Chapter 1: Population-specific HIV/AIDS status report: Gay, bisexual, two-spirit and other men who have sex with men - Introduction

Chapter 1 – Introduction

This Public Health Agency of Canada status report focuses on HIV/AIDS among gay, bisexual, two-spirit and other men who have sex with men in Canada. These populations share common HIV risk and resiliency factors. Nonetheless, this report recognizes the distinct identities of gay, bisexual, two-spirit and heterosexual men who are part of this population, as well as the diversity of identities and experiences related to ethnicity, age, socioeconomic status, sexual orientation, gender identity and other factors within these groups. In particular, the report recognizes that openly gay, bisexual and two-spirit men have unique identities, form distinct communities within the larger Canadian society and have shared histories as minority communities in Canada. Men who have sex with men who do not identify as gay, bisexual or two-spirit do not generally share these identities, histories and perspectives.

The term "men who have sex with men" (MSM) is an epidemiological category that denotes a specific transmission route for HIV. As a result, the term encompasses gay, bisexual, two-spirit and other men who have sex with men. Members of the National Expert Working Group, who guided the development of this report, as well as other researchers, have noted that the use of this term is problematic, as it can be seen to mask gay, bisexual and two-spirit identities, histories and communities by reducing them to a set of sexual practices. This report acknowledges the limitations of this term. Outside epidemiological discussions, this report only uses the term to highlight the fact that not all men who have sex with men identify as gay, bisexual, or two-spirit.

This report summarizes available evidence from Canadian sources related to gay, bisexual, two-spirit and other men who have sex with men, including the following: demographic characteristics; the burden of HIV/AIDS on this population; factors which impact on this population's vulnerability to, and resiliency against, HIV/AIDS; and research and response initiatives in Canada. The report takes a population health approach, which is in keeping with the Agency's approach to public health in its ongoing efforts to protect and promote the health of Canadians. A population health approach uses evidence to examine how determinants outside the health sector (i.e., a variety of social and economic factors) affect an individual's health status. This report pays particular attention to those determinants that increase or decrease the vulnerability or susceptibility to HIV infection and AIDS of gay, bisexual, two-spirit and other MSM. The report also examines determinants that contribute to resilience against HIV infection and AIDS among gay, bisexual, two-spirit and other MSM.

A population health approach focuses on improving the health status of the population. Action is directed at the health of an entire population, or subpopulation, rather than individuals. Focusing on the health of populations also necessitates the reduction in inequalities in health status between population groups. An underlying assumption of a population health approach is that reductions in health inequities require reductions in material and social inequities. [1]

Determinants examined in this report include biology and genetic endowment, gender, healthy child development, culture, social support networks, income and social status, social and physical environments, health services, and personal health practices and coping skills. In addition, this report considers homophobia, heterosexism and related stigma and discrimination that affect the health of gay, bisexual, two-spirit and other MSM.

These determinants of health may affect an individual's likelihood of engaging in risk behaviours, such as having unprotected sex or using contaminated needles, which put them at higher risk of becoming infected with HIV. In this context, risk is not absolute, but based on probability; therefore, not everyone experiences adverse outcomes. [2] Chapter 4 provides a more detailed discussion of the relationship between the determinants of health, vulnerability and resiliency.

It should be noted that an individual, group or community can overcome negative determinants of health by adopting approaches that foster resilience—that is, protective factors that mitigate risk. In preparing this report, the National Expert Working Group emphasized the importance of highlighting sources and examples of resilience among gay and other MSM living with, and at risk of, HIV/AIDS. This report integrates evidence of resilience where possible.

1.1 Methodology

This report uses the following types of evidence: peer-reviewed and grey literatureFootnote 3, which includes published and unpublished sources. The report focuses on print evidence; nonetheless, it also integrates the voices of gay and other MSM living with, and affected by, HIV/AIDS in Chapter 4, using personal quotations. These are provided in an attempt to better connect the reader with the evidence presented.

To support the development of this status report, the Public Health Agency of Canada established an Expert Working Group composed of community and population representatives, non-governmental organizations, researchers and policy and program experts. The working group acted as an advisory body, providing guidance and feedback on the report process, themes and drafts. The non-governmental working group members were selected following a national open call based on their personal and professional expertise on issues related to HIV/AIDS and gay, bisexual, two-spirit and other MSM. The working group also included representation from relevant areas of the Agency.

The methodology for each chapter was designed to ensure that the most current and relevant evidence was synthesized and presented. Demographic data were extracted from available sources, including Statistics Canada. Epidemiological information and surveillance data were gathered from reports published by the Agency and other published and unpublished data. Data and information on vulnerability to, and resilience against, HIV/AIDS among gay, bisexual, two-spirit and other MSM were collected from peer-reviewed publications and grey literature. The literature included in the report met the following criteria: published between 2002 and 2011; focused on gay, bisexual, two-spirit or other MSM in Canada; addressed one or more of the health determinants related to HIV or AIDS, or characterized HIV or AIDS in the context of prevention, care, treatment, support or diagnosis for gay, bisexual, two-spirit or other MSM; and written in English or French. A list of search terms and the databases searched can be found in Appendix A. Additional information was also included in the report to provide context and address gaps identified by the working group.

Information from current research underway between 2006 and 2011 was gathered from the following organizations: British Columbia Centre for Excellence in HIV/AIDS; Canadian Association of HIV Research (CAHR); Canadian Foundation for AIDS Research (CANFAR); Canadian Institutes of Health Research (CIHR); Fonds de recherche du Québec – Société et culture (FQRSC); Michael Smith Foundation for Health Research; Ontario HIV Treatment Network (OHTN); and the Social Sciences and Humanities Research Council of Canada (SSHRC). Through the literature search and discussions with the Working Group membership, some research areas were identified for which Canadian evidence could not be found. These knowledge gaps have been identified in a list of areas for further research in Chapter 5 of this report.

To gather information on the current response to HIV/AIDS among gay and other MSM, including time-limited projects, networks, coalitions, committees, strategies, and policy initiatives in place between 2006 and 2010, information-gathering templates were circulated to federal, provincial and territorial officials through the following mechanisms: Federal/Provincial/Territorial Advisory Committee on AIDS, and Agency national and regional HIV/AIDS program consultants. Responses were received from all provinces and territories. Projects funded by the Toronto Public Health AIDS Prevention Community Investment were also included in the analysis. The National Expert Working Group was also instrumental in identifying additional networks, coalitions, strategies and projects for inclusion in the report.

It is recognized that many HIV/AIDS-specific programs and services serve gay and other MSM in addition to, or as part of, other key populations. For the purposes of this report, however, only time-limited HIV/AIDS projects that explicitly focus on gay and other MSM are included. In addition, although evidence demonstrates the impact of the determinants of health on the vulnerability of gay and other MSM to HIV/AIDS, due to time and methodological constraints, Chapters 5 and 6 focus on HIV/AIDS-specific projects only.

1.2 References

[1] Public Health Agency of Canada. What is a population health approach? [Internet]. Ottawa: Public Health Agency of Canada. 2001 [cited 2009 June]. Available from:

[2] Public Health Agency of Canada. Risk, Vulnerability, Resiliency - Health System Implications [Internet]. Ottawa: Public Health Agency of Canada. 1997 [cited 2009 June]. Available from:

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