony” (Cynthia), illustrating a balanced approach between Western medicine and Indigenous ceremonial practices, and a commitment to incorporating Indigenous practices into their services. Service provider from one organization highlighted the role of cultural workers:

We have our cultural support worker here who provides smudging for anyone at 10:00 every day… She provides information about upcoming sweats and holds ceremonies. (Amanda)

This demonstrates an active involvement in facilitating access to ceremonies. In some cases, there was a recognition of a need for greater involvement. A service provider mentioned, “I think that we need to have a bigger role... COVID kind of knocked it out of our path” (Kieren), indicating a desire to enhance their organization's role in connecting community members to ceremonies.

Discussion

This study underscores the critical importance of integrating cultural and ceremonial practices as foundational elements of care for IPLH. By centering Indigenous knowledge systems within healthcare, particularly in the context of HIV, we aim to address deep-seated disparities shaped by colonial history and ongoing structural inequities. The COVID-19 pandemic revealed and exacerbated these inequities, highlighting the need for healthcare models that not only incorporate but prioritize culturally responsive and anti-colonial approaches. Such approaches require healthcare systems to acknowledge the relational, ceremonial, and holistic aspects of health and well-being that are essential for IPLH.

Our findings amplify the importance of centering cultural and ceremonial practices as core components of overall health and well-being for IPLH. As seen in prior studies (Hillier et al., 2020 & Souleymanov et al., 2024). Findings have demonstrated that while some organizations actively worked towards mitigating the effects of structural violence by facilitating access to traditional ceremonies, others were constrained by the same structural barriers that perpetuate inequalities. This is reflected in other studies discussing barriers and the need for culturally responsive measures within the HIV care cascade when working with IPLH (Christianson, 2024; Larcombe et al., 2020; Watson et al., 2022). Given the rising cases of HIV throughout Manitoba and Saskatchewan and the disproportioned number of Indigenous peoples impacted (Challacombe, 2024; Public Health Agency of Canada, 2023; Statistics Canada, 2024) the disregard for the centering of cultural care throughout COVID-19 not only underscores the requirement for anti-colonial responses within the HIV care cascade but exemplifies the ongoing structural violence within these systems. This approach would ensure that Indigenous practices are not just included but are central to healthcare strategies, thereby promoting healing and well-being in a manner that is wholistic, culturally sensitive, respectful, and empowering.

From an anti-colonial social work perspective, findings highlight the varied understanding and involvement of service providers in the cultural practices of Indigenous communities during the pandemic. As explained by Hart (2009), Smith (2021), & Grey et al., (2013) social workers and other professionals in health and social care need to understand the importance of cultural practices within healthcare for Indigenous communities. Our findings reflect their messages of the necessity of properly integrating Indigenous knowledge systems and ceremonies into the HIV care cascade. The different responses from service providers, ranging from active facilitation to limited involvement in connecting Indigenous clients to ceremonial practices, reflect the ongoing struggle against systemic barriers in healthcare as well as the need for centering Indigenous ways of healing within the care of IPLH. Advocating for these changes that are demonstrated in the findings of this study are pivotal for social workers to be able to adhere to the updated core values of the Social Work Code of Ethics which includes pursuing Truth and Reconciliation (Canadian Association of Social Work, 2024) and subsequently working towards the Calls to Action for Indigenous rights to healthcare (Truth and Reconciliation Commission of Canada, 2015).

Previous research demonstrates how structural inequalities, rooted in historical and ongoing colonialism, exacerbate the health challenges faced by Indigenous peoples, specifically those living with HIV (Krusz et al., 2020; Laracome et al., 2020; Lavallee and Poole, 2010; Peltier et al., 2020; Ristock et al., 2010; Wilson et al., 2016). Our research aligns with this knowledge base as it showcases the considerations of the mainstream systems throughout the COVID-19 pandemic, which did not prioritize culturally relevant care for Indigenous peoples. Indigenous centered care among IPLH is something that has been present since the initial HIV epidemic (CAAN, 2024; Kulkarni, 2022). Our research activates a wider health agenda that situates the responsibility of Indigenous health care dualistically within Indigenous and mainstream models (Hilliar et al., 2020; Larcombe et al., 2020; Masotti et al., 2023). A theme within this study was the challenge for IPLH in accessing traditional ceremonies. In the context of the COVID-19 pandemic, integrating anti-colonial social work theory is essential in analyzing the role of ceremony for IPLH. Structural violence (Farmer, 1999; Lawrence and Hirsch, 2020) within the HIV care cascade was enacted through the pandemic’s restriction effects on healthcare, further marginalized these communities by disrupting cultural and spiritual practices vital to many for resilience and identity. Despite facing compounded adversities, IPLH demonstrated adaptability and resilience by maintaining or starting a connection to their spirituality through individual ceremony or when able, connecting to innovative offerings of ceremony and cultural connection online, thereby resisting the attempted erasure of cultural practices.

We call for a more profound recognition of the historical and ongoing impacts of colonization on Indigenous health and the need for health services to embrace anti-colonial practices that honour and center Indigenous ceremonial practices as essential components of wholistic health and well-being (Haynes et al., 2021; Marsh et al., 2015; Masotti et al., 2023; Peltier et al., 2020; Wilson et al., 2016).The experiences shared by those with lived experience align closely with the literature highlighting the crucial role of traditional ceremonies and medicines in promoting well-being among IPLH. Studies have shown that culturally safe, relational-based care remains essential, especially during periods like the COVID-19 pandemic, when IPLH often found themselves disconnected from traditional supports (Reading et al., 2013; Souleymanov et al., 2024). Social workers embedded within interdisciplinary health teams are particularly well-positioned to facilitate wholistic care that incorporates culturally relevant practices (Hillier et al., 2020). It may be also more effective for social workers and service providers to build and maintain relationships with traditional healers who can offer culturally appropriate care directly. This approach respects the autonomy of Indigenous healing practices by fostering access within community-centered and culturally relevant settings.

Furthermore, to better support IPLH, social workers should engage more intentionally with decolonizing (Haynes, 2021; Hillier et al., 2020) and anti-colonial (Hart, 2009) approaches. The Canadian Association of Social Workers’ recent integration of Truth and Reconciliation principles into its Code of Ethics emphasizes the need for social workers to engage with Indigenous worldviews and ways of being, a mandate that could be met by requiring social workers who serve IPLH to demonstrate a foundational understanding of Indigenous knowledge systems as part of ongoing professional education. This competency requirement would prepare social workers to provide more responsive care and to align their practices with the core principles of social justice and cultural safety (Bainbridge et al., 2015).

Structural barriers within healthcare, which prevent equitable access to essential cultural supports, are well-documented in the literature, especially in the context of the HIV care cascade (Hosein, 2022; Masotti et al., 2023; Mbuagbaw, 2024; Peltier et al., 2020; Wilson et al., 2016). This underscores the need for social workers to take on a more active advocacy role within their organizations, promoting program development that aligns with Indigenous needs and cultural perspectives on health. For example, frontline social workers can strengthen care for IPLH by establishing relationships with Indigenous healers and cultural practitioners, facilitating client access to traditional practices, and working to integrate these into service delivery. Additionally, as frontline practitioners are often aware of service disparities, they can advocate for increased Indigenous resources by bringing these needs to agency leadership and influencing program development to include Indigenous-centered supports. Such steps align with the anti-colonial social work frameworks described in Hart (2009) and Gray et al. (2013), which call for resisting complicity within colonial healthcare systems and championing Indigenous-led health services. Furthermore, research by CAAN (2024) and Kulkarni (2022) advocates for health agencies to incorporate peers with lived experience into service delivery, creating culturally relevant programming that honors IPLH perspectives and directly addresses gaps in cultural safety.

Ongoing research on service gaps for IPLH remains essential. Studies examining Indigenous-led care models within the HIV care cascade reveal a dual approach that integrates Indigenous and Western care frameworks is crucial to bridging existing divides (Hillier et al., 2020; Kulkarni, 2022). Social work researchers should engage with IPLH communities to explore service delivery challenges and develop recommendations for strengthening social work practices and policies, as emphasized by Lawrence and Hirsch (2020). These insights can also guide advocacy efforts aimed at promoting culturally safe care environments for IPLH.

From an academic perspective, prioritizing Indigenous knowledges in social work curricula is vital for adequately preparing future practitioners to work with Indigenous populations. Authors like Tuhiwai Smith (2021), Gray et al. (2013), and Hart (2009) call for education to support culturally competent social work. By incorporating Indigenous knowledges into core curricula, social work programs can better equip graduates to dismantle structural inequities and promote the cultural competence needed to support IPLH. Integrating anti-colonial and decolonizing methods is essential in creating culturally safe, equitable healthcare environments that directly address the lasting impacts of structural violence (Farmer, 1999) and colonialism.

Limitations

Given the research design’s purposive sampling method, findings cannot be generalized to beyond the scope of this study. Additionally, the snowball sampling method which transpired among IPLH participants led to an overrepresentation of individuals already connected to HIV care as well as a connection to each other’s communities. Resultingly, there may be additional challenges those not yet connected to care are experiencing. As with any research project, time is always a factor. Ideally with the utilization of Indigenous Storywork one would become a member of the community (Archibald, 2008). Although lifelong relationships were forged throughout the project, the time required to be emersed within a community to achieve belonging was not possible for each researcher to obtain in this timeframe. Secondly, most participants received or provided services within the capital cities of Manitoba and Saskatchewan. Experiences of those in northern, rural, and First Nations communities within each province may vastly differ than of those in these large urban settings. Further research is needed to address the experiences of IPLH living outside Winnipeg and Regina.

Conclusion

The findings from the Gigii-Bapiimin project underscore the urgent need for healthcare systems to acknowledge and integrate Indigenous practices as foundational, rather than supplemental, to care. Long-standing inequities rooted in colonialism continue to shape HIV and healthcare for IPLH, and these disparities persist today. Social workers within health and social care settings have an ethical responsibility to resist colonial practices that perpetuate oppression and inequity for IPLH. Stories shared by IPLH highlight the critical role of traditional ceremonies and medicines in their overall well-being and care. However, our findings reveal a varied response among service providers regarding their personal and organizational capacity to facilitate these connections for those seeking them. Recognizing the resilience and adaptability of IPLH in preserving cultural connections despite systemic adversity further underscores the value of centering Indigenous ways of healing within health and social care contexts.

With the recent revision to the Canadian Association of Social Workers’ Code of Ethics, our profession is called to harness the knowledge shared by Indigenous peoples and actively work to apply anti-colonial and decolonizing perspectives. By fostering a healthcare system that is inclusive of and responsive to these practices, social workers can help dismantle structural inequities and enhance the cultural safety of HIV care for IPLH, ultimately promoting their health and well-being in a way that respects and upholds Indigenous sovereignty and knowledge systems.