Figure 7: Hierarchy of Risk
This chapter summarizes the most recent data available on the HIV/AIDS epidemic in Canada among people from countries where HIV is endemic. It also presents specifi c data on the Black population in Canada, including people of African and Caribbean communities using surveillance ethnicity data.
It begins with an overview of the HIV/AIDS epidemic in sub-Saharan Africa and the Caribbean, before focusing on the epidemic in Canada in persons from countries where HIV is endemic, including geographic information as reported by the provinces and territories. Data surrounding gender, perinatal transmission, immigration, location of infection acquisition and virus strains will also be discussed, as these infl uence and impact prevention, treatment, and response strategies for this population.
PHAC uses various types of epidemiological information, including surveillance, research data and estimates, to monitor HIV infections and AIDS cases in Canada. There are benefi ts and limitations to each type of information requiring their combined use to create a more comprehensive picture of the concentratedxiii HIV/ AIDS epidemic in Canada.
Surveillance data are provided voluntarily to PHAC by the provinces and territories, and comprise reported HIV-positive test results and diagnosed AIDS cases. As HIV and AIDS are reportable in all Canadian jurisdictions, case reporting standards have been developed by PHAC to facilitate data sharing at the national level. While a minimum amount of information is provided for each case (the “Core Set” of variables), the amount of supplementary data provided varies between provinces and territories . In particular, important missing surveillance data can include country of birth, ethnicity and exposure category. Country of birth and ethnicity can help organize data according to the HIV-endemic country list (Appendix A), while exposure category refers to the most likely route by which a person became infected, as defi ned by a hierarchy of risk.
As illustrated in Figure 7, the fi rst four categories in the hierarchy of risk are 1) men who have sex with men (MSM), 2) people who inject drugs (IDUs), 3) recipients of blood and blood products, and 4) heterosexual contact. The category “Heterosexual contact” includes a subcategory specifi c to those whose likely route of HIV exposure is connected to an HIV-endemic country (person is a heterosexual from an HIV-endemic country). This is the subcategory that will be referenced throughout this chapter. The fi rst three categories are generally accepted to be higher risk activities than heterosexual contact .
Due to the considerations listed above, to individuals’ reluctance to report risk factors, to the fact that many Canadians do not routinely undergo test for HIV testing and that cases are not always reported immediately to PHAC, surveillance data alone do not refl ect absolute numbers of HIV/AIDS cases in Canada at any given time. Statistical modelling (i.e. estimates) is thus 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 (incidencexiv ) and the number of people living with HIV infection (prevalence) can be obtained. In fact, PHAC is responsible for reporting Canadian estimates of national HIV incidence and prevalence rates to UNAIDS .
The methods used to estimate HIV incidence and prevalence at the national level bring together all available forms of data and are subsequently used in this report.
Unlike Canada, where HIV is mainly concentrated in specifi c populations, some countries have experienced HIV infection rates of signifi cant proportions in the general population. This is also known as a “generalized epidemic” where the main route of transmission is through heterosexual sex, thereby affecting the general population. PHAC defi nes an HIV-endemic country as a country that has an HIV prevalence rate of 1.0% or greater in adults (ages 15-49) and any one of the following:
In much of sub-Saharan Africa and the Caribbean, countries report endemic levels of HIV. In 2007, it was estimated that out of 33.2 million (30.6 – 36.1 million) adults and children living with HIV worldwide, 22.5 million (20.9 – 24.3 million) were living in sub-Saharan Africa. The approximate HIV prevalence rate in adults was 5% (4.6% - 5.5%). The Caribbean had an estimated 230,000 (210,000 – 270,000) adults and children living with HIV, with an estimated adult prevalence rate of 1% (0.9% - 1.2%). Prevalence in this region was highest in the Dominican Republic and Haiti, which together accounted for nearly three quarters of the 230,000 (210,000 – 270,000) people living with HIV in the Caribbean, including the 17,000 (15,000 – 23,000) who were newly infected in 2007 .
In 2005, there was an estimated 2,300 to 4,500 new HIV infections in Canada, of which 400 to 700 (16%) were attributed to the HIV-endemic exposure subcategory. The infection rate among individuals from HIV-endemic countries was estimated to be at least 12.6 times higher than among other Canadians in 2005 . PHAC estimates that at the end of 2005, 58,000 (48,000 – 68,000) people in Canada were living with HIV (including AIDS). The HIV-endemic exposure subcategory was estimated to account for approximately 7,050 (5,200 – 8,800) of these HIV infections. If using the mean estimates provided (7,050 / 58,000), in 2005 approximately 12.2% of HIV infections in Canada were attributed to the HIV-endemic exposure subcategory (see Figure 8) .
Figure 8: Estimated number of prevalent HIV cases in Canada by exposure category, 2005 (n=58,000)
Legend: Heterosexual exposure: HIV-endemic = origin in a country where HIV is endemic. All other categories include MSM = men who have sex with men;
IDU = people who inject drugs; Heterosexual/non-endemic = heterosexual contact with a person who is either HIV infected or at risk of HIV or heterosexual as the only identifi ed risk; recipients of a blood transfusion or clotting factor, and occupational transmission (Source: , p. 3, table 1).
As shown in Figure 9, the absolute number of positive test reports in the HIV-endemic exposure subcategory increased from 36 in 1998, to a peak of 112 in 2004. In 2005, this exposure subcategory accounted for 100 positive test reports and for 106 in 2006. The proportion of overall positive test reports attributed to the HIV-endemic subcategory increased from 3.0% in 1998 to a peak of 8.5% in 2004 and more recently to 8.4% in 2006 .
Figure 9: Number of positive HIV test reports attributed to the HIV-endemic exposure subcategory and proportion of all HIV-positive test reports by year, 1998-2006
(Source: , p. 93, fi gure 1).
Proportionally, these numbers are comparable to the reported AIDS cases attributed to the HIV-endemic exposure subcategory. As shown in Figure 10, although the total number of AIDS cases per year attributed to this exposure subcategory has declined (from 66 in 2002 to 63 in 2004), the proportion of overall reported cases increased from 9.6% in 1998 to a peak of 16.9% in 2002 (16.4% in 2004) .
Figure 10: Number of reported AIDS cases attributed to the HIV-endemic exposure subcategory and proportion of all AIDS cases by year, 1998-2004
Data excludes the provnice of Quebec (Source: , p. 93, fi gure 2)
Figure 11 shows the number of reported AIDS cases by province/territory for the HIV-endemic exposure subcategory, as well as the national distribution (%) by province/ territory to December 31, 2006xv. Ontario and Quebec share the highest number and proportion of reported AIDS cases for the HIV-endemic exposure subcategory. While it is expected that Ontario and Quebec would have the highest proportion of cases based on the geographic location of the Black population in Canada (see Figure 2), the number of reported AIDS cases are not distributed proportionally between the two provinces. Which approximately 62.1% of the Black population in Canada resides in Ontario , the proportion of AIDS cases for the HIV-endemic exposure subcategory is approximately xv A similar distinction for positive HIV test reports could not be reported due to data limitations. 36.1% . Quebec on the other hand has approximately 23.0% of the Black population in Canada , but 55.3% of the national proportion of AIDS cases . This suggests that the Black population in Quebec seems to be overrepresented in its proportion of AIDS cases.
Studies and subsequent analysis would be required to better understand this fact, however a plausible explanation points to the fact that Haiti was one of the first countries to be seriously affected by HIV/AIDS. The Black Haitian population living with HIV/AIDS in Quebec was likely diagnosed earlier with a larger number of individuals having progressed to AIDS.
Figure 11: Number of reported AIDS cases by province/territory and national proportional distribution (%) of total AIDS cases for the HIV-endemic exposure subcategory, cumulative to December 31, 2006 (n=1248)
(Source: , p. 54, table 19).
When using surveillance data that include ethnic status or country of birth, the provinces and territories show a similar increase in the number of positive HIV tests attributable to persons as having an ethnic origin associated with the Black population:
As described in Section 3.1, exposure category information is used in HIV/AIDS surveillance to monitor HIV transmission routes and AIDS cases. Due to the hierarchy of risk, persons from HIV-endemic countries who are not exposed to HIV through heterosexual sex are not included in the HIV-endemic subcategory. Therefore, ethnicity data coupled with exposure category data help further characterize HIV infection in Canada.
From 1998 to 2006, 396 HIV-positive test reports identifi ed through the National HIV and AIDS Surveillance System belonging to the HIV-endemic exposure subcategory included information on ethnicity. Of those, 92.7% identifi ed themselves as Black, 3.8% as Asian, 2.0% as White and 1.5% as other. Similarly from 1998 to the end of 2006, for the 334 AIDS cases in the HIV-endemic exposure subcategory and with information on ethnicity, 88.0% identifi ed themselves as Black, 6.9% as Asian, 3.0% as other, and 2.1% as White . In the majority of cases where ethnicity data are collected in this exposure subcategory, ethnicity was described as Black.
The number of HIV positive test reports from 1998 to 2006 by ethnic status shows that the “Black” ethnic status represented 9.7% (608 test reports) of the 6,253 reports with known ethnic status for all ages. Surveillance data indicates that of the total number of reported AIDS cases from 1979 to 2006 in Canada that included ethnic status (16,349), those who identifi ed as “Black” represented 9.4% (1,537 cases) of cases for all ages .
Limitations with ethnicity reporting at the national level must be noted. Specifi cally, two of Canada’s largest provinces, Ontario and Quebec, do not provide ethnic information on positive HIV test reports at the national level. This hinders the national monitoring of the epidemic among persons from countries where HIV is endemic, as the two provinces account for over two-thirds of all positive HIV test reports and include two large urban centres (namely Toronto and Montreal) both with large Black populations .
Related data have, however, been published at the provincial level. The Ontario HIV Epidemiologic Monitoring Unit has collected information looking at Black ethnicity relating to HIV exposure categories. While this information may not necessarily be refl ective of the situation across Canada, it does provide a portrait of HIV/AIDS in Black communities in Ontario and could be helpful to other jurisdictions when undertaking data analysis.
According to Lui and Remis , from 1980 to 2004, in Toronto, while more than half (56.4%) of all HIVpositive tests in the Black population were attributed to the HIV-endemic subcategory, 21.2% were attributed to the MSM exposure category, 0.95% to the MSM-IDU exposure category, 1.6% to the IDU exposure category, and 20.4% to other exposure categories. From 1983 to 2004, more than 80% of infections in Ottawa’s Black community were attributed to the HIV-endemic exposure subcategory, MSM representing 7.7% of infections (refer to Figure 12). While HIV-positive test results were not available province-wide, Black ethnicity AIDS data for Ontario are discussed in this section.
Cumulative Ontario provincial data from 1981–2004 indicate that 58.3% of all AIDS cases with reported Black ethnicity/race were attributed to the HIV-endemic exposure subcategory, 26.3% were from the MSM exposure category, approximately 2% in each the MSM/ IDU and the IDU exposure categories, and 11.4% attributed to other exposure categories (refer to Figure 13) . It may not be possible to ascertain whether the Ontario-wide data are skewed by Toronto’s large population (thus more closely refl ecting the Toronto epidemic), or if time, treatment advancements, and changing immigration patterns have affected the presentation of AIDS cases in the province.
Figure 12: Number and proportion of reported HIV cases by exposure category and race/ethnicity Toronto (1980-2004, n=945) and Ottawa (1983-2004, n=300)
Legend: Other - Black exposure category = Heterosexual-Black [Toronto:146, 15.4%, Ottawa: 15, 5%], Transfusion-Black [Toronto: 11, 1.2%, Ottawa: 0, 0%], Perinatal-Black [Toronto: 27, 2.9%, Ottawa: 11, 3.7%], NIR (No identifi ed risk)-Black [Toronto: 9, 0.96%, Ottawa: 1, 0.33%]. (Source: , p. 25, table 2.3b).
Figure 13: Total AIDS cases for all exposure categories within the Black race/ethnicity group in Ontario, 1981 to 2004 (n=537)
Legend: Other - Black exposure category = Heterosexual-Black [13, 2%], Transfusion-Black [2, 0.37%], Clotting factor-Black [4, 0.74%], Perinatal-Black [25, 5%], NIR (No identifi ed risk)-Black [7, 1.3%]. (Source: , pp. 17-19, tables 1.6-1-1.6-3).
Women are becoming increasingly affected by HIV in Canada. Nationwide data have shown a steady rise in the proportion of reported HIV-positive test results in adult women, climbing from 25.1% (540/1,614) in 2001 to 27.8% (698/1,810) in 2006 . In the HIV-endemic exposure subcategory between 1998 and 2006, women accounted for 54.2% of all positive HIV test reports and 41.8% of AIDS case reports . In 2006 alone, of the 104 reported HIV-positive test results in the HIV-endemic exposure subcategory, only 39 cases were male while 65 were female .
While national data illustrate that the HIV-endemic exposure subcategory makes up a cumulative average of 9.0% of newly diagnosed HIV infections in women (from 1985–2006), when separated by year, the 2006 data show the HIV-endemic exposure subcategory represents 20.4% (65/319) of new HIV diagnoses in women where exposure category was reported . In 2005, women accounted for 63.9% (140) of the 219 people from countries where HIV is endemic who were newly diagnosed with HIV in Ontario, and according to HIV surveillance data from the same year, females from countries where HIV is endemic accounted for 50.8% of all new HIV diagnoses among women in Ontario (see Figure 14).
Similarly 2006 Quebec data reveal that 41.3% of newly diagnosed HIV infections among women were attributed to the HIV-endemic exposure subcategory. While this trend has been observed for the last few years , a comparison of the estimated prevalence of HIV infections for the HIV-endemic country exposure subcategory in Quebec revealed an increase from 11% (1,770) in 1999 to 14% (2,500) in 2002. The same study also noted that women from countries where HIV is endemic account for the highest number of AIDS cases among women .
Figure 14: Number and proportion of HIV diagnoses among females by year of diagnosis and exposure category, Ontario 2005 (n=276)
Legend: Blood/Blood product =Clotting factor and transfusion; HR Hetero = High risk heterosexual contact; LR Hetero = Low Risk Heterosexual contact; Other = Mother to child transmission, needle stick injury, tattoo, etc. (Source  p. 60, table 1.5b).
Women in the 20 to 39 age group made up more than two thirds (66.9%) of positive HIV test reports among adult women in Canada in 2006 . The high proportion of women in the HIV-endemic exposure subcategory has implications for perinatal transmission. Although provinces and territories offer HIV testing to pregnant women, not all women choose to get tested . Cumulative surveillance data available from 1984–2006 show that nationally, Black infants comprised more than half of the 477 confi rmed perinatally exposed HIV cases in Canada (refer to Figure, 15). This trend has, however, decreased over time. In 2006, 97 infants were born to HIV-positive mothers with reported as having an ethnic origin associated with the Black population. Of the 97, only one infant was confi rmed to be HIV positive, 83 were not infected perinatally, and the serostatus of 13 infants was unknown at the time of data publication .
Figure 15: Cumulative number of Canadian perinatally HIV-exposed infants by ethnic status, 1984-2006 (n=477)
Legend: Black ethnicity = For example Somali, Haitian, Jamaican; All other ethnicities include: White, Latin American = For example Mexican, Central/South American, Aboriginal = Includes Inuit, Métis, First Nations and Aboriginal unspecifi ed, Asian = For example Chinese, Japanese, Vietnamese, Cambodian, Indonesian, Laotian, Korean, Filipino, Other = 50 children whose ethnic status was undetermined. (Source: , pp. 35-36, table 12).
At the national level, from 1998 to 2006, a substantial proportion of AIDS cases and positive HIV test reports in the HIV-endemic exposure subcategory occurred in young age groups. When the HIV-endemic exposure subcategory is broken down by age, 78.2% of positive HIV test reports from 1998 to the end of 2006 occurred in those less than 40 years of age (34.2% among those under 30 years of age and 44.0% among those aged 30 to 39). From 2001 to 2006, when age was known, 59% of all positive test reports were among those less than 40 years of age (22% among those under 30 years of age and 37.2% among those aged 30 to 39) .
For the same exposure category, 43.9% of AIDS cases from 1998 to the end of 2006 were diagnosed in individuals between the ages of 30 and 39, another 15.3% were under the age of 30 , while the 30 to 39 age group represented 38% of the total reported AIDS cases from the same time period .
HIV/AIDS appears to be affecting younger persons in this subcategory. Again, this re-emphasizes the importance of considering women of childbearing age from countries where HIV is endemic (ages 15 to 44) for prevention and testing initiatives, as well as for potential risks for perinatal transmission of HIV .
Routine HIV testing of immigrants was implemented in January 2002 by the CIC. All individuals applying to come to Canada permanently and, some applying for temporarily status, are required to undergo an immigration medical examination (IME) and are tested for HIV if aged 15 years and older (or at any age if they present a known risk factor such as a blood transfusion). To be inadmissible under health grounds, an applicant must have a condition that is likely to be a danger for public health, or public safety, and/or is likely to create an excessive demand on Canadian health and social services .
HIV is generally not considered a danger to public health and safety. However, if the HIV-positive applicant’s medical requirements are likely to create an excessive demand on the Canadian health care system, the applicant may be deemed inadmissible to Canada under health grounds. The Immigration and Refugee Protection Act  exempts certain groups of applicants from the excessive demand determination. These groups include refugees, the sponsored spouse of a Canadian permanent resident/citizen and their dependent children. The vast majority of persons diagnosed with HIV during the immigration medical process fall within these groups. Consequently, the majority of HIV-positive applicants are admissible to Canada.
From January 15, 2002, to December 31, 2006, 2,567 applicants who underwent an IME tested positive for HIV. In 2006 alone, 597 applicants tested HIV-positive through this process. As illustrated in Figure 16, their distribution is such that 417 (69.8%) were born in Africa and the Middle East, 131 (21.9%) in the Americas, 29 (4.9%) in Asia and 20 (3.4%) in Europe. These 597 positive tests can be further characterized by testing location as 215 (36%) were from persons who were tested outside of Canada and 382 (64.0%) who were tested in Canada. The 382 HIV-positive tests identifi ed in Canada in 2006 through the IME process represent 14.9% of the total number of HIV-positive tests reported to PHAC through the national HIV/AIDS surveillance system (i.e. a total of 2,558 HIV positive tests were reported to PHAC in 2006) .
Figure 16: Proportion (%) of HIV-positive tests received through IME and geographic location of birth of applicant, January 15, 2002 to December 31, 2006 (n=597)
Legend: Other = Asia [29, 4.9%] and Europe [20, 3.4%]. (Source: , p. 97).
It is not possible to differentiate between infections acquired abroad from those acquired in Canada for individuals tested in Canada. The methods and data currently used by PHAC to estimate the number of new infections in Canada do not allow for this type of analysis. However, this has been the subject of some research.
Data collected in 1999 by Adrien et al.  showed an overall HIV prevalence rate of 1.3% among Montrealers of Haitian origin who were either born in Haiti or had at least one parent who was born in Haiti. This study further noted that HIV prevalence was lower among individuals born in Canada and those who had had a longer residence in Canada. In another study, in an attempt to differentiate between the sources of HIV infection in Ontario, a modelling exercise completed by Remis and Merid  in 2002 suggested that 20% to 60% of new infections in the HIV-endemic group in Ontario occurred after arrival in Canada. Strain isolation supports this theory, indicating that infections in this population are occurring on Canadian soil, the extent of which is uncertain. More data on HIV transmission needs to be collected to truly understand these trends.
Test results for HIV-positive applicants diagnosed through Canadian laboratories are reported to provincial and territorial public health officials. Currently, test reports for HIV-positive applicants diagnosed overseas are not reported to provincial and territorial surveillance systems. However, since 2004, jurisdictions wishing to receive this information are notifi ed by the CIC of applicants diagnosed abroad who have entered Canada . The objective of the notifi cation process is to link HIV-positive newcomers to the Canadian health care system upon arrival.
Two types of human immunodefi ciency virus (HIV-1 and HIV-2) cause illness in humans. Of the two strains, HIV-1 is responsible for the majority of HIV/AIDS cases worldwide. HIV-2 is much rarer, much less lethal and currently mostly limited to Western Africa . Different subtypes or “clades” of HIV-1 have been discovered and are known to be distributed around the world (see Figure 17). The most common strain in Canada is HIV-1, group M, subtype B, representing 88.3% of infections (refer to Figure 18) .
Figure 17: HIV strains
Legend: Group M = main; Group N = new, non-M, non-O; Group O = outlier, CRFs = circulating recumbent forms i.e.: subtype AB, BD, or AG. (Source , p. 3).
Figure 18: HIV-1 B and non-B strain distribution in Canada 1984 – March 31, 2005 (n=2759)
Legend: HIV-1 Non B = HIV-1 A, C, D, F, G, H, K, AB, AC, AD, AE, AG, BC, BD, B/AG, K/AE, and K/AG (Source: , p. 10, table 6).
Research indicates that 82.8% of cumulative HIV cases reported in the HIV-endemic exposure subcategory were non-B clades of HIV-1 (see Figure 19). Similar numbers are present when analyzing ethnicity data. For example, 74.5% of cumulative cases identifi ed as African or Caribbean were infected with a non-B subtype of HIV. Comparatively, HIV-1 B makes up 97.7% and 96.8% of the MSM and IDU exposure categories, respectively, and 96.1% of cases identifi ed among Caucasians . Higher proportions of non-B subtype infections were detected among females, compared to males which is refl ective of the high proportion of females in the HIVendemic exposure subcategory. Subtypes vary across Canada, likely refl ecting travel and migration from regions where other subtypes are dominant .
Figure 19: HIV-1 B and non-B strain distribution in the HIV-endemic exposure subcategory in Canada 1984 – March 31, 2005 (n=145)
Legend: HIV-1 Non B = HIV-1 A, C, D, F, G, H, K, AB, AC, AD, AE, AG, BC, BD, B/AG, K/AE, and K/AG (Source: , p. 10, table 6).
All HIV subtypes are currently showing drug resistance in countries where antiretroviral therapies (ARVs) are widely used, and drug resistance patterns, developing in Canada, are similar to the prevalence of resistance rates observed in other countries where ARVs are used. Data indicating primary drug resistance have been found among the following main exposure categories: MSM, IDU, and heterosexual contact . Additional data are needed at this time to follow patterns and trends in drug resistance in Canada to identify if certain subtypes develop greater resistance than others. Subtypes greatly affect future prevention efforts, such as vaccine development, as any HIV vaccine developed will likely be strain specifi c [2, 21].
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xiii Concentrated HIV epidemics occur where HIV has spread rapidly in one or more defi ned subpopulations but is not well-established in the general population. (Available from: http://www.unaids.org/en/KnowledgeCentre/Resources/FeatureStories/ archive/2008/20080609_Providing_leadership_in_countries_ with_concentrated_epi.asp