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

HIV/AIDS EPI Update

April 2003

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

Introduction

In Canada, the Aboriginal populations are very diverse with many sub-groups (First Nations, Inuit and Metis) that reflect variations in historical backgrounds, language and cultural traditions. These groups represent 3.3% of the Canadian population.¹ However, they are disproportionately affected by many social, economic and behavioral factors (such as high rates of poverty, substance abuse, sexually transmitted diseases, limited access to or use of health care services) which increase their vulnerability to HIV infection. Hence, in recent years, an increase in the HIV/AIDS epidemic has been observed in some Aboriginal communities, particularly those in inner-cities. This report updates current information on the status of the HIV/AIDS epidemic among Aboriginal persons in Canada.

Increasing Proportion of Reported AIDS Cases Attributed to Aboriginal Persons

• As of June 30, 2002, there have been 18,336 AIDS cases reported to the Centre for Infectious Disease Prevention and Control (CIDPC) in Canada of which 15,713 contained ethnic information.² Of that total, 459 were reported as Aboriginal persons. In 1993, the proportion of reported AIDS cases with known ethnicity attributed to Aboriginal persons was 2.0%.  This proportion steadily increased until reaching a high of 10.0% in 1999. In 2000 and 2001, the proportion of reported AIDS cases among Aboriginal persons decreased to 7.9% and 5.3% respectively; however an increase was seen in the first six months of 2002, where Aboriginal persons accounted for 14.1 % of the total reported AIDS cases where ethnicity was known. This trend will be monitored closely to see if it is confirmed when data for the full year are available.

Injecting Drug Use - A Major Risk Factor

• There have been 352 Aboriginal males with a reported AIDS diagnosis up to June 30, 2002. Of those with known exposure, 46.2 % were men who have sex with men (MSM), 27.6% were injecting drug users (IDU), 12.2% were MSM/IDU, 11.3% were at risk through heterosexual contact, 0.9% had received blood/clotting factors and 1.5% were infected though perinatal transmission.

• There were 106 Aboriginal women with a reported AIDS diagnosis up to June 30, 2002. Among those with known exposure, 64.4% were IDU, 31.7% at risk through heterosexual contact, 2.0 % had received blood/clotting factors, 2.0% were infected through perinatal transmission.

• Of reported AIDS cases with known exposure, the proportion of Aboriginal cases attributed to injecting drug use has dramatically increased over time, from 10.3% prior to 1992 to 30.0% during 1992-1996 and 53.1% during 1997-2001.  In the first six months of 2002, 55.6% of reported AIDS cases among Aboriginal persons were attributed to injecting drug use.² The proportion of females and the proportion less than 30 years old among reported Aboriginal AIDS cases are higher than among non-Aboriginal AIDS cases (Table 1). Also, there is a higher proportion of Aboriginal AIDS cases that are IDU as an exposure category compared to non-Aboriginal cases (35.9% vs 6.3%).²

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Table 1: Gender, Age and Injecting Drug Use among Aboriginal and Non-Aboriginal Reported AIDS Cases up to June 30, 2002

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Reported AIDS Cases among Canada's Aboriginal Communities

• Of the 459 AIDS cases among Aboriginal persons reported to June 30, 2002, 18 were identified as Inuit, 35 as Metis, and 372 as Native Indians (i.e. First Nations), and 34 as Aboriginal unspecified.

• Reported AIDS cases among First Nations and Inuit communities are most often male, however as shown in Table 2, females make up a notable proportion of cases at 24.8% and 38.9% respectively.  Females however, make up 8.6% of reported AIDS cases among Metis persons.

• When examined by age group, reported AIDS cases among the Inuit and Metis population tend to be younger than those reported for First Nations communities.  Those under 30 years accounted for nearly 40% of cases among Inuit persons, whereas they accounted for just over 20% of reported AIDS cases attributed to people from the First Nations.

• The exposure category MSM is attributed to over one-third of reported AIDS cases in each of the three identified Aboriginal populations where risk factors are known.  However, the proportion of reported AIDS cases attributed to injecting drug use in First Nations communities is 39.1%, compared to 22.2% and 28.6% for Inuit and Metis communities respectively.  Although 33.3% of reported AIDS cases among Inuit persons are attributed to heterosexual HIV transmission, 16.1% and 17.1% of First Nations and Metis cases can be attributed to the same exposure category.

• When examining national surveillance data for persons identified from an Aboriginal population, it is important to consider that over 7% (34/459) were not identified as being of one specific Aboriginal group. In addition, the number of reported cases is small.  As a result, these data should be interpreted with caution.

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Table 2: Gender, Age and Exposure Categories of Reported AIDS Cases among Aboriginal groups in Canada up to June 30, 2002

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A Notable Proportion of Positive HIV Test Reports is Among Females

• Positive HIV reports from provinces with ethnicity reporting (British Columbia, Yukon Territory, Alberta, Saskatchewan, Manitoba, Prince Edward Island, and Newfoundland and Labrador) indicate that Aboriginal persons were over-represented among new HIV diagnoses, i.e. 19.2% in 1998, averaging 24.0% in 1999-2001, and peaking at 26.5% in the first six months of 2002.

• Table 3 shows the distribution of gender, age, and exposure category among positive HIV test reports from 1998-Ju

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  ne 2002 for Aboriginal and non-Aboriginal persons. Females represent nearly half (45.3%) of all positive HIV test reports among Aboriginal persons, however females represent 19.9% of reports for non-Aboriginal persons. In addition, compared to non-Aboriginal persons, a higher proportion of Aboriginal persons test positive for HIV infection at a younger age. Although proportions are comparable for HIV infection through heterosexual transmission, Aboriginal persons have a higher proportion of reports attributed to IDU and a smaller proportion to MSM.²

Table 3: Gender, Age and Exposure Categories among Reported HIV Tests, Aboriginal vs Non-Aboriginal Persons in Provinces with Reported Ethnicity**, 1998-June 30, 2002

** BC, YK, AB, MB, SK, PEI, NFLD and Labrador
Subtotals differ due to unknown gender, age and exposure in some reports.

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Aboriginal Persons Over-represented Among IDU

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 among Aboriginal persons.

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.³

• In a further analysis of the VIDUS study, investigators found that Aboriginal status was significantly associated with new HIV infection, separately in both men and women⁴ and also among study participants 24 years of age or younger.⁵ 

• VIDUS has reported that as of December 2001, 19.1% of Aboriginal participants had seroconverted compared to 9.6% of persons who identified as non-Aboriginal.⁶  In a 2003 publication, investigators conclude that in Vancouver, Aboriginal IDUs are becoming HIV positive at twice the rate of non-Aboriginal IDUs.⁷

• In a study of Calgary's Needle Exchange Program, most participants were Caucasian (75%), however Aboriginal persons were the second highest ethnic group, representing 20% of total participants.⁸

• A 2000 study of IDU's in Regina, Saskatchewan indicated that of the 255 participants, 90% self-identified as an Aboriginal person.⁹

Aboriginal Women and Children

• Infected pregnant women are at risk for transmitting HIV to their unborn child. Recent data from some sites in western Canada have shown that a high proportion of HIV-infected pregnant women who deliver are Aboriginal. Among all pediatric centers across Canada where children and HIV infected mothers were followed between 1995-1997, 19% (n=259) were Aboriginal women.¹⁰ Of 32 HIV-infected women who delivered in Northern Alberta or the NWT in 1996-98, 29 (91%) were Aboriginal.¹¹

• Despite high numbers of Aboriginal women seen at HIV clinic and pediatric centres, there was encouraging news that during the period 1995-1997, pregnant Aboriginal women (62%) were as likely to be on antiretroviral therapy as pregnant Caucasian women (66%) and pregnant Black women(63%).¹²

• In a recent study of antiretroviral therapy in a cohort of HIV-positive pregnant women recruited in 7 sites in Ontario, Manitoba and Saskatchewan, results show that 20% of women were Aboriginal. Late use of antiretroviral therapy (in third trimester or intrapartum) was unequally distributed by ethic status occurring in 38% of Aboriginal, 27% of Black and 9% of White women.¹³

Of the infants known to have contracted HIV via maternal fetal transmission in British Columbia between 1994-1999, 50% were Aboriginal.¹⁴

Aboriginal Men Who Have Sex with Men

A study done among MSM in Winnipeg in 1995 found that 17% were Aboriginal persons.¹⁵

• The proportion of Aboriginal participants was 41% in a recent cross-Canada study (1999-2000) among male street youth who reported having sex only with men.¹⁶

• In a study of young MSM in Vancouver, 8% of participants were Aboriginal men. These Aboriginal MSM were more likely than non- Aboriginal MSM to be unemployed, to live in unstable housing, to have higher depression scores, to report non-consensual sex or sexual abuse during their childhood, and to be involved in the sex trade.¹⁷

Aboriginal Inmates

• Across Canada, 14% of federal inmates are Aboriginal persons, with rates up to 40% in provincial or federal jails in some provinces.^18-20

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

According to the latest estimates of HIV prevalence and incidence produced by CIDPC, the number of Aboriginal persons living with HIV has increased from 1,430 in 1996 to 2,740 in 1999 (91% increase during the 3 year period).²¹ The estimated number of incident infections among Aboriginal persons increased from 310 in 1996 to 370 in 1999. Although Aboriginal persons comprised only 2.8% of the general Canadian population in 1996, they accounted for 5.5% (2,740/49,800) of all prevalent infections and 8.8% (370/4,190) of all new infections in Canada in 1999. In 2001, 3.3% of Canada's populations identified themselves as Aboriginal.  The estimated exposure category distribution of prevalent and incident infections among Aboriginal persons in 1999 is shown in Table 4. Injecting drug use is the predominant risk factor for HIV infections among Aboriginal populations representing an estimated 54% of prevalent infections and 64% of incident infections in 1999. When the exposure category MSM/IDU is included, these proportions increase to 60% and 72%, respectively. New estimates of prevalence and incidence for 2002 are expected to be released later in 2003.

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Table 4: Estimated Exposure Category Distribution among prevalent and incident HIV infections among Aboriginals in Canada, 1999

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Comment

Aboriginal HIV and AIDS data are incomplete for several reasons. The major reason is the incomplete ethnic information in current surveillance data.  Since 1982, 14% of reported AIDS cases have had no ethnic information. Ethnicity data for positive HIV test reports have only been available since 1998.  Furthermore, 71% of positive HIV test reports between 1998 and June 30, 2002 lack ethnic information.  Other reasons include interprovincial variations in reporting ethnicity, misclassification of ethnic status, and delays in reporting. With respect to positive HIV test reports among Aboriginal persons, they only represent those infected individuals who came forward for testing and are subsequently reported. Therefore, the numbers do not represent the total number of Aboriginal persons infected with HIV. Despite these limitations, available evidence suggests that Aboriginal persons are infected at a younger age than non-Aboriginal persons, that  injecting drug use is the most important mode of transmission, and that the HIV epidemic among the Aboriginal community shows no sign of abating. Furthermore, the mobility of Aboriginal persons between inner cities and rural areas may bring the risk of HIV to even the most remote Aboriginal community. Better data on HIV/AIDS epidemiology and HIV testing among Aboriginal persons in Canada are needed to guide prevention and control strategies.

References

1. Statistics Canada. The Daily.  "Aboriginal Peoples of Canada: A demographic profile".  21 January, 2003.  http://www12.statcan.ca/english/census01/products/
   analytic/companion/abor/canada.cfm .

2. Health Canada. HIV and AIDS in Canada. Surveillance report to June 30, 2002 and unpublished data from the Division of HIV/AIDS Epidemiology and Surveillance, Centre for Infectious Disease Prevention and Control, Health Canada, November 2002.

3. Tyndall MW, Craib KJP, Currie S, Li K, O'Shaughnessy MV, and Schecter MT. Impact of HIV infection on mortality in a cohort of injection drug users. JAIDS 2001; (28) 4:351-357

4. Spittal PM, Craib KJP, Wood E, Laliberté N, Li K, Tyndall MW, O'Shaughnessy MV, and Schecter MT. Risk factors for elevated HIV incidence rates among female injection drug users in Vancouver. CMAJ 2002; (7) 166:894-899

5. Miller CL, Tyndall M, Spittal P, Li K, LaLiberte N and Schechter MT. HIV incidence and associated risk factors among young injection drug users. AIDS 2002, (16) 3: 491-493.

6. Craib KIP, Spittal PM, Li K, Heath K, Laliberte N, Tyndall M, O'Shaughnessy M and Schechter M.  Comparison of HIV incidence rates among aboriginal and non-aboriginal participants in a cohort of injection drug users in Vancouver. Can J Inf Dis 2002, (13) Supp A;48A {Abstract 315}.

7. Craib KJP, Spittal PM, Wood E, Laliberte N, Hogg R, Li K, Heath K, Tyndall MW, O'shaughnessy MV and Schechter MT.  Risk factors for elevated HIV incidence among Aboriginal injection drug users in Vancouver.  CMAJ; (168) 1: 19-24.

8. Guenter CD, Fonseca K, Nielsen DM, Wheeler VJ, Pim Cp. HIV prevalence remains low among Calgary's Needle Exchange Program Participants Can J Public Health 2000; (91) 2: 129-132

9. Findlater R, Young, Bangura H, Sidaway F, Hay K, Archibald C, Siushansian J,Williamson N. The Regina Seroprevalence study: A profile of injection drug use in a prairie city, 2000.  Unpublished report.  Available through the Division of HIV/AIDS Epidemiology and Surveillance, Health Canada.

10. 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 Inf Dis 1997;(8):31A {Abstract 235} and personal communication (Forbes).

11. 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}.

12. Lapointe N, Forbes J, Singer J, et al. Antiretroviral therapy in pregnant women in Canada: Access and outcome 1995-97. Can J Inf Dis 1998;(9) Suppl A:70A {Abstract 449P}.

13. King SM and the Motherisk-HIV Network Members. Antiretroviraal therapy (ART) in a cohort of HIV-positive pregnant women in Canad.  Can J Infect Dis 2001;(12) Suppl B: 26B {Abstract 203}.

14. Ogilvie G, Money D, Forbes J, Remple V, Alimenti A and Burdge D.  Perinatal infection in Aboriginal maternal infant pairs (MIP)in British Columbia.  Can J Inf Dis 2002; (13) Suppl A:50A {Abstract 321}.

15. Myers T, Calzavara L, Morrison K. A report on a National Research Needs Assessment for HIV prevention among gay and bisexual men and a socio-behavioural and epidemiological pilot study in a non-clinical sample of self-identified gay and bisexual men. Final report to the Division of HIV/AIDS Epidemiology and Surveillance, Centre for Infectious Disease Prevention and Control, Health Canada, August 1995.

16. Presentation by Wong T. in Proceedings of the MSM/IDU Consultative Meeting (March 8-9, 2001, Ottawa, Canada). Centre for Infectious Disease Prevention and Control, Health Canada.

17. Heath KV, Cornelisse PGA, Strathdee S. HIV-associated risk factors among young Canadian Aboriginal and non-Aboriginal men who have sex with men. Int J STD and AIDS 1999;(10):582-7.

18. Correctional Services Canada (personal communication, Portman J, October 1996).

19. Alberta Justice (personal communication, Harrison S, March 1997).

20. Rothon DA, Strathdee SA, Cook D, Cornelisse PGA. Determinants of high risk behaviours for HIV infection among young offenders in British Columbia detention centres. Can J Infect Dis 1995;(6) Suppl:32B.

21. Geduld J, Archibald CP. National Trends of AIDS and HIV in CCDR 2000;26(23):193-201.

For more information please contact:

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Health Canada

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