In Canada, the HIV/AIDS epidemic continues to have a disproportionate effect on gay, bisexual and other men who have sex with men (MSM). Despite past achievements in curbing the epidemic among MSM, research in the early 21st century pointed to an increase in the transmission of HIV among MSM in Western countries, including Canada. This evidence renewed questions about how to enhance existing programs and policies aimed at preventing the transmission of HIV among MSM.Footnote 1 Footnote 2
This chapter draws together findings from multiple sources to provide an update on the status of HIV/AIDS among MSM in Canada. Specifically, it summarizes selected data from the most recently available routine HIV and AIDS surveillance data, selected findings from Phase 1 of M-Track (the national, second- generation HIV surveillance system focused on MSM in Canada) and data from the most recently available national estimates of HIV in Canada. Selected findings from recent research are also presented, including information on the prevalence and incidence of HIV among MSM in Canada and associated factors, as well as findings from research focusing on risk behaviours and correlates of risk behaviour among MSM in Canada. The chapter concludes with a discussion of the strengths and limitations of existing research and provides a summary of the findings presented.
The Public Health Agency of Canada's Centre for Communicable Diseases and Infection Control (CCDIC) collects surveillance data on positive HIV test reports and reported AIDS cases in Canada. Epidemiologic information includes (but is not limited to) age, sex, risks associated with the transmission of HIV and self-reported ethnicity. For AIDS cases, death data are also collected. Health care providers and/or laboratories forward this information to provincial and territorial public health officials, who, in turn, voluntarily submit positive HIV test reports and AIDS diagnoses to the Centre, where the data are synthesized and analyzed at the national level. There are several limitations regarding surveillance data, including reporting delays, underreporting, missing information and undiagnosed infections. (Please refer to Chapter 3 for a full description of HIV/AIDS surveillance in Canada).
± MSM/IDU: men who have sex with men/people who inject drugs combined exposure category. For details on exposure categories, please refer to Chapter 3.
As part of the Federal Initiative to Address HIV/AIDS in Canada, PHAC monitors trends in HIV prevalence and associated risk behaviors in key vulnerable populations identified in Canada. The overall objectives of these second-generation HIV surveillance systems (known as the "Track" systems) are to describe the changing patterns in the prevalence and incidence of HIV infections, risk behaviour practices and testing patterns for HIV, hepatitis C and other sexually transmitted and blood borne infections (STBBIs) in each respective population. For a more detailed description of the Track systems, please refer to Chapter 3.
M-Track is the national, second-generation HIV surveillance system among MSM in Canada. As of December 31, 2009, a total of six sites had participated in M-Track across Canada. M-Track was first implemented in Montreal in 2005. Between 2006 and 2007, four additional sites joined M-Track: Toronto, Ottawa, Winnipeg and Victoria. Over 4,500 men participated in M-Track between 2005 and 2007 (Phase 1). In 2008, Vancouver became the most recent site to implement M-Track (see Table 1).
† Unless otherwise noted, the data presented here include eligible respondents (for any given variable) who provided responses. Respondents who did not provide responses (i.e. "Missing") or who responded "Don't know" or who "Refused" to answer were excluded from the analyses. Respondents who provided a dried blood specimen only (i.e. did not respond to the questionnaire) are excluded from all analyses presented here unless otherwise stated. No tests of statistical significance were conducted.
|Province / Site||2005||2006||2007||2008|
|British Columbia / Victoria||Phase 1 - 224 men|
|British Columbia / Vancouver||Phase 2 - 1,169 men|
|Manitoba / Winnipeg||Phase 1 - 121 men|
|Ontario / Toronto||Phase 1 - 2,020 men|
|Ontario / Ottawa||Phase 1 - 516 men|
|Quebec / Montreal||Phase 1 - 1,957 men||Phase 2 - 1,873 men|
|All sites||4,838 men surveyed||3,042 men surveyed to date|
*A casual partner is a man with whom the respondent had sex only once (a "one night stand" or an encounter in a bathhouse, for example). Casual partners do not include men to whom the respondent gave or from whom he received money, drugs or other goods or services in exchange for sex.
**Commercial sex involvement: giving or receiving sex in exchange for money, drugs or other goods or services.
† HIV screening was performed using the Bio-Rad GS rLAV HIV-1 EIA (enzyme immunoassay). Confirmatory testing was subsequently performed using the Bio-Rad Genetic SystemsTM HIV-1 Western Blot assay. A positive result indicates a current HIV infection. Both the HIV screening (EIA) and confirmatory assay (Western Blot) are approved by Health Canada as diagnostic assays for use with dried blood spot (DBS) specimens.
‡ Excludes respondents who did not provide answers to questions regarding HIV testing history.
In addition to determining the prevalence and identifying patterns of HIV, HCV and syphilis testing, and describing changing patterns and trends in sexual behaviour among MSM in Canada, one of M-Track's primary objectives is to establish a core set of comparable behavioural measures across participating sentinel surveillance sites while addressing local and regional issues and questions of specific local interest. As such, respective sentinel sites produce and publish site-specific findings in the form of summary reports, research papers, conference posters and abstracts. Site- specific publications often explore questions and issues of particular interest to community members, researchers, and policy and program analysts.
Selected site-specific findings from M-Track sentinel sites are presented along with other independent research findings below (please see "Summary of recent data on HIV prevalence, incidence and risk behaviours among MSM").
PHAC uses multiple methods to provide an overall picture of the HIV epidemic among all Canadians living with HIV (including AIDS), including those with both diagnosed and undiagnosed infection. Using these combined methods, PHAC produces two types of estimates: prevalence, the number of people living with HIV (including AIDS), and incidence, the number of new infections in a 1-year period. PHAC produces estimates of national HIV prevalence and incidence approximately every 3 years. (Please refer to Chapter 1 for a full description of national HIV prevalence and incidence estimates for 2008).
§ HCV testing was performed using the Ortho® HCV version 3.0 EIA. Confirmatory testing is not performed for samples that test positive.
A positive result indicates past or present HCV infection and does not discriminate acute from chronic or resolved infections. Validation of commercially available laboratory tests on DBS specimens for HCV is ongoing.
Syphilis testing was performed using the Serodia® TP-PA assay. Confirmatory testing is not performed for samples that test positive.
A positive result indicates past or present syphilis infection. Validation of commercially available laboratory tests on DBS specimens for syphilis is ongoing.
¶ For the purpose of these analyses, STBBI included gonorrhoea, chlamydia, genital or anal warts, syphilis, genital herpes, hepatitis A and B or unknown hepatitis virus.
In addition to the data gathered through routine and enhanced HIV surveillance, as well as the national HIV estimates, several studies exploring HIV and associated risk factors among MSM in Canada are ongoing.
Below is a summary of available data and literature results for the period 2006 to 2009 in MSM populations in Canada.
Earlier on in the HIV/AIDS epidemic, study findings suggested that the prevalence of HIV among MSM in Canada was very high.Footnote 6 Footnote 7 Footnote 8 Footnote 9 More recent findings, however, suggest that it may have declined and/or that there is significant variation across different subpopulations (Annex 1).Footnote 1 Footnote 10 Footnote 11 Footnote 12 Footnote 13 Footnote 14 Footnote 15 Footnote 16 Footnote 17 Footnote 18 Footnote 19 As described in some detail in Annex 1, the prevalence of HIV among MSM in more recent analyses ranges from a low of 1.0% in a subsample of young non-White MSM born outside of Canada and living in Vancouver or Montreal Footnote 18 to a high of 24% in a small sample of Black MSM in Toronto ( n = 168).Footnote 13
Recently described correlates of HIV prevalence include unprotected receptive anal sex, lower levels of education, not being in the labour force and regular attendance at bathhouses, as well as hepatitis B infection, urethral gonorrhoea and genital or anal warts.Footnote 11 An independent analysis that explored the relationship between circumcision and HIV status did not find any correlation between the two variables.Footnote 20
Fewer recent publications have provided estimates of the incidence of HIV among MSM (Annex 1).Footnote 21 Footnote 22 Footnote 23 Despite differences in methodology, studies continue to document a relatively high incidence of HIV among MSM, ranging from a low of 0.62/100 person-years (py) in a cohort of MSM in MontrealFootnote 21 to a high of 1.14/100 py based on data from the Laboratory Enhancement Study in Ontario.Footnote 22
Similar to the conclusions drawn from the national estimates of HIV incidence among MSM in Canada,Footnote5 recent studies suggest that the incidence of HIV among MSM in Canada is relatively stable or is increasing slightly.Footnote22
In addition to documenting the incidence of HIV among MSM, several researchers have explored factors associated with HIV seroconversion among MSM. Recently reported risk factors for HIV seroconversion include any anal-sex-related practices with a serodiscordant, casual or commercial sex partner,Footnote 21 as well as high numbers of casual partners, sharing a needle with someone who is HIV positiveFootnote 21 and experiencing stressful life events.Footnote 24
Recent data on sexual practices and HIV-related risk behaviour indicate that certain subgroups of MSM continue to be at considerable risk of HIV infection by engaging in risky sexual practices, such as unprotected anal intercourse (UAI) with serodiscordant partners or partners of unknown HIV status.Footnote 13 Footnote 21 Footnote 25 Footnote 26 Recent studies also indicate that casual sex is common among MSM; these studies point out that the majority of men surveyed continue to practise safe sex.Footnote 13 Footnote 21 Footnote 26 Differences across studies, including definitions of safe sex, however, make it difficult to make direct comparisons across findings and thus generally preclude one from drawing any specific conclusions regarding trends in risk behaviours over time.
Numerous and conceptually diverse correlates of HIV risk behaviours, such as UAI, having multiple partners and commercial sex involvement, have been explored among MSM. Studies have primarily focused on factors associated with UAI in general, such as recreational drug use.Footnote 17 Footnote 19 Footnote 28 Footnote 29 Footnote 30 Footnote 31 Footnote 32
Although findings across studies have varied, recent publications continue to support the notion that a host of complex and interrelated factors are associated with HIV-related risk behaviours among MSM. The reasons underlying these behaviours, however, are equally numerous and complex.
Others have explored the role that the Internet may be playing in the lives of MSM with respect to risk behaviour.Footnote 17
The social influences of risk taking among MSM are equally multifaceted.Footnote 32
Patterns of risk behaviours across different types of partnerships have also recently been addressed in the literature:
In their brief synopsis of findings from a subsample of partnered men who took part in the Men, Sex and Love Web study, the authors reported that HIV discordant couples were significantly more likely to consistently use a condom during anal sex. By contrast, being in a partnership of unknown concordance was not associated with consistent condom use.Footnote 39
The characteristics of, and HIV-related risk behaviours in, specific subpopulations of MSM, such as MSM who also inject drugs (MSM/IDU), MSM who were born outside of Canada and MSM who are living with HIV, have also been the subject of recent analyses.
In addition to studying correlates and causes of HIV- related risk behaviours among MSM, other topics of relevance have also recently been studied, including HIV testing patterns and factors associated with HIV testing among MSM. HIV testing uptake is relatively high among MSM in Canada, including subpopulations of MSM, and men who report higher-risk behaviours also report higher odds of testing.Footnote 4 Footnote 44 Footnote 45 Non-consensual condom removal during anal sex and non-disclosure of HIV-positive status by a partner have been reported as reasons for seeking HIV testing among MSM.Footnote 31
Many of the research studies presented in this chapter have a number of important strengths. For example, most of the findings presented here are based on recent data drawn from large community samples of MSM, enabling researchers to explore a wide variety of hypotheses. Many of these studies have generated new evidence, critical to prevention programs and policy making at all levels: national, provincial and local. Moreover, because of the relatively large survey sample sizes, adequate statistical power is available to examine multiple risk behaviours and their associated factors.
There are also several limitations that should be considered when interpreting the results presented here. The majority of the findings are based on cross-sectional studies, thus, any inferences regarding cause and effect between the variables being explored must be made with caution. Generally, studies in this area must rely on self- reported data, which may introduce a variety of social biases. For example, it is possible that some information, such as sexual behaviours and recreational drug use, were misreported or underreported by some respondents because of the sensitive nature of the questions. To overcome some of the inherent challenges in this type of research, most studies used venue-based or other forms of convenience sampling. Given this, the findings cannot be generalized beyond the study populations.
For more specific study-level limitations, please refer to the respective studies referenced within this chapter.
Finally, as previously noted, an important limitation of the present update on the epidemiology of HIV/AIDS among MSM in Canada is that differences across studies, including variations in recruitment methods, eligibility criteria, variable definitions, as well as differences in statistical methods and power, make it challenging to make direct comparisons across findings. This makes it difficult to draw any specific conclusions regarding trends in risk behaviours over time.
When available data from the literature, HIV surveillance systems and the national HIV estimates are considered as a whole, it is clear that the transmission of HIV among MSM in Canada is ongoing.
Recent research indicates that certain subgroups of MSM continue to be at considerable risk of HIV infection by engaging in risky sexual practices, such as UAI with serodiscordant partners or partners of unknown HIV status. Research further suggests that men who engage in one high-risk behaviour tend to engage in other, higher-risk, behaviours, forming clusters of men at higher risk of HIV transmission. For example, men who partake in or seek sex in one higher-risk behaviour or in higher-risk environments, such as in bathhouses, also tend to partake in or seek sex in other higher-risk environments, such as public settings and on Internet sites.Footnote 1 Footnote 28 Footnote 34 Footnote 37 Footnote 40 Footnote 46 Footnote 47
UAI, particularly receptive UAI, with a partner of unknown or HIV-positive status or with a casual or commercial sex partner continues to be reported as the main risk factor for HIV seroconversion among MSM.Footnote 10 Footnote 21 Footnote 28 Footnote 48
Several hypotheses have been explored in an effort to explain why some men continue to practise unsafe sex. Although specific outcome measures and findings across studies have varied, recent publications continue to support the notion that a host of complex and interrelated factors are associated with HIV-related risk behaviours among MSM.Footnote 17 Footnote 19 Footnote 28 Footnote 29 Footnote 30 Footnote 31 Footnote 32 Footnote 33 Footnote 34 A limited number of recent studies have also started exploring and identifying the psychological and social factors underlying decisions to engage in riskier sexual behaviours.Footnote 31 Footnote 32 Footnote 33 Footnote 35
Despite the continuing risk behaviours reported in many studies, a growing body of research indicates that most men continue to have safe sex most of the time.Footnote 26 41, 49 Nonetheless, as outlined above, those who report UAI with both regular and casual partners represent a significant subpopulation.Footnote 33
While the scientific community continues to be interested in gaining a better understanding of the context in which high-risk behaviours take place, research suggests that some MSM are using strategies, such as "serosorting", to mitigate their risk of acquiring HIV.Footnote 21 Footnote 43 Footnote 50 51 The effectiveness of said strategies, however, is still controversial.Footnote 21 Footnote 51
Myths and misconceptions regarding the transmission of HIV still exist among some groups of MSM.Footnote 52 Thus, as Adam and colleagues have recently suggested, prevention messages are still valuable, "as there are always new men entering into relations with other men, whether they arrive from the upcoming generation, immigration, or self-discovery" (p. 420).Footnote 1 These authors note, however, that simply having the facts at hand is not necessarily enough to bring about behaviour change and thus a consistent reduction in the transmission of HIV in all MSM.Footnote 1 Rather, the implication for prevention programs is to recognize that there is an uneven distribution of risk among MSM and that prevention messages relevant to one group of men may lack resonance with others.Footnote 1 Researchers have further argued that sexual health services should offer services in multiple languages and offer multicultural services through various mediums to meet the needs of diverse MSM.Footnote 52 Footnote 53
Some have specifically suggested that the Internet is an important delivery tool for information about safer sex and the transmission and prevention of HIV and sexually transmitted infections among MSM.Footnote 54
Taken together, the findings presented here suggest that investigation of specific risk behaviours, measured more consistently over time in diverse groups of MSM across Canada, is still needed. Improved information could, in turn, be used to enhance policies, programs and services intended to reach and benefit MSM in Canada.
For more information, please contact:
Surveillance and Risk Assessment Division
Centre for Communicable Diseases and Infection Control
Public Health Agency of Canada
Postal locator: 0602B
Ottawa, ON K1A 0K9
Tel: (613) 954-5169
Fax: (613) 957-2842
To promote and protect the health of Canadians through leadership, partnership, innovation and action in public health.
Public Health Agency of Canada
|Authors and year of publication||Study design & study objectives||Recruitment & study period||Study population & sample size||Subsample used for analysis||HIV incidence||HIV prevalence|
|Allman et al. (2009)Reference 1||
"To examine the prevalence of [delayed condom application] within a gay community and explore factors associated with condom use among those who practice only safer sex and those who report at least some unprotected anal sex." (775)
|Venue-based purposive sampling February–June 2002||Gay and bisexual men 15 years and older in Ontario n = 5,080||Men who answered questions about delayed condom application in the previous 12 months n = 2,614||NA||Based on self report 8.9%|
|Myers et al. (2009)Reference 2||
"To describe hepatitis C (HCV) and HIV prevalence and co-infection, and to examine variables associated with infection in a community sample of men who have sex with men (MSM)." (1)
|Venue-based sampling purposive sampling February-June 2002||Gay and bisexual men, 15 years and older in Ontario
n = 5,080
|Men who provided sufficient fluid to conduct laboratory tests to detect the presence of both HCV and HIV antibodies
n = 3,304
|NA||Based on saliva specimen
|Xu et al. (2009)Reference 3||
"To compare the prevalence of HIV, HCV, HIV-HCV co-infection between bisexual and gay men in two cross-sectional studies undertaken at different points in time." (66B)
|Overall sample size not speciffied
Bisexual, n = 355 Gay, n = 2,480
Bisexual, n = 217 Gay, n = 1,876
|Men who provided biological specimens of sufficient quantity for laboratory testing||NA||OMS
(Based on saliva sample) 7.3% among bisexual men; 1.3% among gay men
(Based on dried blood spot [DBS]): 14.7% among bisexual men; 20.7% among gay men
|Adam et al. (2008)Reference 4||
"To delineate characteristics of men who report that they like to participate in the "bareback scene" and cruise "bareback Web sites" by comparing them with men who had casual male partners during the last 6 months but do not report an interest in bareback scenes or Web sites." (421)
|Men who attended Toronto Pride Event 2005 June 2005||Men who had sex with a man during the previous 6 months or reported a gay identity n = 922||NA||NA||Based on self-reported serostatus 12.6%|
|George et al. (2008)Reference 5||
"To improve our understanding of BMSM communities and networks in Toronto for evidence-informed HIV prevention efforts/ programs." (80A)
|Venue-based sampling June 2007-January 2008||Black MSM in Toronto
|NA||NA||Based on self-report
|Hirshfield et al. (2008)Reference 6||
"To assess the utility of screening for, and characteristics associated with, depressive symptoms in an online survey of MSM." (904)
|Banner linking to survey advertised on gay-oriented American and Canadian websites October 2003- March 2004||MSM 18 yrs & older from 10 Canadian provinces, the United States and 65 other countries
n = 4,030
|Men who met the study criteria and did not refuse or omit a response: n = 2,964
Prevalence is based on those who had been tested: n = 2,414
|NA||Based on self-reported HIV status Overall: 9.0%|
|Lampinen et al. (2008)Reference 7||
"To determine incidence of, prevalence of, and risk factors for sexual orientation-related physical assault in young men who have sex with men (MSM)." (1028)
|Venue-based convenience sampling May 1995-May 2004||Young (15 to 30 years of age), gay, bisexual and other MSM living in the greater Vancouver area who had not previously received an HIV- seropositive test result n = 863||Men with ≥1 follow-up study visit and complete data for the variables of greatest interest in present analysis n = 521||NA||Based on blood sample 7.1% among men with history of assault prior to study enrolment; 2.3% among men with no history of assault prior to study enrolment.|
|Lavoie et al. (2008)Reference 8||
"To estimate human immunodeficiency virus (HIV) incidence risk factors among men who have sex with men (MSM)." (25)
|Venue- and other convenience-based sampling October 1996-July 2003||MSM 16 yrs & older, HIV negative at baseline living in Montreal or surrounding area n = 1,846||Participants with at least one follow-up visit n = 1,587||0.62/100 person years (PY) (95% confidence interval 0.41-0.84)||NA|
|Remis et al. (2008)Reference 9||
"To examine the association of HIV prevalence and participant characteristics." (26A)
|Venue-based sampling March-July 2007||MSM: Toronto: n = 2,021 Ottawa: n = 517||MSM who provided DBS sample||NA||Based on DBS sample Toronto: 23.2% Ottawa: 11.9%|
|Chiasson et al. (2007)Reference 10||
"To assess whether men who have sex with men (MSM) are more likely to report unprotected anal intercourse (UAI) with partners met online compared with those met offline" (235)
|Banner linking to survey advertised on gay-oriented American and Canadian websites October 2003-March 2004||MSM 18 yrs & older from 10 Canadian provinces, the United States and 65 other countries n = 4,030||18 years of age or older from the United States or 10 Canadian provinces and reported sex with a new or casual male partner in their last sexual encounter in the previous 3 months: n = 1,683
Prevalence is based on those who reported ever having an HIV test: n = 1,298
|NA||Based on self- report 11%|
|George et al. (2007)Reference 11||
"To identify key differences in sexual, psychological and other characteristics between foreign-born and Canadian born MSM that may increase their vulnerability for HIV."(10)
|Vanguard: Venue- based sampling May 1995-May 2004 Omega: Venue- and other convenience- based sampling October 1996-July 2003||Vanguard:
Young (15 to 30 years of age) HIV-seronegative gay, bisexual and other MSM living in the greater Vancouver area: n = 863
Omega Cohort: MSM 16 yrs & older, HIV seronegative at baseline living in Montreal or surrounding area: n = 1,846
|Combined sample from both studies used for analysis: n = 1,148. Analysis restricted to baseline data as of Sept 1999 for subjects <30 years of age Canadian Aboriginals excluded from analysis||NA||Based on biological samples
1.5% - White born in Canada
2.1% - White born outside of Canada
2.8% - Non- white born in Canada
1.0% - Non- white born outside of Canada
|Lampinen et al. (2007)Reference 12||
"To study the prevalence and correlates of contemporary nitrite inhalant use among young MSM in Vancouver." (2)
|Venue-based sampling May 1995-May 2004||Young (15 to 30 years of age) HIV- seronegative gay and bisexual men living in the greater Vancouver area n = 863||Restricted to eighth and final wave of data collection, Oct 2002 to May 2004 n = 354||NA||Based on biological sample Overall: 7%|
|Remis et al. (2007)Reference 13||
||Questionnaire was sent with all first- time HIV-positive test results and 1:200 sample of HIV- negative results January 2001- September 2006||All those who received first-time HIV-positive test results and 1:200 sample of HIV-negative results in Ontario from January 2001 to September 2006||People reporting MSM as a risk factor n = 2,745||Laboratory based (detuned assay) Crude: 1.75/100 PY Adjusted: 1.14/100 PY||NA|
|Burchell et al. (2006)Reference 14||
"To describe incidence among men who have sex with men (MSM) undergoing repeat testing in Ontario in 1993-2003 and to determine whether rates have declined since 1999." (44A)
|MSM in Ontario identified by computerized and manual record linkage 1993-2003||n = 603 seroconverters; 17,361 repeat-negative testers Combined: 60,469 PY||Men who reported sex with men but no injection drug use||0.97/100 py||NA|