HIV/AIDS Epi Update - May 2004

HIV/AIDS Among Aboriginal Peoples in Canada: A Continuing Concern

Introduction

In Canada, Aboriginal populations are very diverse, with communities (First Nations, Inuit and Métis) that reflect variations in historical backgrounds, language and cultural traditions. Yet, unfortunately, these communities are disproportionately affected by many social, economic and behavioural factors such as high rates of poverty, substance abuse, sexually transmitted infections and limited access to or use of health care services, all of which increase their vulnerability to HIV infection. This report updates current information on the status of the HIV/AIDS epidemic among Aboriginal peoples in Canada. To summarize Canadian HIV and AIDS surveillance data, Aboriginal peoples are identified as First Nations, Inuit and Métis. The category Aboriginal Unspecified is also used if no further details are known. National HIV and AIDS surveillance data that appear in this document are from both a) HIV and AIDS in Canada. Surveillance report to June 30, 20031 and b) unpublished data, from the Surveillance and Risk Assessment Division, Centre for Infectious Disease Prevention and Control (CIDPC), Health Canada. Aboriginal Peoples are Overrepresented in the HIV/AIDS Epidemic in Canada AIDS Surveillance Data

• Between 1979 and June 30, 2003, there have been 18,934 AIDS cases reported to CIDPC, of which 16,244 (85.8%) included information on ethnicity. Of these 16,244 cases, 509 were reported to be Aboriginal peoples (3.1%).
• According to the 2001 Census, Aboriginal communities make up 3.3 % of the Canadian population.²

HIV Surveillance Data

• Between 1998 and the end of June 2003, there have been 12,602 positive HIV tests reported to CIDPC, 3,706 of which contained information on ethnicity (29.4%).3* Of these 3,706 reports, 851 were for Aboriginal peoples (23.0%). As ethnicity data for positive HIV test reports have only been available since 1998, comparisons are only possible for this limited period of time.
• In the provinces and territories that report ethnic information with positive HIV tests, Aboriginal communities make up 6.0% of the population.²

Data from Targeted Studies

• Prenatal seroprevalence studies in Canada report an estimated national rate of HIV infection among pregnant women of 3 to 4 per 10,000 population. An ongoing study of pregnant Aboriginal women in British Columbia reported an HIV prevalence rate of 31.3 per 10,000 pregnancies in 2002 (JD Martin, Programs Medical Officer, Pacific Region, First Nations and Inuit Health Branch, Health Canada, and A. Jin, consultant for the BC First Nations Chiefs' Health Committee: personal communication).

Aboriginal Peoples Make Up a Growing Percentage of HIV Reports and AIDS Cases

A steady rise has been seen in the proportion of reported AIDS cases and positive HIV test reports among Aboriginal peoples in Canada over the last number of years.

AIDS Surveillance Data

• Before 1992, out of the 6,203 reported AIDS cases with information on ethnicity, 80 cases or 1.3% were Aboriginal. This proportion steadily increased until it reached a high of 9.7% in 1999. In 2000 and 2001, the proportion decreased to 7.2% and 5.5% respectively. However, an increase was seen in 2002, when Aboriginal peoples accounted for 12.9% of the total reported AIDS cases for which ethnicity was known.

HIV Surveillance Data

• From provinces and territories with ethnicity reporting, there were 119 positive HIV tests among Aboriginal peoples out of the 634 reported in 1998, representing 18.8% of positive HIV tests reported in that period. This proportion increased to 23.8% (169/711) of positive HIV test reports with information on ethnicity in 2002.

Figure 1. Reported AIDS Cases in the Aboriginal Community in Canada

*The provinces and territories that report ethnicity with positive HIV test reports are British Columbia, Yukon Territory, Alberta, Northwest Territories, Nunavut, Saskatchewan, Manitoba, New Brunswick, Nova Scotia, Prince Edward Island, and Newfoundland and Labrador.

Figure 2. Positive HIV Test Reports in the Aboriginal Community in Canada for Provinces and Territories that Report Ethnicity for HIV*

Injecting Drug Use Continues To Be a Key Mode of Transmission in the Aboriginal Community

Injecting drug users (IDU) continue to be an important risk group in the Canadian HIV epidemic. Recent evidence supports the trends seen in surveillance data suggesting that injecting drug use is a particularly important risk factor for HIV and AIDS among Aboriginal peoples.

As Table 1 indicates, there are notable differences between Aboriginal and non-Aboriginal reported AIDS cases and positive HIV test reports with respect to expo- sure category. Although the proportion attributed to heterosexual exposure* is similar, Aboriginal peoples have a higher proportion of reports attributed to IDU and a smaller proportion to MSM.

Table 1. Comparison of selected exposure categories for reported AIDS cases and positive HIV test reports among Aboriginal and non-Aboriginal peoples*
	Aboriginal	non-Aboriginal
	n = number of cases with available information on exposure category
AIDS	n = 495	n = 15 354
IDU	38.0 %	6.5 %
MSM	34.7 %	70.7 %
Heterosexual	16.0 %	14.3 %
HIV	n = 828	n = 2 727
IDU	61.1 %	29.7 %
MSM	7.9 %	36.6 %
Heterosexual**	26,4 %	29.2 %
IDU = Injecting drug users, MSM = Men who have sex with men *For reported AIDS cases, includes data up to June 30, 2003. For positive HIV test reports, includes data from 1998 to June 30, 2003, and from provinces/ territories with reported ethnicity (BC, YT, AB, NT, NU, SK, MB, NB, NS, PEI, NL). **The heterosexual exposure category includes people born in a country where HIV is endemic, people who report heterosexual contact someone who is either HIV-infected or is at increased risk of HIV infection, and people who report heterosexual contact as the only risk factor.

AIDS Surveillance Data

• Of reported AIDS cases with known exposure, the proportion of Aboriginal cases attributed to injecting drug use has dramatically increased over time, from 8.8% before 1992 to 30.1% during 1992-1996 and 54.1% during 1997-2001. In 2002, 53.3% of reported AIDS cases among Aboriginal peoples were attributed to IDU.
• Of the 509 reported AIDS cases among Aboriginal peoples between 1979 and June 30, 2003, there were 383 male cases, 125 were female, and 1 was a transgender person. Figures 3a and 3b display how these cases are distributed by exposure category. As there is only one transgender case, it is not shown.

HIV Surveillance Data

• The monitoring of positive HIV test reports between 1998 and June 2003 also shows that injecting drug use is the most common route of transmission among Aboriginal peoples. Of the Aboriginal reports with exposure category information, 61.1% were attributed to injecting drug use.
• There have been 454 males, 372 females and two cases for which gender was not reported in positive HIV test reports among Aboriginal peoples between 1998 and June 30, 2003. Figure 3c displays how reports among males are distributed by exposure category. Of female reports, 66.9% were attributed to IDU and 31.5% to heterosexual exposure, proportions similar to those for reported AIDS cases.

Data from Targeted Studies

• In the recently initiated, enhanced risk behaviour surveillance system among IDU in Regina, Sudbury, Toronto and Victoria (I-Track), 339 of the 794 participants identified themselves as Aboriginal (38.6%). Of these, 67.6% were from Regina (229/339).³
• A 2000 study of IDU in Regina indicated that of the 255 participants, 90% self-identified as an Aboriginal person.⁴
• In a study of Calgary's Needle Exchange Program, most participants were White (75%), but Aboriginal persons were the second highest ethnic group, representing 20% of total participants.⁵
• The Vancouver Injection Drug Users Study (VIDUS) is an open cohort of IDU. Of the 1,400 recruited between May 1996 and May 2000, 25% of participants were Aboriginal persons, more than half of whom were female (54% female, 46% male). In contrast, females accounted for 29% of non-Aboriginal participants.⁶
• In a further analysis of the VIDUS study, investigators found that Aboriginal status was significantly associated with new HIV infection both in men and in women⁷ and also in study participants 24 years of age or younger.⁸
• VIDUS has reported that, as of December 2001, 19.1% of Aboriginal participants had seroconverted compared with 9.6% of persons who identified as non-Aboriginal.⁹ In a 2003 publication, investigators concluded that in Vancouver, Aboriginal IDU are becoming HIV positive at twice the rate of non-Aboriginal IDU.¹⁰

Figure 3a. Distribution of Exposure Categories among Reported AIDS Cases of Aboriginal Males, November 1979-June 30, 2003

Figure 3b. Distribution of Exposure Categories among Reported AIDS Cases of Aboriginal Females, November 1979-June 30, 2003

Figure 3c. Distribution of Exposure Categories among Positive HIV Test Reports of Aboriginal Males, January 1998-June 30, 2003

HIV/AIDS Has a Significant Impact on Aboriginal Women

In contrast to HIV and AIDS cases in the non-Aboriginal population, females make up a comparatively larger part of the Aboriginal HIV epidemic. Table 2 shows the distribution of gender among positive HIV test reports and reported AIDS cases for Aboriginal and non-Aboriginal peoples. Females represent nearly half (45.1%) of all positive HIV test reports among Aboriginal peoples, compared with 19.5% of reports among non-Aboriginal peoples.

Table 2. Comparison of gender of reported AIDS cases and positive HIV test reports among Aboriginal and non-Aboriginal Peoples*
	Aboriginal	non-Aboriginal
	n = number of cases with available information on gender
AIDS	n = 509	n = 15,717
Female	24.6 %	8.5 %
HIV	n = 847	n = 2,839
Female	45.1 %	19.5 %
*For reported AIDS cases, includes data up to June 30, 2003; for positive HIV test reports, includes data from 1998 to June 30, 2003, from provinces/territories with reported ethnicity (BC, YT, AB, NT, NU, SK, MB, NB, NS, PEI, NL).

AIDS Surveillance Data

• Before 1992, females represented 13.8% of reported AIDS cases among Aboriginal peoples (11/80), yet by 2002, the proportion had increased to 25.8% (8/31).

HIV Surveillance Data

• Among Aboriginal peoples, the proportion of positive HIV test reports attributed to females peaked in 1999 at 52.1% (87/167). In 2002, females represented 39.6% of reports (67/169).

Data from Targeted Studies

• Pregnant women infected with HIV are at risk of transmitting the virus to their unborn child. Data from some sites in western Canada have shown that a high proportion of HIV-infected pregnant women who deliver are Aboriginal. Of all pediatric centres across Canada where children and HIV-infected mothers were followed between 1995 and 1997, 19% (49/259) of the women seen were Aboriginal women.¹¹ Of 32 HIV-infected women who delivered in northern Alberta or the Northwest Territories in 1996-98,
  29 (91%) were Aboriginal.¹²
• Despite high numbers of Aboriginal women seen at HIV clinics and pediatric centres, there was encouraging news that during the period 1995 to 1997, pregnant Aboriginal women were as likely to be taking antiretroviral therapy (62%) as pregnant White women (66%) and pregnant Black women (63%).¹³
• In a 2001 study of anti-retroviral therapy in a cohort of HIV-positive pregnant women recruited at seven sites in Ontario, Manitoba and Saskatchewan, the results show that 20% of women were Aboriginal. Late use of antiretroviral therapy (in third trimester or intrapartum) was unequally distributed by ethnic status, occurring in 38% of Aboriginal, 27% of Black and 9% of White women.¹⁴
• Of the infants known to have contracted HIV through perinatal transmission in British Columbia between 1994 and 1999, 50% were Aboriginal.¹⁵

Aboriginal Peoples Are Being Infected with HIV at a Younger Age than Non-Aboriginal Peoples

HIV and AIDS among young people in Aboriginal communities is an increasing concern. Understanding the epidemic in this group well help to appropriately target early intervention strategies. It is important, however, that caution be used when reviewing proportions by age group, as they can change considerably with the addition of one case, particularly when total numbers are small, such as with youth (less than 30 years).

As indicated in Table 3, a higher proportion of Aboriginal peoples test positive for HIV and also receive an AIDS diagnosis at a younger age than do non-Aboriginal peoples.

Table 3. Comparison of age at time of diagnosis for reported AIDS cases and at time of test for positive HIV test reports among Aboriginal and non-Aboriginal peoples*

Tableau 3. Comparaison de l'âge au moment du diagnostic des cas de sida déclarés et des tests positifs pour le VIH, Autochtones et non-Autochtones*
	Autochtones	non-Autochtones
	n = nombre de cas dont l'âge est connu
AIDS	n = 509	n = 15,733
< 20 yrs	1.8 %	1.5 %
20-29 yrs	21.8 %	14.9 %
30-39 yrs	47.7 %	44.0 %
40-49 yrs	22.6 %	27.9 %
50 yrs plus	6.1 %	11.7 %
HIV	n = 848	n = 2,849
< 20 yrs	4.1 %	1.5 %
20-29 yrs	26.5 %	19.1 %
30-39 yrs	40.9 %	38.9 %
40-49 yrs	22.3 %	26.6 %
50 yrs plus	6.1 %	13.8 %
*For reported AIDS cases, includes data up to June 30, 2003; for positive HIV test reports, includes data from 1998 to June 30, 2003, from provinces/ territories that report ethnicity (BC, YT, AB, NT, NU, SK, MB, NB, NS, PEI, NL).

Data from Targeted Studies

• A study of risk factors among 232 young (less than 25 years) IDU in Vancouver found that 9
  of 16 (56%) of the incident cases were Aboriginal.9

AIDS Surveillance Data

• Before 1992, 9.7% (3/31) of Aboriginal AIDS cases were among youth (less than 30 years), whereas in 2002 youth represented 41.3% (33/80) of cases.
• MSM and IDU each accounts for approximately a third of reported AIDS cases among Aboriginal youth. MSM makes up the largest proportion, at 31.5% (38/120), followed closely by IDU at 30.0% (36/120).

HIV Surveillance Data

• Although reported AIDS cases show a growing number attributed to youth, there has been a decrease in the proportion of positive HIV tests in this age group. Youth accounted for 37.8% (45/119) of positive HIV test reports among Aboriginal peoples in 1998, which contrasts with 19.5% (33/169) of positive test reports in 2002.
• It is essential to note, however, that IDU make up nearly 60.0% (149/253) of positive HIV test reports among youth, followed by the heterosexual exposure category at 25.7% (65/253) and MSM at 10.7% (27/253).

HIV/AIDS Surveillance Data in Canada's Three Aboriginal Communities

When compared with a non-Aboriginal community, the number of positive HIV test reports and reported AIDS cases in Aboriginal communities may appear small. However, it is important to understand that these are individuals, and every new diagnosis has a significant impact on the Aboriginal community. Caution should be used when reviewing community proportions, as they can change considerably with the addition of one case, particularly when total numbers are small.

AIDS Surveillance Data

According to the 2001 Census, 62% of Aboriginal Canadians are First Nations, 30% are Métis, 5% are Inuit and another 3% are from multiple communities.² Of 509 Aboriginal AIDS cases reported to June 30, 2003, 72.3% or 368 were First Nations, 8.3% or 42 were Métis, 4.1% or 21 were Inuit, and 15.3% or 78 were in the category Aboriginal Unspecified.

The data on reported AIDS cases in terms of IDU, females and youth in specific Aboriginal communities and in the Aboriginal Unspecified category are summarized below. Further details regarding gender and selected age and exposure category distribution are shown in Table 4.

First Nations: Reported AIDS cases among First Nations people show that 43.0% of cases can be attributed to injecting drug use (153/356). Females represent 26.6% (98/368) of cases, and youth (< 30 years) account for 22.0% (81/368) of all First Nations cases.

Métis: In the Métis community, 26.8% (11/41) of all reported AIDS cases are attributable to IDU, and few cases are female (3/42 or 7.1%). It is important to note that nearly 40% (16/42) of reported AIDS cases among the Métis occur in those under 30 years of age.

Inuit: The IDU exposure category represents about a third of reported AIDS cases among Inuit people, at 33.3% (7/21). A notable proportion of cases occur in females (8/21 or 38.1%), and youth (less than 30 years) represent 33.3% (7/21) of cases.

Aboriginal Unspecified: IDU account for 22.1% (17/77) of cases for which the specific Aboriginal community is unspecified. Females make up just over 20% of cases (16/78) and youth (less than 30 years) 20.5% of cases in this group (16/78).

Table 4. Gender, and selected age and exposure categories of reported AIDS cases in Aboriginal groups in Canada between 1979 and June 30, 2003
	First Nations	Inuit	Métis	Aboriginal unspecified
	n = number of cases with available information
Gender	n = 368	n = 21	n = 42	n = 78
Female	26.6 %	38.1 %	7.1 %	20.5 %
Age (years)	n = 368	n = 21	n = 42	n = 78
20-29 years	20.4 %	33.3 %	35.7 %	17.9 %
30-39 years	48.4 %	52.4 %	35.7 %	50.0 %
40-49 years	22.6 %	9.5 %	23.8 %	25.6 %
Exposure category	n = 356	n = 21	n = 41	n = 77
MSM	31.2 %	28.6 %	46.3 %	46.8 %
IDU	43.0 %	33.3 %	26.8 %	22.1 %
Heterosexual	14.3 %	28.6 %	14.6 %	20.8 %

Increasing Proportion of Aboriginal Peoples among Estimated HIV Prevalent and Incident Infections at the National Level

National HIV surveillance data capture only those who are tested, whose HIV infection is diagnosed and whose positive test results are reported to Health Canada. As a result, surveillance data do not describe the full scope of the epidemic. However, calculations using these data along with other sources of data are carried out to estimate the number of people living with HIV (prevalence) and the number newly infected with HIV (incidence).

• It has been estimated that 250 to 450 Aboriginal peoples were newly infected with HIV during 2002, compared with 370 in 1999. These figures correspond to 6% to 12% of the total number of new infections in Canada in 2002, compared with 9% in 1999.¹⁶
• It is also estimated that 3,000 to 4,000 Aboriginal peoples were living with HIV (including AIDS) in Canada in 2002, the total.¹⁶ These proportions are noteworthy because of the distinct contrast with the proportion of the population in Canada represented represented by Aboriginal peoples (3.3%).²
• Injecting drug use is the predominant risk factor for HIV infections in Aboriginal populations. The estimated exposure category distribution of prevalent and incident infections among Aboriginal peoples in 2002 is shown in Table 5. Findings for 2002 are similar to those of 1999.¹⁶
• It is important to note that the estimated proportion of new HIV infections due to injecting drug use among Aboriginal peoples (63%) is much higher than among all Canadians (30%),¹⁶ reinforcing the finding given earlier that injecting drug use is a key mode of HIV transmission in the Aboriginal community.

Comment

Aboriginal HIV and AIDS surveillance data are incomplete for several reasons. The primary one is the incomplete information on ethnicity in current surveillance data. Since 1982, 14% of all reported AIDS cases have had no information on ethnicity. Ethnicity data for positive HIV test reports have only been available since 1998. Furthermore, 69.8% of positive HIV test reports between 1998 and June 30, 2003, lack ethnicity. Other reasons include interprovincial variations in reporting ethnicity, misclassification of ethnic status and delays in reporting. Positive HIV test reports and reported AIDS cases represent only those infected individuals who came forward for testing or who received an AIDS diagnosis and are subsequently reported to Health Canada. As a result, the numbers in this report do not represent the total number of Aboriginal peoples who are infected with HIV or whose AIDS has been diagnosed.

Despite these limitations, evidence suggests that the HIV epidemic in the Aboriginal community shows no sign of abating. Injecting drug use is the most common mode of HIV transmission among Aboriginal peoples, Aboriginal women make up a large part of the HIV epidemic in their community, and Aboriginal peoples are infected at a younger age than non-Aboriginals. This indicates the different characteristics of the HIV epidemic among Aboriginal peoples and emphasizes the complexity of Canada's HIV epidemic. Better data on HIV/AIDS epidemiology and HIV testing among Aboriginal peoples in Canada are needed to guide prevention and control strategies. In addition, it is vital to conduct further research to increase our understanding of the specific impact HIV has on Aboriginal peoples.

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.
   Population by Aboriginal group. 2001 Census, Canada, provinces and territories.
3. Health Canada.
   I-Track: enhanced surveillance of risk behaviours among injecting drug users in Canada. Pilot survey report, February 2004.
   Surveillance and Risk Assessment Division, Centre for Infectious Disease Prevention and Control, Health Canada, 2004.
4. Findlater R, Young , Bangura H et al.
   The Regina Seroprevalence Study: a profile of injection drug use in a prairie city, 2000. Unpublished report. Available through the Surveillance and Risk Assessment Division, Health Canada.
5. Guenter CD, Fonseca K, Nielsen DM et al.
   HIV prevalence remains low among Calgary's needle exchange program participants Can J Public Health 2000;(91)2:129-32.
6. Tyndall MW, Craib KJP, Currie S et al.
   Impact of HIV infection on mortality in a cohort of injection drug users. J Acquire Immune Defic Syndr 2001; (28)4:351-57.
7. Spittal PM, Craib KJP, Wood E et al.
   Risk factors for elevated HIV incidence rates among female injection drug users in Vancouver. Can Med Assoc J 2002;166:894-99.
8. Miller CL, Tyndall M, Spittal P et al. HIV incidence and associated risk factors among young injection drug users. AIDS 2002;(16)3:491-93.
9. Craib KIP, Spittal PM, Li K et al.
   Comparison of HIV incidence rates among aboriginal and non-aboriginal participants in a cohort of injection drug users in Vancouver. Can J Infect Dis 2002;13(Suppl A):48A(Abstract 315).
10. Craib KJP, Spittal PM, Wood E et al.
    Risk factors for elevated HIV incidence among Aboriginal injection drug users in Vancouver. Can Med Assoc J 2003;168:19-24.
11. Forbes JC, Burdge DR, Money D.
    Pregnancy outcome in HIV infected women in British Columbia: the impact of antiretroviral therapy on maternal-infant HIV transmission. Can J Infect Dis 1997;8:31A(Abstract 235).
12. Birse E, Shokoples S, Houston S.
    Demographic and clinical features of Aboriginal and non-Aboriginal patients with HIV infection in Northern Alberta. Can J Infect Dis 1999;10(Suppl B):66B(Abstract C387P).
13. Lapointe N, Forbes J, Singer J et al.
    Antiretroviral therapy in pregnant women in Canada: access and outcome 1995-97. Can J Infect Dis 1998;9(Suppl A):70A(Abstract 449P).
14. King SM and the Motherisk-HIV Network Members.
    Antiretroviral therapy (ART) in a cohort of HIV-positive pregnant women in Canada. Can J Infect Dis 2001;12(Suppl B):26B(Abstract 203).
15. Ogilvie G, Money D, Forbes J et al.
    Perinatal infection in Aboriginal maternal infant pairs (MIP) in British Columbia. Can J Infect Dis 2002; 13(Suppl A):50A(Abstract 321).
16. Geduld J, Gatali M, Remis RS, Archibald CP.
    Estimates of HIV prevalence and incidence in Canada, 2002. CCDR 2003;29:197-206.

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