The current investigation used a scoping systematic review methodology. Peterson et al [35] identified this approach as a methodology to advance emerging research topics. Standardized systematic reviews and scoping reviews differ in terms of the specificity of their topic of interest. Scoping reviews tend to investigate broad topics compared to standardized, systematic reviews, which examine a specific, detailed question.

This review included evidence syntheses and qualitative, experimental (randomized or nonrandomized), observational (longitudinal and cross-sectional), and mixed methods studies.

For inclusion in the review, studies must (1) include data on self-identified Black MSM living with or without HIV, (2) research HIV prevention and care among Black MSM, and (3) have been published in at least 1 of the 2 official languages in Canada—English and French.

For exclusion in the review, studies must not (1) focus on Black MSM outside of Canada unless Canadian data are analyzed separately and (2) be published before the 1983 formation of Canada’s AIDS National Task Force.

The primary objectives of interest of this scoping, systematic review include (1) identifying existing literature that examines the HIV prevention and care continuum in Canada for Black MSM, including epidemiological trends, determinants of engagement, and health care experience and (2) determining health access and availability of specific health resources related to the Canadian HIV prevention and treatment interventions for Black MSM.

The secondary objectives of interest include (1) examining the effects of social determinants of health on the HIV prevention and treatment interventions for Black MSM in Canada, (2) consolidating research on unilevel and multilevel interventions that address the social determinants of health for Black MSM in Canada, and (3) identifying existing health promotion for Black MSM in Canada.

There was no direct involvement of the public and patients or participants who are Black MSM in the study.

The approval of the Research Ethics Board was not required. As a scoping systematic review, information was based on secondary published data and not on human subjects. Peer-reviewed manuscripts, conference presentations, and students’ rounds can be strategically used to disseminate study findings. The findings may also influence policy within government health agencies and local HIV or AIDS service organizations.

A health sciences librarian conducted a comprehensive literature search of studies published through the Health Sciences Library in Toronto, Ontario’s St Michael’s Hospital, Unity Health Toronto. This occurred in April 2020. The list of our search terms included “Quality of Health Care,” “Health Status Disparities,” “Social Stigma,” “Human Immunodeficiency Virus,” “Same-Sex Intercourse,” “Blacks OR African OR Caribbean.” The complete search strategy can be found in the published protocol [36].

These searches were done on MEDLINE, Excerpta, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, the NHUS Economic Development Database, Global Health, PsycInfo, PubMed, Scopus, and Web of Science.

Related articles were searched for in the reference lists of all pertinent citations.

Available thesis and conference posters were searched while reports from relevant organizations such as the African and Caribbean Council on HIV or AIDS in Ontario (ACCHO), Black Coalition for AIDS Prevention (Black CAP), Africans in Partnership Against AIDS (APAA), Committee for Accessible AIDS Treatment (CAAT), TAIBU Community Health Centre, Ontario HIV Treatment Network (OHTN), and Canada's source for HIV and hepatitis C information were explored.

The studies were deduplicated in advance, and the web-based app Rayyan QCRI (Rayyan) was used to import and screen citations found using this search strategy [37].

A data collection form customized to reflect the inclusion criteria was pilot tested by 2 independent reviewers. These reviewers played a role in generating and using the given form. A total of 50 abstracts were used as a sample to create consistency of use and establish the instrument’s validity. Interrater reliability was measured using the Cohen κ statistic. The screening began upon the achievement of a 60% (n=979) agreement [38].

The study’s selection process began with title and abstract screening to identify potentially relevant articles. This was followed by retrieving the full text for detailed screening using the inclusion and exclusion criteria before the data extraction procedure. All screening and data extraction were completed in duplicate and blinded by JD, PD, FW, AY, and GRAB. Any disagreements were settled via consensus. However, a third author was available to arbitrate (SG) if an agreement could not be reached.

Bibliometric information such as author names, journal, year of publication, the study location, design, number of participants, outcomes reported, outcome measures overall, and outcome measures in Black MSM participants were extracted. In addition, each outcome is reported through measures of magnitude mean (SD) or percent (95% CIs) where possible, comparing the effect of the intervention in Black MSM versus men in other racialized groups or Black MSW; (odds or risk ratios, mean differences, accompanied with 95% CIs) [39].

We did not appraise the methodological quality and risk of bias in the studies as this is not required in a scoping review [40].

Study findings were reported as per the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines [41,42] through the use of narratives and tables. This is outlined in Multimedia Appendix 1. Data were grouped according to outcomes, with the number of studies and their design displayed using tables. In addition, a narrative synthesis of the data was conducted to identify overlapping themes and knowledge gaps.

Overall, the purpose of this study was to evaluate engagement with HIV services and interventions, identify the relevant facilitators and barriers via the social determinants of health, and determine the research and available interventions for Black MSM in the HIV prevention and care cascade through the lens of intersectional, overlapping identities. This scoping review presents a comprehensive evaluation of the state of the science as it pertains to HIV prevention and treatment interventions for Black MSM in Canada through available literature and reports. Through the 19 published studies and reports included, this review has identified critical points in the HIV prevention and care cascades, where Black MSM experience poor outcomes in knowledge, access, engagement, and quality of HIV care and prevention.

PrEP remains the most accessible and well-established biomedical intervention available in Canada. Yet, there were no identified PrEP delivery strategies that target Black MSM in this study. To inclusively reduce HIV incidence in Canada, it is crucial to identify the factors that promote PrEP access and use. Motivations to use these prevention methods are characterized by the perception of HIV risk, adequate knowledge of the intervention and its benefits, and acceptability within the relevant sociocultural contexts for Black MSM. Limited discussion on HIV risk and prevention methods with health care providers contributes to the low-risk perception and PrEP motivation [55,56,58]. For instance, some health care providers refuse to discuss PrEP with their patients due to being uncomfortable discussing sex, sexuality, and sexual health with same-gender-loving patients [67,68]. Moreover, social stigmas including homophobia, racism, and xenophobia may affect motivation to seek HIV preventative services. These experiences can prevent Black MSM from disclosing their sexual practices, which providers need to assess HIV risk. Ultimately, these gaps expose the need for timely interventions for Black MSM [55,56,58]; priority areas include promoting the relevance of PrEP to health care providers, highlighting culturally responsive strategies, and generating space spaces actively for Black MSM to engage with providers honestly.

Access in the prevention cascade is influenced by numerous factors, including income, employment, proximity to health care facilities, housing, and other social determinants of health [64,69,70]. Many Black MSM describe precarious work and housing statuses, low income, issues related to poverty, and difficulty accessing formal education [50,57]. These disparities are associated with inadequate access to HIV prevention interventions, as high PrEP costs consistently reduce PrEP uptake [49,55,59]. More research is necessary to fully elucidate the mechanisms through which key factors influence health care engagement such as income, housing, and mental health and emotional well-being [71,72]. In the literature, MSM living with HIV experienced depression associated with physical, educational, social, financial, psychological, and short- and long-term health consequences [69]. People living with HIV who experienced depression are exposed to poor health outcomes like poor quality of life and worsening of their disease states. This could have even more consequences on Black MSM who are already impacted by other structural factors [70]. Therefore, if depression is untreated in MSM living with HIV, this can lead to risky sexual behavior, alcohol, and drug misuse and abuse, including suicide [73]. Poor adherence to antiretroviral drugs has also been associated with depression in newly diagnosed people living with HIV, resulting in poor immunological and virological outcomes.

To reduce HIV incidence for Black MSM, interventions that increase access might be beneficial including mass distribution and outreach programs, integrated health services, or legal changes that empower Black MSM to engage with HIV prevention interventions [74]. There is still limited research on intervention strategies to increase access to prevention interventions for Black MSM across Canada. Similar research in the United States investigated specific legislative and structural opportunities for Black MSM to successfully engage in HIV prevention [75,76]. Canada should commit to adopting effective programs in other countries or funding Canadian research that uses implementation science to address the identified challenges in this review for Black MSM.

While HIV prevention and care services exist along the same continuum, HIV care differs from the prevention cascade. People who remain at risk and test negative for HIV need to be linked to prevention services, but an HIV diagnosis requires a specific set of services to maintain viral suppression. The HIV care cascade models HIV testing and diagnosis steps as the starting point to viral suppression through a series of HIV health care services [30]. In comparison to other MSM, Black MSM demonstrate lower testing rates [43,47]. Still, this review shows various HIV testing behaviors among Black MSM dependent on age, sexuality, country of birth, religious affiliation, history of SBBI, and even personal relationships that have been affected by HIV [44,48-50]. Fortunately, this can inform the generation of testing interventions targeting Black MSM subgroups. For instance, many Black MSM were found to receive HIV testing from their family doctor, which can be used to build programming to link Black MSM to HIV tests directly from their primary care physician [48]. Outside of Canada, there have been many HIV testing interventions for Black MSM and other priority populations that have improved HIV testing and knowledge, testing access, and social support [77-81].

Moreover, HIV diagnosis rates are higher among Black MSM than other MSM and Black MSW [43-45]. Once diagnosed with HIV, Black MSM must be linked to HIV primary and specialist care services and antiretroviral therapy to achieve viral suppression [30]. While there were no studies on engagement at these stages by Black MSM, studies address the discriminatory barriers to access for Black MSM [55-57]. Nevertheless, the use of HIV care interventions is shown to be effective with other populations through improvements in retention of care, engagement with providers, and even condom use [82-85]. This review did not identify any HIV care interventions for Black MSM, which exposes the health care gap for Black MSM despite the epidemiological significance. Canada’s goal to dramatically reduce HIV incidence by 2030 is unachievable unless Black MSM are explicitly highlighted by service agencies.

The unilevel interventions mentioned in this study were reported in organizational reports. These are Black community–based initiatives driven by Black-focused organizations such as ACCHO, Black CAP, and APAA. Although they have strong engagement and trust with Black communities, they are limited by a lack of research to support their ability to scale up including a focus on their effectiveness, feasibility, appropriateness, and vitality. Health care organizations, government, and research funding agencies need to invest in interventions led by community stakeholders to reduce HIV incidence in Black MSM. Black MSM in Canada are entitled to an equitable standard of care and should not be confined to select organizations outside of provincially mandated health service providers.

This review provides information that can be used to develop many interventions, including programs that provide support for mental health, immigration, housing, and employment; train providers to deliver culturally responsive HIV prevention and care services; and provide accessible and affordable HIV testing and PrEP services. Combining systems-level, provider-level, and patient-level interventions may be necessary for reducing the effect of these factors, as evidence suggests these interventions improve HIV-related outcomes in Black and nonheteronormative communities [86-88]. Targeting critical points in the HIV prevention and care continuum may lead to improvements for Black MSM. Thus, there is a strong need for unilevel and multilevel HIV prevention and treatment interventions as well as more comprehensive clinical research studies that investigate the outcomes of these interventions across Canada for Black MSM.

The findings of this scoping review are limited by the fact that all study interventions were conducted in the Greater Toronto Area, with English as the dominant language. This approach may not be practical for capturing the diverse experiences of Black MSM across Ontario and in other Canadian provinces and territories. In addition, as no French studies were identified in this review, the specific barriers that Francophone Black MSM experience may not be included.

MSM and Black communities are priority populations most affected by HIV in Canada. Black MSM experience disparities in HIV incidence and are disproportionately affected by the driving factors of HIV transmission, including stigma and discrimination. Singular-focused MSM or Black-specific interventions may not be effective for Black MSM, as they need intersectional intervention strategies that affirm their racial and sexual identities and sexual practices. This review demonstrates evidence that Black MSM experience structural discrimination, stigma, and poor quality of care and linkage to HIV services, and as a result, higher HIV and other SBBIs impact. There is some evidence of HIV interventions in Canada for Black MSM. Still, none of the interventions identified in this scoping review were assessed by randomized control trials to evaluate their effectiveness in alleviating HIV transmission disparities for Black MSM. Thus, an important next step is to develop evidence-based HIV interventions to reduce HIV inequities for Black MSM in Canada. The benefit of this review is that it provides a comprehensive overview of the barriers for Black MSM in HIV care from the individual to environmental, institutional, and structural. Additionally, this review has highlighted gaps in care that need to be addressed and sheds light on the intersectional interplay of identities in Black MSM care. This review can inform the development of these interventions for Black MSM and outline the factors that need to be addressed. Furthermore, community agencies and researchers can use these findings to create the necessary programming and tools to reduce HIV incidence for Black MSM.