HIV/AIDS Epi Update - May 2004
HIV/AIDS Among Aboriginal Peoples in Canada: A Continuing
Concern
Introduction
At A Glance
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Aboriginal peoples are
overrepresented in the HIV
epidemic in Canada.
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Aboriginal peoples make up a
growing percentage of positive
HIV test reports and reported
AIDS cases.
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Injecting drug use continues to
be a key mode of transmission
in the Aboriginal community.
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HIV/AIDS has a significant
impact on Aboriginal women.
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Aboriginal peoples are being
infected with HIV at a younger
age than non-Aboriginal
peoples.
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Surveillance report to June 30, 20031 and b) unpublished data, from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
![Figure 1. Reported AIDS Cases in the Aboriginal Community in Canada](gfx/fig9-1e.gif)
*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*
![Figure 2. Positive HIV Test Reports in the Aboriginal Community in Canada for Provinces and Territories that Report Ethnicity for HIV*](gfx/fig9-2e.gif)
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 3a. Distribution of Exposure Categories among Reported AIDS Cases of Aboriginal Males, November 1979-June 30, 2003](gfx/fig9-3ae.gif)
Figure 3b. Distribution of Exposure Categories among
Reported AIDS Cases of Aboriginal Females, November 1979-June 30,
2003
![Figure 3b. Distribution of Exposure Categories among Reported AIDS Cases of Aboriginal Females, November 1979-June 30, 2003](gfx/fig9-3be.gif)
Figure 3c. Distribution of Exposure Categories among
Positive HIV Test Reports of Aboriginal Males, January 1998-June
30, 2003
![Figure 3c. Distribution of Exposure Categories among Positive HIV Test Reports of Aboriginal Males, January 1998-June 30, 2003](gfx/fig9-3ce.gif)
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
- 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.
- Statistics Canada.
Population by Aboriginal group.
2001 Census, Canada, provinces and
territories.
- 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.
- 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.
- 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.
- 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;
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- 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.
- 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.
- 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
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- 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
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- Forbes JC, Burdge DR, Money D.
Pregnancy outcome in HIV infected women in British
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HIV transmission. Can J Infect Dis 1997;8:31A(Abstract
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- 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).
- 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).
- 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).
- 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
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- Geduld J, Gatali M, Remis RS, Archibald CP.
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