This chapter summarizes the most recent data available on the concentrated HIV/AIDS epidemic in Canada among the Aboriginal population. It begins with an overview of the HIV/AIDS epidemic among Aboriginal people in Canada, and also includes data and information regarding sex; perinatal transmission; age; gay, lesbian, two-spirit, bisexual and other men who have sex with men and women who have sex with women; injection drug use; incarceration; and HIV co-infection. These issues impact prevention, care, treatment and support strategies for Aboriginal populations.
PHAC uses various types of epidemiological data, including surveillance, survey data and estimates, to monitor HIV infections and AIDS cases in the Aboriginal and other populations in Canada. There are benefits and drawbacks to each type of information. Therefore, a complementary approach is adopted in order to create a more comprehensive picture of the HIV/AIDS epidemic in Canada.
Surveillance data are provided voluntarily to PHAC by the provinces and territories, and contains reported positive HIV test results and diagnosed AIDS cases. As HIV and AIDS are both reportable in all jurisdictions in Canada, case reporting standards have been developed by PHAC to facilitate data sharing at the national level. A minimum amount of information is provided for each case. However, the amount of supplementary data provided varies between provinces and territories . Specifically, with reference to the HIV epidemic in Canada among Aboriginal people, important missing surveillance data can include ethnicity.
Most reported HIV diagnoses and AIDS cases include one or more exposure categories. Exposure category refers to the most likely route by which a person became infected, as defined by a hierarchy of risk factors. For the purpose of national reporting, HIV and AIDS cases are assigned to only one single category. As illustrated in Figure 5, the first six exposure categories are
Surveillance data alone do not reflect the burden of HIV/AIDS in Canada, and/or comprehensively characterizes risk factors associated with a given transmission. This is due to several factors including the reluctance of persons to state HIV-related risk factors, delays in national reporting, and the data being reliant on individuals getting tested. Many Canadians, including Aboriginal people, do not routinely test for HIV. In 2008, it was estimated that 26% of people living with HIV in Canada were not aware of their HIV-positive status .
Reporting on HIV and AIDS cases among Aboriginal populations is further challenging because information on ethnicity is not reported by all provinces and territories. Currently, Ontario and Quebec do not report information on ethnicity for positive HIV tests. Between 1979 and the end of 2008, information on ethnicity was reported for 79.0% of all AIDS cases, while just 29.8% of new positive HIV test reports between 1998 (when ethnicity reporting began) and the end of 2008 included information on ethnicity. As a result, data on the incidence and prevalence of HIV among Aboriginal populations in Canada is incomplete and may under-represent the extent of the concentrated epidemic in the Aboriginal population. Lack of available data is exacerbated by stigma and discrimination which work against an individual’s willingness to disclose potentially sensitive information about HIV-related risk activity and sexual orientation.
Statistical modelling and estimation are used to calculate the number of HIV infections and AIDS cases in Canada. By using statistical formulas and secondary sources of data, estimates of the number of new infections (incidence) and the number of people living with HIV/AIDS infection (prevalence) can be generated. PHAC is responsible for reporting Canadian estimates of national HIV incidence and prevalence rates to the Joint United Nations Programme on HIV/AIDS (UNAIDS) . The methods used to estimate HIV incidence and prevalence at the national level bring together all available forms of data and are therefore used in this report.
To complement the data collected through the system described above (known as “first generation surveillance”), PHAC’s Surveillance and Risk Assessment Division has developed several second generation surveillance systems (“Track System” surveys) to capture survey information specific to key populations, and HIV/AIDS and related risk behaviours. Currently, two of these “Track” systems have been implemented and have generated results: M-Track (for gay, bisexual, two-spirit and other men who have sex with men); and I-Track (for people who inject drugs). PHAC is currently working on the development of a similar Track surveillance system for Aboriginal people (A-Track) that will monitor HIV-related risk behaviours among Aboriginal people in selected sites across Canada17. The development of A-Track was guided by a steering committee chaired by PHAC and composed of representatives from Health Canada’s First Nations and Inuit Health Branch, the National Aboriginal Council on HIV/AIDS (NACHA), the Canadian Aboriginal AIDS Network (CAAN), and the National Aboriginal Health Organization (NAHO).
Aboriginal peoples are overrepresented among HIV and AIDS cases in Canada. Between 1998 and 2008, Aboriginal people represented 24.0% of all new HIV-positive test reports that included ethnicity data. This is the highest percentage of any ethnic group other than those identifying as White . Figure 6 shows the total number and percentage distribution of positive HIV test reports among Aboriginal people by the year of test between 1998 and 2008, where ethnicity data were reported by provinces/territories. In the year 2008, for example, there were 201 positive HIV test reports among Aboriginal people, which made up 29.4% of all the positive HIV test reports for that year for those provinces and territories that submitted information on ethnicity.
Note: This table includes data from those provinces/territories that submitted information on ethnicity–British Columbia, Alberta, Saskatchewan, Manitoba, New Brunswick, Nova Scotia, PEI, Newfoundland and Labrador, Yukon Territory, Northwest Territories, and Nunavut. Ethnicity data became part of provincial/territorial submissions for HIV in 1998.
An estimated 4,300 to 6,100 Aboriginal persons were living with HIV (including AIDS) in Canada in 2008 (8.0% of all prevalent HIV infections) which represents an increase of 24% from the 2005 estimate of 3,500 to 4,900 (7.4% of all prevalent infections in 2005). An estimated 300 to 520 new HIV infections occurred in Aboriginal persons in 2008 (12.5% of all new infections), higher than the corresponding figure for 2005 of 240 to 430 (10.5% of all new infections in 2005). These proportions are much higher than the proportion of Aboriginal persons in the total Canadian population, which is 3.8% according to the 2006 census, as discussed in the previous chapter. The new infection rate among Aboriginal persons was about 3.6 times higher than among non-Aboriginal persons in 2008 .
Aboriginal people are also overrepresented among reported AIDS cases in Canada. Among reported AIDS cases with ethnicity information noted, there were 690 AIDS cases among Aboriginal people between 1979 and the end of 2008. Although Aboriginal people represent just 4.1% of all reported AIDS cases between 1979 and 2008, the proportion of Aboriginal persons among reported AIDS cases has increased over time (see Figure 7). During the period 1979-2002, 3.1% of all reported AIDS cases with information on ethnicity were among Aboriginal persons. However, during the period 2003-2008, the proportion was much higher, ranging from 13.9% to 21.7% in a year (year-to-year variability is due to the relatively small number of AIDS cases reported in recent years) .
Note: Due to changes in the reporting of AIDS cases in Ontario, ethnicity was not available for cases reported after the second half of 2005. These cases are categorized as “Not reported”. Percentages are based on the total number of AIDS cases minus reports for which ethnic status was not reported.
Data suggest that First Nations people are overrepresented among reported Aboriginal AIDS cases (see Figure 8). Of the 605 Aboriginal AIDS cases reported up to the end of 2006, 442 (73.1%) of these cases were among First Nations, 44 (7.3%) were among Métis and 22 (3.6%) were among Inuit .
In 2005, the primary HIV exposure categories among newly infected Aboriginal people were injection drug use (53%), heterosexual sex (33%), MSM (10%) and MSM/IDU (3%) . For First Nations, Inuit and Métis, the four main exposure categories of reported AIDS cases between 1979 and the end of 2006 are listed in Table 1.
|n=number of cases with available information on exposure categories|
|Aboriginal, unspecified (n=95)|
As in the non-Aboriginal population, males continue to make up the majority of Aboriginal HIV and AIDS cases. However, females constitute a larger proportion of HIV and AIDS cases among Aboriginal persons compared to non-Aboriginal females. Between 1998 and 2006, Aboriginal females made up nearly half (48.1%) of all new positive HIV test reports among Aboriginal people, whereas only 20.7% of positive HIV test reports were reported among non-Aboriginal females for the same period. Between 1979 and 2006, Aboriginal females made up 26.5% of reported AIDS cases among Aboriginal persons, while non-Aboriginal females made up 9.1% of cases among non-Aboriginal persons for that same period. Since 2001, Aboriginal females represented above 27.0% of reported AIDS cases among Aboriginal persons every year to 2006 .
For Aboriginal males, the main exposure categories are injection drug use, heterosexual sex, MSM and MSM/IDU (see Figure 9). For Aboriginal females, the main exposure categories for HIV are injection drug use and heterosexual contact (see Figure 10) . Receipt of blood or blood products and perinatal exposure to HIV accounted for very few of all HIV exposures among both Aboriginal men and women.
The proportion of females among reported Aboriginal AIDS cases are different for First Nations, Inuit and Métis. The following table describes the percentage of females and males among reported AIDS cases for Aboriginal groups.
|n=number of cases with available information on sex|
The perinatal transmission exposure category refers to the transmission of HIV from an HIV-infected mother to her child either during gestation (in utero), during delivery, or after delivery (through breast milk). It is estimated that, without any intervention, 15-30% of HIV-positive women will transmit HIV during pregnancy and delivery, and 10-20% through breast milk, to their newborn child . By identifying women who are HIV positive through prenatal HIV testing, the risk of mother-to-child transmission of HIV can be greatly reduced by using strategies, such as receiving antiretroviral therapy (ART) during pregnancy and avoiding breastfeeding . However, HIV-positive pregnant women who do not seek prenatal care or who do not receive prenatal HIV testing may not be able to access care that limits the risks of transmitting HIV to the newborn. Lack of awareness of HIV serostatus and uneven HIV testing among pregnant women are major barriers to the prevention of perinatal HIV transmission .
The national rate of HIV infection among pregnant women ranges from about 2 to 9 in 10,000 pregnant women, although rates are not available for all provinces and territories. The HIV infection rate of perinatally HIV-exposed infants in Canada was estimated as 3% in 2006 . As in the general population, perinatal transmission accounts for very few of all HIV infections among Aboriginal people. Between 1998 and the end of 2006, perinatal transmission was reported as the exposure category for just 0.5% of positive HIV test reports of Aboriginal males and 0.1% of positive HIV test reports of Aboriginal females . The vast majority (94.1%) of Aboriginal infants known to have been exposed to HIV perinatally between 2001 and 2008 have been confirmed to be HIV negative . Although perinatal transmission is not a major exposure category, it is an important mode of HIV transmission with serious consequences.
Available evidence suggests that Aboriginal infants are overrepresented amongst infants in Canada who acquired HIV via mother-to-child transmission . Cumulative national surveillance data from 2001 to 2008 indicates that infants of Aboriginal ethnicity constituted 19.3% of the 83 cases of infants perinatally HIV-exposed and confirmed to be infected with HIV (see Figure 11) .
Legend: Aboriginal includes Inuit, Métis, First Nations and Aboriginal unspecified. Other ethnicities include: White, Latin American (e.g. Mexican, Central/South American), Black (e.g. Somali, Haitian, Jamaican), Asian (e.g. Chinese, Japanese, Vietnamese, Cambodian, Indonesian, Laotian, Korean, Filipino), and Other (50 children whose ethnic status was undetermined).
The Aboriginal population is younger than the non-Aboriginal population in Canada. Aboriginal persons who receive an HIV diagnosis also tend to be younger than non-Aboriginal persons. Between 1998 and the end of 2006, nearly one-third (32.4%) of Aboriginal persons diagnosed with HIV infection were under the age of 30 years, compared to 21.0% of HIV-positive tests among non-Aboriginal persons in the same age group .
First Nations youth aged 0 to 29 years made up 20.6% of reported AIDS cases among First Nations people. Both Inuit and Métis youth under the age of 30 years each comprised 31.8% of reported AIDS cases among Inuit and Métis. However, there were no Inuit under the age of 20 years among reported AIDS cases, while 2.3% of reported AIDS cases among Métis were in persons under the age of 20 years .
Between 1979 and the end of 2006, Aboriginal persons aged 50 and older made up 9.3% of reported AIDS cases among First Nations persons, 4.5% among Inuit and 2.3% among Métis.
Positive HIV test reports from 1998 to the end of 2006 indicate that injection drug use was the main category of exposure to HIV for both Aboriginal males and females. Between 1998-2006, injection drug use accounted for 58.8% of HIV-positive test reports among Aboriginal people, and about 40% of reported AIDS cases among Aboriginal people over the years 1979 to 2006 .
There is a substantial difference between Aboriginal people and the general Canadian population in the injection drug use exposure category. In 2005, 53% of new HIV infections among Aboriginal people were due to injection drug use, while just 14% of new HIV infections among Canadians in general were due to injection drug use .
Injection drug use accounts for more HIV infections and AIDS cases among Aboriginal women than Aboriginal men. Between 1998 and the end of 2006, injection drug use was the exposure category for 53.7% of HIV-positive test reports among Aboriginal men and 64.4% of HIV-positive test reports among Aboriginal women . In reported AIDS cases among Aboriginal people between November 1979 and the end of 2006, injection drug use was the exposure category for 62.3% of reported AIDS cases among Aboriginal women and 32.1% of reported AIDS cases among Aboriginal men .
Although Aboriginal persons have been overrepresented in Canadian studies of people who inject drugs [10-14], it is unclear if this pattern is generalizable and indicates the true picture of drug use within Aboriginal populations or if it reflects other factors. In I-Track, the national HIV surveillance system with a focus on people who inject drugs, surveys conducted in 2003-2005 in cities such as Regina, Edmonton and Winnipeg yielded significant proportions of Aboriginal persons among their sampled populations of persons who inject drugs (ranges of 70%-87%), while other cities such as Sudbury, Victoria and Toronto had fewer Aboriginal participants (ranges of 13%-27%) .
Studies suggest that Aboriginal people who inject drugs may be more likely to be infected with HIV than non-Aboriginal people who inject drugs [15-18]. A study of 941 people who inject drugs in Vancouver (nearly one quarter of whom were Aboriginal) found that the incidence of HIV infection among Aboriginal people was twice as high as the incidence among non-Aboriginal people .
Results from the I-Track surveys (2003-2005) indicate that, overall, 14.5% of participants reported injecting with used needles in the 6 months before the survey (ranges from 8.7%-26.7%). Participants reported that they most often borrowed used needles from close friends and family or regular sex partners . The study also found that nearly two-thirds (65.7%) of the sampled population of people who inject drugs had evidence of past or current hepatitis C infection. Of the study participants with laboratory samples taken and tested, 14% were positive for HIV and hepatitis C antibodies. Among those who had HIV, 91% also had evidence of current/past hepatitis C infection .
Injection drug use among youth is a significant concern. More than one-quarter of the participants in the I-Track surveys of people who inject drugs (25.5% of men and 29.9% of women) reported that they began to inject drugs at age 16 or younger . Another study of 291 young people (aged 13-24) who inject drugs found that HIV rates among young Aboriginal people who inject drugs were higher at the beginning of the study than among non-Aboriginal participants. The study also found that young Aboriginal people who inject drugs experienced higher HIV seroconversion rates during the course of the study than non-Aboriginal young people who inject drugs .
Among First Nations people, less than half (45.2%) of all reported AIDS cases up to the end of 2006 were attributed to injection drug use. Among Inuit and Métis for that same time period, less than one-third of cases were attributed to injection drug use (see Table 1).
Men who have sex with men (MSM) is an epidemiological term used to describe the HIV category of men who have had sex with men. In the general Canadian population, the MSM exposure category continues to account for the greatest number of new HIV infections (45% of new infections in 2005) . Among Aboriginal men, however, the MSM exposure category is the third most common after injection drug use and heterosexual contact.
Between 1998 and the end of 2006, 13.0% of HIV-positive test reports among Aboriginal men were attributed to the MSM exposure category and an additional 6.7% to the MSM/IDU18 category . Among reported AIDS cases of Aboriginal men between 1979 and the end of 2006, 41.3% were attributed to the MSM exposure category and an additional 9.4% to the MSM/IDU category.
Studies of gay, two-spirit and bisexual male populations suggest that Aboriginal men who have sex with men may be at increased risk for HIV infection compared to non-Aboriginal men who have sex with men. A study of 910 MSM conducted in Vancouver found that the MSM/IDU in the study group were more likely to be Aboriginal than MSM who did not inject drugs . MSM who inject drugs face higher risks for HIV infection than MSM who do not inject drugs.
Among Métis people, nearly half (48.8%) of all reported AIDS cases up to the end of 2006 were attributed to the MSM exposure category, while less than one-third of reported AIDS cases among First Nations and Inuit were attributed to the MSM exposure category (see Table 1).
Women who have sex with women is an epidemiological term used to describe the HIV category of women who have had sex with women. PHAC does not collect information on this exposure with the national HIV/AIDS surveillance system.
There is little information available on rates of sexually transmitted infections (STIs), including HIV infections, among women who have sex with women. Transmission of STIs among women who have sex with women is often strongly correlated with sexual contact with a male partner . Studies indicate that women who exclusively have sex with women have lower rates of STIs than women who exclusively have sex with men and women who have sex with both women and men . Although sexual transmission of STIs, including HIV, have been reported among women who have sex with women exclusively with no history of a male sexual partner , the risk of HIV infection for a woman whose only risk factor is having sex with another woman is considered low.
Aboriginal people are significantly overrepresented in Canadian prison systems19. Aboriginal peoples comprise 20% of incarcerated federal offenders; Aboriginal women offenders comprise 32% of incarcerated federal women offenders, while Aboriginal men offenders comprise 20% of incarcerated men offenders . In 2006, the majority (68%) of Aboriginal offenders were First Nations, 28% were Métis and 4% were Inuit . The concentration of Aboriginal people in prison was highest in the prairie provinces in 2006, where 60% of people in federal prisons were Aboriginal .
Aboriginal people are also overrepresented among provincial prison systems. For example,
Aboriginal youth are overrepresented in youth detention facilities. In Nova Scotia, 9% of those in youth facilities are Aboriginal. In Ontario in 2007/08, 10.5% of male youth and 20.1% of female youth in secure facilities were Aboriginal, while in Manitoba 81% of male and 88% of female youth in youth correctional facilities are Aboriginal21.
HIV prevalence is higher among persons in prison than in the general Canadian population. In 2006, 1.64% of people in federal prisons were reported to be HIV positive . The rate of HIV infection in federal penitentiaries varied between regions. Data for 2004 indicate that the Pacific region reported the highest HIV prevalence rate among people in federal prisons (2.11%), followed by Quebec (2.03%), the Prairie region (1.07%), Atlantic region (1.00%) and Ontario (0.98%) . Other Canadian studies have identified HIV infection prevalence rates of 0.9% to 4.7% among women in prison .
In 2006, 52.1% of new admissions to federal prisons and 26.4% of the general population in prison had a blood test for HIV . Although HIV testing is available to those new to prison and those already in prison, and is voluntary, only a proportion of people participate. Therefore, it is not known whether the number of reported HIV cases represents the actual prevalence of the disease .
Co-morbidity refers to the co-existence of two or more diseases in one person. The HIV co-morbidities that will be examined in this section are diabetes, tuberculosis, sexually transmitted infections, and hepatitis C.
As discussed in Chapter 2, evidence indicates that First Nations and Métis people experience higher rates of type 2 diabetes than the general Canadian population, while diabetes incidence among Inuit appears to be increasing though is still lower than the general population. Research suggests that the incidence of diabetes among HIV-positive people who are taking ART is higher than for people who are HIV-negative [28-30]. There is also research indicating that HIV and hepatitis C co-infection may also increase the risk of developing diabetes [31-33]. This suggests that Aboriginal people who are HIV-positive and taking ART may be at increased risk for diabetes. Currently, there is no research available on the correlation between HIV, hepatitis C, ART and diabetes in the Aboriginal population, nor information on the management of these diseases among Aboriginal people, including issues related to the challenges of managing multiple conditions and medications.
Worldwide, tuberculosis (TB) is the leading cause of death among people living with HIV . Without ART, people with HIV are up to 100 times more likely to have active TB during their lifetime than people who do not have HIV. TB also causes “more rapid deterioration of the immune system of people with HIV or AIDS” . At the national level in Canada, the HIV status of active TB cases, including pulmonary and non-pulmonary, is not measured [34;35]. As discussed in Chapter 2, high rates of TB in the Aboriginal population are likely mainly due to housing conditions such as overcrowding , which may increase exposure to TB infection. The 2006 census found that Aboriginal people were nearly four times more likely than non-Aboriginal people to live in a crowded house . Because Aboriginal people are disproportionately affected by both HIV and TB infection, the population is also considered at risk for co-infections .
Sexually transmitted infections (STIs), such as chlamydia, gonorrhoea and syphilis, increase the risk of HIV transmission and acquisition. This means that an HIV-positive person who also has an STI is more likely to transmit HIV to an uninfected sexual partner. A person who has an STI and is exposed to HIV is also more likely to acquire HIV than someone who does not have an STI . Available surveillance data suggest that Aboriginal people are overrepresented among cases of STIs. Although ethnicity data are not reported for the majority of STI cases, in 2006 Aboriginal people accounted for 15.0% of reported genital chlamydia cases, 27.4% of reported gonorrhoea cases and 19.7% of reported infectious syphilis cases in the four jurisdictions that regularly report ethnicity data to PHAC . Higher rates of STIs contribute to increased risk for Aboriginal people in acquiring and transmitting HIV.
Hepatitis C is a chronic liver disease caused by the hepatitis C virus (HCV). Because HCV is spread through blood-to-blood contact, many of the risk factors for HCV infection are the same as for HIV infection (i.e. needle sharing among people who use injection drugs or tattooing with shared, unsterilized equipment). However, HCV transmits more easily than HIV in infected blood. As a result, people whose behaviour puts them at risk of HIV infection through blood-to-blood contact are at increased risk for HCV infection.
It is estimated that 242,500 people in Canada are infected with HCV, and almost 8,000 people were newly infected in 2007 . Though some people (15-25%) appear to clear their HCV infection without treatment, the majority become chronic carriers of HCV. Long-term consequences of HCV infection can include cirrhosis and liver cancer . Some studies suggest that Aboriginal people are more likely to spontaneously clear an HCV infection than non-Aboriginal people [41;42]. Nonetheless, HCV reinfection can occur after spontaneous clearance or successful completion of treatment for HCV infection [43-48].
Between 2004 and 2008, reported rates of acute HCV infection were 5.5 times higher in Aboriginal people than in non-Aboriginal people . People co-infected with both HCV and HIV are more likely to transmit HCV to others . Some evidence also suggests that the use of ART to treat HIV infection may contribute to more rapid progression of HCV for those infected with both viruses . Studies also suggest that Aboriginal people are overrepresented among persons who are co-infected with HIV and HCV. A study of 484 HIV-infected persons in British Columbia found that study participants who were co-infected with HCV were more likely to be Aboriginal (20% versus 3%) . Another study of 510 people living with HIV in Ontario found that participants who were co-infected with HCV were more likely to be Aboriginal than those who were only infected with HIV .
The source of the majority (70-80%) of HCV infections in Canada is injection drug use (IDU), resulting from the sharing of needles, syringes and other injection equipment . IDU is also a key risk factor for HIV and HCV co-infection. In a study of HIV-positive residents in northern Alberta, HIV and HCV co-infection were found to be significantly associated with both IDU and Aboriginal ethnicity. In that study, a large proportion (40.0%) of co-infected participants were Aboriginal, while among the HIV-positive/HCV-negative cohort, just 25.7% of the participants were Aboriginal . Another study of 479 youth who inject drugs in Vancouver found that more than 45% of HIV and HCV co-infected participants were Aboriginal .
Data from Canadian federal penitentiaries indicate that the prevalence of HCV is higher among people in federal prisons than in the general Canadian population. In 2006, 49.4% of new admissions to federal prisons and 22.6% of the general prison population were voluntarily tested for HCV. In 2006, 27.6% of people in federal prisons were known to be HCV positive , although the actual number of HCV-infected individuals may be higher. As Aboriginal people are overrepresented in the prison system, and among the IDU population, they may be overrepresented in federally incarcerated persons with HCV infection.
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