HIV/AIDS Epi Update - May 2004

Ethnicity Reporting for AIDS and HIV in Canada: Aboriginal and Black Communities Demand Attention

Introduction

At A Glance

Aboriginal peoples and Blacks are overrepresented among reported AIDS cases in Canada.

Nearly half of all positive HIV test reports among Aboriginal peoples and Blacks are attributable to females, yet females account for only 16.4% of reports among Whites.

Positive HIV test reports indicate that injecting drug use and heterosexual exposure are key factors for Aboriginal peoples and Blacks respectively.

Documentation of ethnicity for reported AIDS cases and positive HIV test reports has become an important component of AIDS and HIV surveillance because of the unique perspective it offers on the epidemic. As with other demographic identifiers, ethnic information can contribute to the creation and evaluation of targeted prevention and treatment programs as well as to the development of health policy. This Epi Update presents a summary of ethnic information from the national AIDS and HIV surveillance system. Additional information is available in HIV and AIDS in Canada: Surveillance Report to June 30, 2003.¹

AIDS

Improved Ethnicity Reporting Among AIDS Cases Since 1982, when the first AIDS case was reported in Canada, a total of 85.8% (16,244/18,934) of AIDS cases reported up to June 30, 2003, have included ethnic information. During this time, the proportion of cases with this information has increased. Between 1982 and 1991, 80.6% of reported AIDS cases included information about ethnicity, increasing to 89.6% in the period between 1992 and 2001. In 2002, reporting of ethnicity was achieved in 85.2% (241/283) of cases.

Reported AIDS Cases and Ethnicity: A Balance of Changing Proportions

The total annual number of reported AIDS cases has declined over the last 10 years, from 1,750 cases in 1992 to 283 in 2002. In the first six months of 2003, 71 AIDS cases were reported. The number of cases in some ethnic groups, however, has not declined at the same rate as in others. In order to better understand trends by ethnic status, it is helpful to examine the proportion of all reported AIDS cases attributed to a particular ethnic group.

Whites have historically represented the largest proportion of reported AIDS cases, yet this proportion has declined over the last 10 years. The proportion of reported AIDS cases with known ethnicity attributed to Whites was highest in 1988, at 91.1%, but declined steadily to 68.0% in 1999. Since that time, the proportion increased to 74.5% in 2000 and dropped to 68.1% in 2001. In 2002, 58.9% of reported AIDS cases with known ethnicity occurred in Whites.

With a decrease among Whites, there has been a corresponding increase in the proportion of reported AIDS cases in other ethnic groups. The increase in the proportion has been most notable among Aboriginal peoples and Blacks since 1994 (Figure 1). In 2001, Aboriginal peoples and Blacks accounted for 3.3% and 2.2% of Canada's population respectively.² In the same year, they respectively accounted for 5.5% and 15.3% of reported AIDS cases with known ethnicity. In 2002, these proportions were 12.9% and 18.3% respectively. This indicates that both Aboriginal peoples and Blacks are overrepresented in reported AIDS cases. Blacks account for the highest proportion of reported AIDS cases among non-White groups. This is notable considering the population of this community in Canada.

HIV

Missing Pieces: Positive HIV Tests Often Reported Without Ethnicity Information

Ethnicity reporting for positive HIV test reports is not as complete as that for reported AIDS cases because ethnicity data are available only for some provinces and territories. Reporting of HIV is more recent than AIDS, and there is still some concern regarding documentation of confidential information. As a result, the analysis of ethnicity information for HIV test reports presents a challenge.

Ethnicity data for positive HIV test reports have only been available since 1998, and therefore comparisons are possible only for this limited period of time. Between January 1998 and June 30, 2003, a total of 29.4% of positive HIV test reports have included ethnic information (3,706/12,602). The proportion of positive HIV test reports with ethnicity information was 27.1% in 1998, and peaked at 32.8% in 2000 before dropping to 28.5% in 2002.

Figure 1. Proportion of Reported AIDS Cases for Selected Ethnic Groups by Year

When examining HIV data, it is important to consider that HIV ethnicity data are not available for all provinces and territories. Provinces and territories that report ethnic information include British Columbia, Yukon Territory, Alberta, Northwest Territories, Nunavut, Saskatchewan, Manitoba, New Brunswick, Nova Scotia, Prince Edward Island, and Newfoundland and Labrador. As a result, only data from these provinces and territories are used when examining data by ethnic category, including reports for Aboriginal peoples or Blacks. Of those provinces and territories that report information on ethnicity, a total of 90.8% of positive HIV test reports have included ethnic information between January 1998 and June 30, 2003 (3,706/4,080). Therefore, please note that reports on ethnicity should not be viewed as representative of all of Canada. It must also be considered that the sources of HIV reports that include ethnicity are some areas where the Aboriginal population is large in comparison with other parts of Canada.

Aboriginal Peoples Constitute a Notable Proportion of Positive HIV Tests with Known Ethnicity

The majority of positive HIV test reports with ethnicity information are among Whites, as is the case with reported AIDS cases. Whites represented 67.8% of positive HIV test reports with known ethnicity in 1998. This figure dropped to 60.6% between 1999 and 2001 and decreased again, to 56.1%, in 2002 (399/711).

In 1998, 18.8% of positive HIV tests with known ethnicity were from Aboriginal peoples, as compared with a high of 26.2% in 2001 (Figure 2). The proportion of positive HIV test reports attributed to Aboriginal peoples in 2002 was 23.8%. These proportions are higher than the proportions attributed to Aboriginal peoples for reported AIDS cases. For example, in 2001, Aboriginal peoples accounted for 5.5% of reported AIDS cases with known ethnicity. This difference is likely due in part to HIV ethnicity information being primarily from western provinces where the Aboriginal population is greater. In addition, positive HIV test reports better reflect the current HIV epidemic than do reported AIDS cases. For additional information on HIV/AIDS among Aboriginal peoples, refer to the Epi Update entitled "HIV/AIDS Among Aboriginal Peoples in Canada: A Continuing Concern", May 2004.³

Compared with other non-White groups, Aboriginal peoples account for a higher proportion of positive HIV test reports where ethnicity has been recorded (Figure 2). However, one must remember that the two largest provinces, Ontario and Quebec, are not represented in HIV ethnicity data.

Figure 2. Proportion of Positive HIV Test Reports with Known Ethnicity Attributed to Non-White Ethnic Groups, 1998-2002

The Proportion of Positive HIV Test Reports Attributed to Blacks on the Rise

As data for ethnicity are incomplete for positive HIV tests at the national level, caution must be taken when making interpretations. It is important to note, however, that the proportion of reports among Blacks has steadily increased over the last five years. In 1998, Blacks represented 5.5% of positive HIV test reports with known ethnicity. This figure rose to 10.7% in 2002.

Positive HIV Tests Reflect Differences among Ethnic Groups

Of the 3,706 positive HIV test reports with ethnic information reported between January 1998 and June 30, 2003, 851 were among Aboriginal peoples, 306 among Blacks and 2,254 among Whites. The remaining 295 reports were attributed to other ethnic categories. Table 1 shows the distribution of gender, age and exposure category of positive HIV test reports for the three named ethnic groups. Such information may be of assistance in the design and targeting of prevention and care programs.

As shown in Table 1, reports for Aboriginal peoples and Blacks are equally distributed between males and females, and there is a higher proportion at a younger age as compared with Whites. Injecting drug use has been a key mode of transmission among Aboriginal peoples. As shown in Table 1, injecting drug users (IDU) accounted for 61.1% of positive HIV test reports among Aboriginal peoples between 1998 and June 30, 2003. Among Whites, the highest proportion of positive HIV test reports was attributed to men who have sex with men (MSM) (40.0%) and IDU (34.2%). People whose HIV infection was attributed to heterosexual exposure* represented the largest proportion of positive HIV test reports among Blacks (75.3%). The majority (68.1%) of those in the heterosexual exposure category are categorized to the subgroup indicating origin in an endemic country (a country where heterosexual transmission of HIV predominates).

Limitations of Ethnicity Data from Reported HIV and AIDS Cases

There are several significant limitations regarding the accuracy of ethnicity data obtained from AIDS and HIV surveillance information. The following should be kept in mind when examining such data:

• Misclassifications of ethnic status may occur at the time of HIV or AIDS diagnosis.
• People in certain communities may not wish to identify their ethnicity, resulting in underrepresentation.
• For AIDS reporting, patients and health care providers are constrained by the list of ethnic categories available on the AIDS Case Report Form, which may compromise the accuracy of ethnicity reporting.
• Not all provinces and territories routinely collect and/or report ethnicity.
• Variations in the completeness of ethnicity reporting among and within provinces may result in a systematic over or result in a underrepresentation of specific communities.
• Reporting delay may vary by ethnicity and may therefore affect how representative ethnicity data are for recently reported HIV and AIDS cases.
  Given these limitations, caution should be exercised in interpreting the AIDS and HIV ethnicity data presented. This is particularly true of positive HIV test reports, for which there is less complete ethnicity information.

Comment

Community health groups and public health officials may use information about ethnicity in HIV/AIDS surveillance data to more effectively plan prevention and care programs for the different ethnic communities. When combined with other epidemiological descriptors of the HIV/AIDS epidemic, such as gender, age group and exposure category, such information becomes a powerful tool for directing programs to where they will have the most impact. To increase our ability to do this, it is essential that the completeness and accuracy of ethnicity reporting in surveillance data be improved.

References

1. Health Canada.
   HIV and AIDS in Canada: surveillance report to June 30, 2003. Surveillance and Risk Assessment Division, Centre for Infectious Disease Prevention and Control, Health Canada, 2003.
2. Statistics Canada January 30, 2003.
3. Health Canada.
   HIV/AIDS among Aboriginal peoples in Canada: a continuing concern, HIV/AIDS Epi Update. Centre for Infectious Disease Prevention and Control, Health Canada, 2004.

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