HIV and Aids in Canada

Surveillance Report to December 31, 2003

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Acknowledgements: National level HIV and AIDS surveillance is possible as a result of all provinces and territories participating in, and setting directions for, HIV and AIDS surveillance. Accordingly, the Centre for Infectious Disease Prevention and Control acknowledges the provincial/territorial HIV/ AIDS coordinators, laboratories, health care providers and reporting physicians for providing the non-nominal confidential data that enable this report to be published. Without their close collaboration and participation in HIV and AIDS surveillance, the publication of this report would not have been possible. A complete listing of these contributors is available in Appendix 5.

We also thank Scientific Publication and Multimedia Services, Population and Public Health Branch, for its contribution in editing and producing the report, both in print and on the internet..

N.B. This document must be cited as the source for any information extracted and used from it.

Suggested citation: Health Canada. HIV and AIDS in Canada. Surveillance Report to December 31, 2003.

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Information to the readers of HIV and AIDS in Canada

On behalf of the HIV/AIDS Surveillance Section, I would like to present you with the HIV and AIDS in Canada: Surveillance Report to December 31, 2003. This report is part of a semi-annual series providing a review of available HIV and AIDS surveillance data in Canada.

The HIV/AIDS Surveillance section is part of the Surveillance and Risk Assessment Division, at the Centre for Infectious Disease Prevention and Control. This section is responsible for data collection and management, analysis and report production. In addition, we continue to improve data quality, define and set surveillance standards, as well as support the use of these data to influence programmatic and policy action.

The main findings of the surveillance data are outlined in the section entitled At a Glance, and this is followed by a series of tables summarizing the underlying data. Technical notes, in addition to references and data sources, are available in the Appendices. Explanatory details specific to provincial or territorial surveillance data issues are located at the beginning of each section.

A further description of HIV and AIDS surveillance data is available in the HIV/AIDS Epi Updates reports that are also available on our website listed on the front cover of this report.

The publication of this report would not be possible without the submission of HIV and AIDS surveillance data from all provinces and territories. Their ongoing contribution to national HIV and AIDS surveillance is gratefully acknowledged and is further listed in Appendix 5.

Yours sincerely,

Jennifer Geduld, MHSc Manager
HIV/AIDS Surveillance Section
Surveillance and Risk Assessment Division

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Table of Contents

At a Glance
TABLES
SECTION I HIV in Canada: Positive HIV Test Reports to December 31, 2002, Reported to CIDPC up to February 14, 2003
1.	Number of positive HIV test reports by year of test (all ages)
2.	Cumulative number of positive HIV test reports occurring in adults and children by gender between November 1, 1985, and December 31, 2003
3.	Number of positive HIV test reports among adults (>= 15 years) by year of test and gender
4A.	Number of positive HIV test reports by age group and year of test
4B.	Number of positive HIV test reports among males by age group and year of test
4C.	Number of positive HIV test reports among females by age group and year of test
5A.	Number and percentage distribution of positive HIV test reports among adults (15 years) by exposure category and year of test
5B.	Number and percentage distribution of positive HIV test reports among adult males (>= 15 years) by exposure category and year of test
5C.	Number and percentage distribution of positive HIV test reports among adult females (>= 15 years) by exposure category and year of test
5D.	Number and percentage distribution of positive HIV test reports among children (< 15 years) by exposure category and year of test
5E.	Number of positive HIV test reports by exposure category and age group between January 1, 2003, and December 31, 2003
6A.	Number of positive HIV test reports by province/territory and gender between November 1, 1985, and December 31, 2003 (all ages)
6B.	Number of positive HIV test reports by province/territory and year of test (all ages)
7.	Number of postitive HIV test reports by exposure category and province/territory between January 1, 2003, and December 31, 2003 (all ages)
8.	Number of positive HIV test reports by year of test and ethnic status for those provinces that submitted ethnicity data between 1998 and December 31, 2003 (all ages)
SECTION II Report of the Canadian Perinatal HIV Surveillance Program
SECTION III AIDS in Canada: AIDS Surveillance to December 31, 2003
13.	Number of reported AIDS cases by year of diagnosis (all ages)
14.	Cumulative number of reported AIDS cases occurring in adults and children by gender between 1979 and December 31, 2003
15.	Number of reported AIDS cases among adults ( 15 years) by year of diagnosis and gender
16A.	Number of reported AIDS cases by age group and year of diagnosis
16B.	Number of reported AIDS cases among males by age group and year of diagnosis
16C.	Number of reported AIDS cases among females by age group and year of diagnosis
17A.	Number and percentage distribution of reported AIDS cases among adult (>=15 years) by exposure category and year of diagnosis
17B.	Number and percentage distribution of reported AIDS cases among adult males (>= 15 years) by exposure category and year of diagnosis
17C.	Number and percentage distribution of reported AIDS cases among adult females (>= 5 years) by exposure category and year of diagnosis
17D.	Number and percentage distribution of reported AIDS cases among children (< 15 years) by exposure category and year of diagnosis
17E.	Number of reported AIDS cases among adults (>= 15 years) by exposure category and age group between 1979 and December 31, 2003
17F.	Number of reported AIDS cases among children (< 15 years) by exposure category and age group between 1979 and December 31, 2003
18A.	Number of reported AIDS cases by province/ territory and gender between 1979, and December 31, 2003 (all ages)
18B.	Number of reported AIDS cases by province/ territory and year of diagnosis (all ages)
18C.	Number of reported AIDS cases among males by province/territory and year of diagnosis (all ages)
18D.	Number of reported AIDS cases among females by province/territory and year of diagnosis (all ages)
19.	Number and percentage distribution of reported AIDS cases by province/territory and exposure category to December 31, 2003 (all ages)
20.	Number of reported AIDS cases by year of diagnosis and ethnic status (all ages)
SECTION IV
a.	Mortality due to HIV/AIDS in Canada: Surveillance to December 31, 2003, and Reported to CIDPC up to February 14, 2004
21.	Reported deaths among reported AIDS cases by year of death (all ages)
22.	Cumulative number of reported deaths among reported AIDS cases occurring in adults and children by age of death and gender between 1979 and December 31, 2003
23.	Reported deaths among reported AIDS cases among adults ( 15 years) and children by year of death
24.	Reported deaths among reported AIDS cases among adults ( 15 years) by year of death and gender
25A.	Reported deaths among reported AIDS cases and percentage distribution of adults (>= 15 years) by exposure category and year of death
25B.	Reported deaths among reported AIDS cases and percentage distribution of adult males (>= 15 years) by exposure category and year of death
25C.	Reported deaths among reported AIDS cases and percentage distribution of adult females (>= 15 years) by exposure category and year of death
b.	Mortality due to HIV/AIDS in Canada: Vital Statistics from 1987 to December 31, 2001
21S.	Deaths attributed to HIV infection by year of death (all ages)
22S.	Number of deaths attributed to HIV infection by age of death and gender from 1987 to December 31, 2001
23S.	Deaths attributed to HIV infection among adults (>= 15 years) and children by year of death
24S.	Deaths attributed to HIV infection among adults (>= 15 years) by year of death and gender
SECTION V International Statistics on AIDS
APPENDICES Appendix 1. Technical Notes Appendix 2. Data Limitations Appendix 3. Terminology Appendix 4. References Appendix 5. Data Sources

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At a Glance

Introduction

The following report outlines HIV and AIDS surveillance data providing a description of persons who have been diagnosed with HIV and AIDS in Canada. Surveillance data understate the magnitude of the HIV epidemic and consequently does not represent the number of people infected with HIV (prevalence) or the number infected each year (incidence). Some of the reasons for this include the fact that surveillance data are subject to delays in reporting, underreporting and changing patterns in HIV testing behaviours (who comes forward for testing). In addition, surveillance data can only tell us about persons who have been tested and diagnosed with HIV or AIDS and not those who remain untested and undiagnosed. Furthermore, because HIV is a chronic infection with a long latent period, many persons who are newly infected in a given year may not be diagnosed until later years.

The Centre for Infectious Disease Prevention and Control (CIDPC) has recently produced estimates of HIV prevalence to the end of 2002 and HIV incidence in 2002¹. These estimates were produced using a combination of methods, incorporating data from a wide variety of sources, including HIV test reports, AIDS case reports, population-based surveys, targeted epidemiological studies and census data. It was estimated that at the end of 2002 there were approximately 56,000 (46,000-66,000) people in Canada living with HIV (including those living with AIDS), of which approximately one third were undiagnosed. The number of people in Canada newly infected with HIV in 2002 was estimated to be 2,800-5,200.

HIV Surveillance Data

There have been 55,180 positive HIV tests reported to CIDPC since HIV testing began in 1985. The annual number has declined from 2,996 in 1995 to 2,187 in 2001 and has since increased to 2,504 in 2002 and 2,482 in 2003 (Figure 1). The increase in the number of positive HIV test reports in the last two years may be partly attributed to recent changes in immigration policies at Citizenship and Immigration Canada². These changes have included the addition of HIV screening to the routine immigration medical assessment in January 2002 and reduced restrictions on certain groups of immigrants who would have previously been considered medically inadmissible associated with changes to the definition of some applicant groups. In most provinces and territories, for the HIV screening conducted in Canada, the positive HIV test reports are handled in the same manner as all other positive HIV and are included in provincial/ territorial HIV reporting to CIDPC.

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¹ Geduld J, Gatali M, Remis RS, Archibald CP. Estimates of HIV prevalence and incidence in Canada, 2002. Can Commun Dis Rep, 2003;29:197-206.

² Citizenship and Immigration Canada. Immigrant and Refugee Protection Act. Statutes of Canada 2001. Chapter 27. Also available at url: http://www.cic.gc.ca/english/pdf/pub/C-11_4.pdf or url: http://www.ci.gc.ca/cicexplore/english/org/bpd/bps/irpa_lipr/act_loi/C-11_4.pdf

FIGURE 1
Positive HIV test reports and AIDS diagnoses by year of diagnosis, 1993-2003

Females are representing a growing proportion of positive HIV test reports. For the last three years females have accounted for around one quarter of positive HIV test reports with known gender, this is a rise from 8.9% during the period between 1985 to 1992 (Table 3). This pattern is seen in all age groups and most notably in the 15-29 and 30-39 year age group as seen in Figure 2.

FIGURE 2
Proportion of females among positive HIV test reports by age group

As outlined in Figure 3, men who have sex with men (MSM) continue to account for the largest number and proportion of positive HIV test reports. This proportion decreased from close to 75% between 1985-1994 dropping in the mid to late 1990's remaining close to 37% until a slight increase in the last three years to 44.4%. The diverse heterosexual exposure category has steadily increased from 7.5% before 1995 to 36.9% in 2003. This exposure category is made up of three subcategories including heterosexual contact with a person who is either HIV-infected or at increased risk for HIV, heterosexual as the only identified risk, or origin in a country where HIV is endemic. Over the last five years, from 1998 to 2003, the proportion of positive HIV test reports attributed to the latter heterosexual subcategory has increased from 2.9% to 10.2%. Further details of the trends in the heterosexual subcategories for the last five years are outlined in Figure 4.

FIGURE 3
Positive HIV test reports by exposure category and year of test

MSM: men who have sex with men; IDU: injecting drug users; Endemic: born in a country where HIV is endemic; Het-Risk: heterosexual contact with a person who is either HIV-infected or at increased risk for HIV; NIR-Het heterosexual as the only identified risk; Other: recipients of blood transfusion or clotting factor and occupational transmission.
Percentages are based on total number minus reports for which risk was not reported.

FIGURE 4
Positive HIV test reports among heterosexual transmission by sub category, 1998-2003

Het-Risk: heterosexual contact with a person who is either HIV-infected or at increased risk for HIV; Endemic: born in a country where HIV is endemic; NIR-Het heterosexual as the only identified risk

AIDS Surveillance

There have been a cumulative 19,344 AIDS diagnoses in Canada reported to the CIDPC up to the end of 2003. The annual number of reported AIDS diagnoses adjusted for reporting delay increased throughout the 1980's and early 1990's, peaking at 1,953 in 1993 and has since declined and has started to level off to 500-600 diagnoses per year (Figure 1, Table 11). This pattern of declining AIDS diagnoses has been reported in other industrialized areas including the United States, Australia, and the United Kingdom. The decline has been largely attributed to the widespread use of highly effective antiretroviral therapy since 1996, however, there is a growing concern that reporting of AIDS diagnoses are becoming increasingly under reported.

The largest proportion of reported AIDS cases are among those aged 30-44 years followed by the 45-59 and 15-29 year age groups accounting for 60.4%, 19.4% and 15.9% of all AIDS diagnoses respectively. Adult females are increasingly representing a larger proportion of diagnosed AIDS cases. Over the last 10 years this proportion has increased from 7.0% in 1993 to 24.2% in 2003 (among AIDS diagnoses with reported age and gender). In 2003, females represented 42% of AIDS diagnoses among those aged 15-29 years, 25.4% among those aged 30-44 years and 18.2% among 45-59 year olds.

Over the last decade, there has been a decrease in the proportion of reported AIDS cases among men who have sex with men (MSM) falling from 73.8% in 1993 to 35.3% in 2003. Conversely, the diverse heterosexual exposure category has shown an increase in this proportion, from 13% in 1993 to 43.8% in 2003 during this same period. The distribution of exposure categories for the last five years can be seen in Figure 5.

FIGURE 5
Reported AIDS diagnoses by exposure category,1999-2003

MSM: men who have sex with men; IDU: injecting drug users; Endemic: born in a country where HIV is endemic; Het-Risk: heterosexual contact with a person who is either HIV-infected or at increased risk for HIV; NIR-Het heterosexual as the only identified risk; Other: recipients of blood transfusion or clotting factor and occupational transmission
Percentages are based on total number minus reports for which risk was not reported

The proportion of reported AIDS cases attributed to White Canadians has been decreasing over time, from 86.8% prior to 1993 to 54.3% in 2003. This decrease is coupled with increases seen in among both Black and Aboriginal Canadians as outlined in Figure 6 and Table 18. Black Canadians represented 8.4% of cases before 1993 and 21.5% in 2003; during the same period this proportion increased from 1.2% to 13.4% among Aboriginal Canadians.

FIGURE 6
Non-White Ethnic categories as a percentage of all reported
AIDS diagnoses, by year of diagnosis (all ages)

Interpretation

The increasing proportion of both positive HIV test reports and AIDS diagnoses attributed to the heterosexual exposure category and the distribution in its subcategories is a trend that will be followed and further analyzed in the upcoming months. The rising proportion of positive HIV test reports among Aboriginal and Black Canadians as well as among females in each age group, especially in the younger years, is an important finding that has implications for guiding prevention and treatment programs.