HIV in Canada Among Persons from Countries where HIV is Endemic

Centre for Infectious Disease Prevention and Control

Table of contents

• Introduction
• Background
  • People from countries where HIV is endemic
  • HIV and AIDS Surveillance
• HIV and AIDS Surveillance Data
• Immigration and HIV/AIDS Surveillance
• HIV/AIDS Incidence and Prevalence Estimates Among Persons from Countries where HIV is Endemic
• Comment
  • Limitations
  • Interpretation
  • Public Health Implications
• References
• Appendix A Hiv-endemic Country List
• Appendix B Exposure Category Hierarchy
• Need more information?

Introduction

Reports by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organiza-tion (WHO) estimated that at the end of 2004, the total number of people living with HIV/AIDS was 39.4 million (35.9 - 44.3 million) worldwide, which corresponds to an HIV prevalence of 1% among adults aged 15 - 49 years.¹ Some countries are more affected by HIV and AIDS than others. Most countries with high rates of HIV/AIDS are experiencing generalized epidemics, meaning that HIV is spreading throughout the general population rather than being confined to specific populations at higher risk (such as men who have sex with men and injecting drug users).² In countries experiencing these generalized epidemics, HIV is mainly spread through heterosexual contact.

The Centre forInfectiousDisease Prevention and Control (CIDPC) maintains a list of countries that are experiencing generalized epidemics and refers to these countries as 'HIV-endemic countries' for the purpose of surveillance. 'HIV-endemic countries' are generally defined as those that have an adult prevalence (ages 15 - 49) of HIV that is 1.0% or greater and one of the following:

• 50% or more of HIV cases are attributed to heterosexual transmission;
• Male to female ratio of 2:1 or less; or
• HIV prevalence greater than or equal to 2% among women receiving prenatal care.

Examples of regions where HIV prevalence in adults is greater than one per cent include sub-Saharan Africa (7.4%, or 25.4 million people), and the Caribbean (2.3%, or 444,000 people). ² A comprehensive list of HIV-endemic countries appears in Appendix A of this Epi-Update. This list is currently being updated to include other countries that meet the above criteria.

This Epi Update provides the most current information on the status of the HIV/AIDS epidemic in Canada among persons from countries where HIV is endemic, and is the product of collaboration between the Surveillance and Risk Assessment Division (SRAD) of CIDPC, Public Health Agency of Canada (PHAC), and the HIV-Endemic Working Group. ^* The data in this report are drawn from voluntarily submitted provincial and territorial surveillance data on positive HIV test reports and diagnosed AIDS cases from 1998 to the end of 2004.

Background

People from countries where HIV is endemic

In Canada, the proportion of the population born in a country where HIV is endemic is 1.5%, according to the 2001 Census. 3 Relative to other provinces, Ontario and Quebec have a larger proportion of individuals born in countries where HIV is endemic, representing 2.6% and 1.3% of the provincial populations, respectively. ³ Within these provinces, there are concentrations of individuals born in countries where HIV is endemic in such urbancentres as Toronto (4.9%), Ottawa (2.9%) and Montreal (2.4%). The community of persons from countries where HIV is endemic is actually larger than what is captured by Census data, particularly when Canadian-born descendents of persons born in countries where HIV is endemic are considered.

The communities of people from countries where HIV is endemic are diverse, reflecting variations in historical backgrounds, language and cultural traditions. Unfortunately, these communities are disproportionately affected by many social, economic, and behavioural factors that not only increase their vulnerability to HIV infection, but also act as barriers to accessing prevention, screening and treatment programs. Two community surveys ^4,5 conducted among African and Caribbean communities and service providers found that such factors as racism, homelessness, transience, poverty, under-employment, settlement and status concerns presented barriers to program access. Other barriers identified by the surveys included: fear and stigma; denial as a coping mechanism; social isolation; lack of social support; job loss; fear of deportation; discrimination; power relations; and cultural attitudes and sensitivities about HIV/AIDS transmission, homosexuality, status of women, and sex/sexuality. ^4,5,6,7,8 In addition to these barriers, the surveys also found that there is a lack of culturally competent and accessible services due to location of services, language barriers, and the fact that health care may not be free depending on immigration status. Stigma, the isolation of HIV-positive individuals, and cultural and linguistic barriers to treatment were also identified as particularly critical issues by members of five East African communities in Toronto. ^9,10,11

HIV and AIDS Surveillance

The ability to adequately monitor the HIV/AIDS epidemic among persons from countries where HIV is endemic requires accurate and complete access to key data elements, specifically country of birth and ethnicity. These data elements are collated at the national level, and provide information on ethnic categories (for example: White, Black, North American Indian) and country of birth. Country of birth information can be cate-HIV/ gorized according to the 'HIV-endemic' country list that appears in Appendix A. Unfortunately, the completeness of these data elements across Canada is variable.

For HIV surveillance data, there are a limited number of cases with complete data on country of birth and ethnicity: less than 10% of records are submitted with country of birth data, and ethnicity data accompanies approximately one third (29.4%) of positive HIV test reports. Two of Canada's largest provinces, Ontario and Quebec, do not routinely collect and/or report country of birth data or ethnic information on their positive HIV tests. This is a limitation for conducting surveillance as these two provinces together account for over two-thirds of all positive HIV test reports. These provinces also include two large urban centers (specifically, Toronto and Montréal) that are ethnically diverse. The lack of country of birth and ethnicity data impairs the ability to accurately describe the HIV/ AIDS epidemic among ethnic sub-groups. Reported AIDS cases are more complete for both fields. Data on country of birth are available for half of all cases, and ethnicity data for 87.6% reported AIDS cases. For more information on ethnicity, refer to the Epi Update entitled: “Ethnicity Reporting for AIDS and HIV in Canada: Aboriginal and Black Communities Demand Attention”. ¹²

Due to the limited coverage of these two data elements, CIDPC also uses exposure cate-gory information to monitor the HIV/AIDS epidemic within this population. The term “exposure category” refers to the most likely way a person became infected with the HIV virus, and is assigned according to a hierarchy of exposure categories. ^** The first four exposure categories are men who have sex with men (MSM), injecting drug use (IDU), recipient of blood/blood products (before 1985), and 'Heterosexual Contact'. These first three exposure categories are generally accepted to be higher risk activities than heterosexual activity; if these activities are present, they are assumed to be the likely route of HIV acquisition.

The category most relevant to this discussion is the 'HIV-endemic' subcategory of the broader 'Heterosexual Contact' exposure category. The HIV-endemic exposure sub-category was first reported to CIDPC as its own category in 1998. In addition to the HIV-endemic subcategory, other sub-categories within the Heterosexual Contact exposure category include 'Sexual contact witha person at risk'(such as an injecting drug user or a bisexual male) and 'No Identified Risk - Heterosexual' (NIR-HET) (cases where no HIV risks were reported except for a history of heterosexual sex). When using exposure categories to monitor the HIV/AIDS epidemic in this population, it is important to consider that it only captures those individuals from HIV-endemic countries who have been exposed to HIV/AIDS through heterosexual contact and excludes those who may have been exposed through other risks such as MSM and IDU. While much of the transmission within this population is through heterosexual contact, Remis & Merid ¹³ provide evidence that a non-negligible proportion of HIV-infected men in Ontario from regions where HIV is endemic reported having had sex with other men (refer to the section entitled: 'HIV/AIDS Incidence and Prevalence Estimates Among Persons from Countries where HIV is Endemic', later in this document).

Although exposure category data are more complete than country of birth or ethnicity data, they are nonetheless incomplete. Exposure category information accompanies only 50% of positive HIV test reports at the national level, but is more complete for AIDS cases with 93% of cases containing these data. Because of the large amount of missing data, and the fact that the HIV-endemic exposure category is not inclusive of all persons from countries where HIV is endemic, the surveillance data presented in this report cannot provide a representative national picture of the HIV/AIDS epidemic among persons from countries where HIV is endemic. Caution should be used when making conclusions based on the percentages and frequencies in this document, as many estimates are based on small numbers.

For more information, please contact: Surveillance and Risk Assessment Division Centre for Infectious Disease Prevention and Control Public Health Agency of Canada Tunney's Pasture Postal Locator 0602B Ottawa, ON K1A 0K9 Tel: (613) 954-5169 Fax: (613) 957-2842 http://www.phac-aspc.gc.ca/aids-sida/about/surv_e.html

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* The HIV-endemic Working Group is comprised of representatives from community groups (specifically: The African and Caribbean Council on HIV and AIDS in Ontario, and GAP-Vies in Montreal), public health departments, academia, and CIDPC. Members of the working group were from the following geographic areas: British Columbia, Ontario (Toronto and Ottawa), Quebec (Montreal), and Nova Scotia. Working group members helped to select the content of this publication and were an integral part of the review process.

** Even though all risk factors associated with a positive HIV test report are reported to CIDPC, only one exposure category is assigned for national HIV/AIDS surveillance reporting. A person reporting more than one HIV-related risk factor will be placed in the exposure category corresponding to the activity or situation that is considered to have the highest risk of HIV transmission. The exposure category hierarchy appears in Appendix B.