Executive Summary: Population-specific HIV/AIDS status report: Gay, bisexual, two-spirit and other men who have sex with men
Since the beginning of the HIV/AIDS epidemic in the early 1980s, gay, bisexual, two-spirit and other men who have sex with men have remained the population most affected by HIV and AIDS in Canada. The Public Health Agency of Canada estimates that in 2011, the exposure category of men who have sex with men (MSM) accounted for 46.6% of new HIV infections and 46.7% of prevalent HIV infections in Canada.
The term "men who have sex with men" is used to denote a specific transmission route for HIV in epidemiological data and does not refer to anyone's personal identity. Outside epidemiological discussions, this report uses the term MSM only because not all men who have sex with men identify as gay, bisexual, or two-spirit.
Few Canadian studies have examined the demographic characteristics of gay and other MSM outside the context of HIV/AIDS. As a result, the total number of gay, bisexual, two-spirit and other MSM in Canada is not known. The majority of self-identified gay, bisexual and other MSM surveyed in a variety of Canadian studies identified White as their ethnocultural background.
According to an analysis of data from the 2007 – 2008 Canadian Community Health Survey, men who self-identified as gay or bisexual resided primarily in the three most populous provinces in Canada: Quebec, Ontario and British Columbia. These men reported higher levels of education than self-identified heterosexual men, but similar levels of income. Gay and bisexual men also reported the same levels of general health, including mental health, as heterosexual men. However, bisexual men reported poorer levels of mental health and both groups reported more chronic conditions and mood and anxiety disorders than heterosexual men. Gay and bisexual men also reported having more unmet health needs in the past year than heterosexual men.
Epidemiology of HIV and AIDS
From 1985 to 2011, over half (54.7%) of the 69,856 positive HIV tests among adults with a known exposure category were attributed to MSM. The number of new positive HIV test reports among adults attributed to the MSM exposure category has remained relatively stable between 2002 – 2011, with a peak of 593 cases in 2008. From 1998 to 2011, white men accounted for the majority (81.1%) of positive HIV test reports attributed to the MSM exposure category. From 1979 to the end of 2011, the MSM exposure category accounted for 64.8% of all adult AIDS cases (≥ 15 years) with a known exposure category. In 2011, nearly one third (30.5%) of the 188 new AIDS cases reported to the Agency were attributed to the MSM exposure category.
Data from Phase 1 of M-Track, a Public Health Agency of Canada behavioural and biological surveillance system of HIV and other sexually transmitted and blood-borne infections (STBBIs) among MSM in Canada, found an HIV prevalence of 15.1% among participants who provided a biological sample of sufficient quantity for testing and who completed a questionnaire. Of these, 19% were unaware of their HIV-positive status.
Determinants of Health
Homophobia and related stigma and discrimination have a significant, overarching impact on the determinants of health experienced by gay and other MSM, which in turn influence the population's vulnerability to HIV. Gay and other MSM who are members of ethnocultural minority groups can face a double burden of homophobia from within and outside their communities, as well as racism. Research suggests that homophobia is linked to negative mental health outcomes, increased social exclusion and decreased access to social support and health services for gay and other MSM. International research has demonstrated an association between experiences of homophobic victimization in youth and a higher rate of health issues, such as depression, anxiety, substance use, sexual risk behaviours and suicide. Canadian research also indicates that gay and other sexually diverse youth are more likely to experience harassment and victimization than their heterosexual peers. Experiences of childhood abuse, including sexual abuse, are also linked to an increased likelihood of engaging in HIV risk behaviours, including sexual risk taking and drug use. Stigma and discrimination can also reduce access to health care and other important sources of support for gay and other MSM.
Unprotected anal sex is the most common risk factor for HIV infection among gay and other MSM, and is related to various interconnected environmental, psychosocial, and personal factors. Strategies to reduce one's risk of HIV infection rely on individuals knowing their HIV status and accurately informing one another before engaging in risky sexual behaviour. This is often complicated by some men's unwillingness to disclose their HIV status due to shame, fear, or insecurity. HIV testing is quite high among gay and other MSM. It is estimated that in 2011, 20% of gay and other MSM in Canada who were HIV-positive were unaware of their status, which is lower than the estimated 25% of HIV-positive people in the general population who were unaware of their status.
Romantic relationships, friendships, and gay-specific venues and activities are all cited as important sources of social support that promote resilience against HIV infection and empower those living with it. The gay community's history of activism, including the development of an early and effective community response to AIDS when it first emerged, continues tobe a source of resilience against HIV.
A total of 48 Canadian research projects underway from 2006 to 2011 that focused on gay, bisexual, two-spirit and/or other MSM were identified. Over three quarters of the projects took place in Ontario, Quebec or British Columbia. The main areas of investigation were HIV prevention (32 projects), sexual risk behaviours (20 projects), and community research capacity, dissemination and knowledge transfer (19 projects). The projects identified also examined access to care and treatment (11 projects); homophobia, stigma and discrimination (10 projects); and sources of vulnerability to HIV infection (10 projects). Fewer than 10 projects were found for each of the following areas: culture, mental health, income and social status, social support networks, and social and physical environments. Half of the projects focused on one or more specific populations of gay and other MSM, primarily those living with HIV/AIDS (14 projects), as well as gay and other MSM from countries where HIV is endemic (4 projects), trans people (4 projects), gay and other MSM who use drugs (3 projects), youth (1 project) and Aboriginal Peoples (1 project). Areas identified for further research include the following: vulnerability to, and resiliency against, HIV; specific populations of gay and other MSM, such as older men, ethnocultural minority men, men living in rural areas, men in prison, men engaged in sex work, MSM who do not identify as gay or bisexual; HIV prevention, care, treatment, support and HIV co-infections; and research on gay men's health not specifically tied to HIV vulnerability and resiliency.
Policy and Program Response
The report examined the current response to HIV/AIDS among gay and other MSM at both the policy and program levels. This included an overview of population-specific strategies at the national and provincial/territorial levels, population-specific networks, coalitions, advisory bodies and organizations and projects focused on the delivery of programs addressing HIV among gay and other MSM. A variety of organizations are involved in delivering prevention, care, treatment and support services to gay and other MSM. The majority of projects identified were delivered by AIDS service organizations; however, community health, social service and governmental organizations, and organizations serving lesbian, gay, bisexual, two-spirit and queer populations were also identified as a key part of the programmatic response. Most of the projects serving gay and other MSM took place in Ontario, Quebec and British Columbia. Over one third of the projects focused on a specific subpopulation of gay and other MSM, including people from specific ethnocultural communities, Aboriginal Peoples, youth, people living with HIV/AIDS, transmen, gay and other MSM with disabilities, sex workers, and people with substance use issues.
Only Quebec had a provincial HIV/AIDS strategy specific to gay men. Several other jurisdictions identified gay men and/or MSM as a priority population under more generalized HIV/AIDS or sexually transmitted and blood-borne infections strategies. In addition, community-based networks or coalitions addressing HIV/AIDS among gay and other MSM were identified in Ontario, Manitoba and British Columbia.
Communities, organizations and governments have taken up the challenge and are doing their part to reduce HIV transmission in this population, and to meet the needs of gay, bisexual, two-spirit and other MSM living with, or at risk of, HIV/AIDS. Despite these important and significant efforts, much remains to be done. Effective, tailored and continued efforts in preventing the transmission of HIV and improving the quality of life of gay and other MSM living with HIV are required to successfully address the epidemic within this population.
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