Estimates of HIV incidence, prevalence and Canada’s progress on meeting the 90-90-90 HIV targets

On this page

• Highlights
• Acknowledgements
• Introduction
  • Why is monitoring progress important?
  • How are we monitoring progress in Canada?
• Canada’s progress on meeting the 90-90-90 HIV targets
• 90-90-90 estimates in federal correction facilities
• 90-90-90 estimates for on-reserve First Nations communities in Saskatchewan
• Estimates number of new HIV infections
• Estimated number of people living with HIV
• Conclusion
• Apendix 1. Additional detail related to Canada’s modelling method
• Appendix 2. Key populations used for the national estimates of HIV incidence and prevalence
• References

Highlights

• In 2018, there were an estimated 62,050 people living with HIV (PLHIV) in Canada.  The number of people living with HIV in Canada continues to increase, due to ongoing transmission and increased longevity for people living with HIV.
• Among the 62,050 PLHIV in Canada, an estimated 87% were diagnosed. Engagement in the HIV care continuum has improved over time, with 85% of those diagnosed on antiretroviral treatment (ART) and 94% of people on treatment with a suppressed viral load at the end of 2018.
  • This means that an estimated 13% (or 8,300 people) were not aware of their infection. Community-based testing strategies, such as self-testing, provide new opportunities to reach the undiagnosed, which can lead to better health outcomes and fewer new HIV transmissions.
  • Structural and social barriers continue to present challenges for successful linkage to care and initiation of HIV treatment. In recent surveys of people who use drugs, nearly half of all participants who were aware of their HIV-positive status reported avoiding HIV services because of stigma and discrimination.
  • Identifying predictors and groups at increased risk of not achieving viral suppression can help target intervention efforts. Surveys of key populations have demonstrated variation in the reporting of an undetectable viral load, from 63% among people who inject drugs and up to 96.7% among gay, bisexual and other men who have sex with men.
• An estimated 2,242 new HIV infections occurred in Canada in 2018, which is a slight increase from the estimate for 2016.
  • The recent trend in HIV incidence does not appear to be decreasing, which has also been shown for other STBBIs (for example Hepatitis C).
• Canada still has work to do to meet all of the 90-90-90 targets. These estimates will be used to support the Measuring Impact commitment within the Government of Canada five-year action plan on sexually transmitted and blood-borne infections, with the goal of accelerating prevention, diagnosis and treatment to reduce the health impacts of STBBI in Canada by 2030.

Acknowledgements

The Public Health Agency of Canada acknowledges the Provincial / Territorial Public Health Authorities and other government departments for their contribution to the national estimates of HIV incidence, prevalence and 90-90-90 targets.

The Public Health Agency of Canada acknowledges the efforts by First Nations partners in the prevention of HIV infections, the care of people living with HIV, and their contribution in estimating HIV indicators for First Nations on-reserve communities in Saskatchewan.

Introduction

This report provides an update for 2018 on Canada’s estimates of national HIV incidence and prevalence and on progress towards meeting the UNAIDS 90-90-90 targets. Reporting on these targets supports a pan-Canadian multi-sectoral response to HIV/AIDS in which this information can be used to help provide an understanding of the effectiveness of current responses to HIV in Canada, and to identify areas for improvement to guide HIV prevention and care work.

Why is monitoring progress important?

Canada has endorsed the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization global health sector strategy on HIV that includes global targets to generate momentum towards the elimination of AIDS as a public health threat by 2030.^{Footnote 1} The 90-90-90 targets state that by 2020, 90% of all people living with HIV know their status, 90% of those diagnosed receive antiretroviral treatment, and 90% of those on treatment achieve viral suppression.  When these three targets have been achieved, at least 73% (90% x 90% x 90%) of all people living with HIV (PLHIV) will be virally suppressed. UNAIDS’ modelling suggests that achieving these targets by 2020 will enable the world to eliminate the AIDS epidemic by 2030.^{Footnote 1}

The continuum of HIV care is a useful framework for assessing progress against the 90-90-90 targets. The sequential nature of the stages in the continuum can point to where efforts need to be focussed and which areas require improvement. Estimating HIV prevalence (the number of people living with HIV - both diagnosed and undiagnosed) is the first step in the continuum of care, and is critical for guiding the planning and investment for treatment, care and ongoing support for people living with and affected by HIV and AIDS.  In addition, understanding HIV incidence (the number of new infections occurring during a specific period of time) is fundamental for understanding temporal changes in transmission patterns, and is useful for public health decision makers to monitor, strengthen and evaluate the impact of multi-sectoral public health actions.

Globally, estimating HIV incidence, prevalence and progress on the 90-90-90 targets is undertaken to monitor HIV epidemics and to guide prevention and control programs. These estimates support all partners and stakeholders to have a better understanding of key populations where action is needed to reduce the public health impact of HIV and AIDS.

How are we monitoring progress in Canada?

In February 2018, PHAC convened an expert working group meeting to discuss the measures within the HIV continuum of care for Canada. Based on a review of measures used internationally, the PHAC expert group recommended monitoring a four-stage continuum: Stage 1 – the estimated number of all people living with HIV (PLHIV); Stage 2 – the number of all PLHIV who have been diagnosed; Stage 3 – the number on PLHIV who have been diagnosed and who are on ART; and Stage 4 – the number of PLHIV on ART who are virally suppressed (Figure 1).

Figure 1 - Text description

This diagram shows the four-stage continuum Canada uses to measure the HIV continuum of care:

Stage 1 – the estimated number of all people living with HIV (PLHIV);
Stage 2 – the number of all PLHIV who have been diagnosed;
Stage 3 – the number on PLHIV who have been diagnosed and who are on ART; and
Stage 4 – the number of PLHIV on ART who are virally suppressed.

The Public Health Agency of Canada works closely with provinces, territories and other government departments to develop the national estimates of HIV incidence, prevalence and 90-90-90 measures using statistical modelling methods and available surveillance information from each jurisdiction. Measures were refined through an iterative process with provinces and territories, particularly where adjustments were necessary to account for uncertainty due to incomplete or lack of representative data. The national estimates were developed by weighting and rolling-up consensus-based estimates from each jurisdiction.

Standard definitions for each of the measures were developed and used where possible (Table 1). These definitions, which were agreed to by the expert working group supporting the pan-Canadian monitoring of national progress, are aligned with the definitions used by the European Centres for Disease Control, the United States Centers for Disease Control and Prevention, The Kirby Institute (Australia), and Public Health England (United Kingdom). In some instances, definitions were adapted by jurisdictions to account and adjust for differences in the definitions of “on treatment” and “suppressed viral load”.

Table 1. Consensus definitions used in Canada’s 2018 national estimates of 90-90-90 measures

Measure	Definition
Total estimated number of people living with HIV	The total estimated number of people living with HIV at the end of 2018 based on a bespoke modelling approach, using the Canadian HIV Modelling Tool.Footnote 2 The estimate includes diagnosed and undiagnosed people.
Number/percentage diagnosed 1st 90	Among those estimated to be living with HIV in Canada at the end of 2018, the number and proportion (%) of people who were diagnosed. Numerator: Number of people living with diagnosed HIV Denominator: Number of people living with HIV (both diagnosed and undiagnosed)
Number/percentage who are currently on antiretroviral treatment 2nd 90	Among those living with diagnosed HIV, the number and proportion (%) of people with ≥1 antiretroviral therapy (ART) in 2018 (prescribed, dispensed or recorded on patient forms) Numerator: Number of people on treatment (≥1 antiretroviral therapy in 2018) Denominator: Number of people living with diagnosed HIV
Number/percentage who had suppressed virus 3rd 90	Among those on treatment, the number and proportion (%) of people whose last HIV RNA measurement in 2018 was <200 copies/ml Numerator: Number of people with <200 copies/ml on their latest viral load (VL) test in 2018 Denominator: Number of people on treatment

Data Sources

HIV estimates related to incidence, prevalence and the first 90-90-90 target were developed using HIV surveillance data reported by provinces and territories, estimated deaths among persons living with HIV, and back-calculation statistical modelling methods. Additional detail on these methods is provided in Appendix 1.

The development of estimates for the second and third 90-90-90 targets required additional information from the provinces and territories, including the following where available:

• Centralized HIV care program data, including linked treatment and laboratory viral load data;
• Provincial antiretroviral drug prescription data linked to HIV laboratory data;
• Unlinked data from drug prescription databases, laboratories, and HIV clinics;
• Cohorts of diagnosed persons engaged in HIV care.

Data limitations and caveats

Data systems, type of data available, and the capacity to link information from different sources vary across jurisdictions. Therefore, the measures developed through this process should be interpreted within the context of plausible ranges around each estimate, which reflect inherent uncertainty as a result of these measurement considerations and limitations.

Estimates published in this report replace all previous estimates published by the Agency concerning HIV incidence, prevalence and 90-90-90 targets in Canada. Assumptions, methods and primary data may have changed for some provinces because our knowledge of the epidemic has improved and the primary data provided by the provinces and territories for use in the model have been refined. Revisions to the methods and data mean that estimates for past years in this report may differ from previously published estimates, and the 2018 estimates should not be compared directly with previously published estimates.

Canada’s progress on meeting the 90-90-90 HIV targets

In Canada at the end of 2018, an estimated 62, 050 people were living with HIV (plausible range 54,600 – 70,500). Among those living with HIV, an estimated 87% (plausible range 81-93%) were diagnosed. Of those diagnosed, 85% were estimated to be on treatment (plausible range 81% to 89%) and Canada has achieved the third 90 target with an estimated 94% of persons on treatment having a suppressed viral load (plausible range 92% to 96%) (Figure 2).

Canada's 2018 90-90-90 estimates lie within the range reported by other developed countries such as the United States of America, Germany, Australia, and Finland.

Figure 2 - Text description

This graph shows the estimated number of persons in Canada at the end of 2018 who were living with HIV, diagnosed, on treatment, and virally supressed. The horizontal axis shows the four components that were estimated (people living with HIV, diagnosed with HIV, on treatment, suppressed virus). The vertical axis shows the estimated number of persons, with the low and high ranges associated with each component.

This graph also shows the point estimate and plausible range associated with each of the three 90-90-90 targets. The first target is the percent of persons living with HIV who are diagnosed. The second target is the percent of persons diagnosed who are on treatment. The third target is the percent of persons on treatment who are virally suppressed.

Estimated number of persons living with HIV, diagnosed, on treatment, and virally suppressed, Canada, 2018

Estimate	Low range	Point estimate	High range
Estimated number of persons
Living with HIV	54,600	62,050	70,500
Diagnosed with HIV	50,260	53,750	57,710
On treatment	43,540	45,910	47,840
Suppressed virus	42,240	43,350	44,070
90-90-90 estimates
Percent of persons living with HIV who were diagnosed	81%	87%	93%
Percent of persons diagnosed who were on treatment	81%	85%	89%
Percent of persons on treatment who were virally suppressed	92%	94%	96%

Table 2. Estimated number and percentage of persons living with HIV, diagnosed, on treatment, and virally suppressed with plausible ranges, Canada, 2018

Measure	People living with HIV	People living with HIV who were diagnosed	People diagnosed with HIV who were on treatment	People on treatment who had suppressed viral load
Estimated %	n/a	87%	85%	94%
Plausible Range (%)	n/a	81%-93%	81%-89%	92%-96%
Estimated #	62,050	53,750	45,910	43,350
Plausible Range (n)	54,600 – 70,500	50,260 – 57,710	43,540 – 47,840	42,240 – 44,070

Canada has demonstrated improvement in all three 90-90-90 targets since 2016. Using current methods and data to revise previous estimates, it was estimated that in 2016, 86% (80-92%) of all people living with HIV knew their status, 84% (80-88%) of those diagnosed were on antiretroviral treatment, and 92% (90-94%) of those on treatment had a suppressed viral load.

The 90–90–90 targets and the HIV testing and treatment cascade (or care continuum) are two ways of looking at the same data. When we report on the progress towards the 90-90-90 targets, the denominator for each of the 90s targets is different (described in Table 1). The first 90 numerical value (e.g. 53,750 for Canada in 2018) is the denominator for the second 90, and the second 90 numerical value (e.g. 45,910 for Canada in 2018) is the denominator for the third 90.

If we look at the data differently, across the care continuum, the denominator for each step remains the same - all people living with HIV (e.g. 62,050 for Canada in 2018). In this approach, when all three 90-90-90 targets are achieved, 81% of all people living with HIV will be on ART (90% x 90%), and 73% of all people living with HIV will be virally suppressed (81% x 90%).^{Footnote 3}

As a country, Canada has not met all three of the 90-90-90 targets individually. However using the care continuum measurement approach, 70% (87% x 85% x 94%) of people living with HIV in Canada in 2018 were estimated to have a suppressed viral load and were consequently unable to pass on the infection. From this perspective, the gap to achieving the overall target of 73% of those living with HIV who are virally suppressed is relatively small for Canada (Figure 3).

Figure 3 - Text description

This graph shows Canada’s continuum of care, and gap to meet global elimination targets, 2018.

Canada’s progress on HIV continuum of care, and gap to meet global elimination targets, 2018

90-90-90 estimates	Global elimination target	Canada
Percent of persons living with HIV who were diagnosed	90%	87%
Percent of persons living with HIV who were on treatment	81%	74%
Percent of persons living with HIV who were virally suppressed	73%	70%

Canada is closing the gap; however, progress is slow and there is still work to be done in order to meet the 90-90-90 targets. Typically, we focus our reporting on the proportion of people who are diagnosed and know their status, the proportion of people on treatment, and the proportion of people on treatment who have a suppressed viral load. By using data to better understand who has not been reached (for example those who are undiagnosed or are not on treatment), community and public health programs can be adjusted to improve their reach and help Canada meet its targets.

It is estimated that 18,700 people in Canada were missed throughout the care continuum, including those who were either undiagnosed, diagnosed but not on treatment, or on treatment but not virally suppressed. These present an important opportunity for intervention to reduce the number of individuals who may potentially transmit infection and who would benefit from being engaged in HIV care and support (Figure 4). Data from 2018 shows that the most significant gaps were among those who were undiagnosed (8,300), and among those who were diagnosed, but not on treatment (7,840), thus implying a need for targeted testing and linkage to care interventions.

Figure 4 - Text description

This pie chart shows the number of people undiagnosed, diagnosed but not on treatment, or on treatment but not virally suppressed by the end of 2018.

Estimated number of people undiagnosed, diagnosed but not on treatment, on treatment but not virally suppressed, Canada, 2018

Group	Number
undiagnosed	8,300
diagnosed but not on treatment	7,840
on treatment but not virally suppressed	2,560

Several factors play a role, either facilitating or creating barriers, in achieving each of the 90-90-90 targets. Given that testing and diagnosis is the entry point to HIV treatment, care and support for people living with HIV, it is likely that those who are undiagnosed, and thus unaware of their status, are not seeking or engaging in HIV services. As such, innovative approaches to HIV testing are needed to overcome barriers that prevent individuals from accessing STBBI testing and care, such as stigma.^{Footnote 4}

Although the Canadian HIV screening and testing guide encourages the integration of HIV testing into other services, particularly those that test for infections with similar transmission routes,^{Footnote 5} this does not always occur. A recent internet survey showed that among Canadian gay, bisexual and other men who have sex with men (gbMSM), less than two-thirds (62.5%) had tested for HIV in the previous year and only one-quarter reported full STI screening in the last 12 months.^{Footnote 6}

While testing, linkage to care and treatment for HIV within traditional clinical settings remain foundational to HIV care programs, other emerging strategies that use community-based services and HIV self-testing could help Canada reach the undiagnosed. The World Health Organization considers HIV self‐testing an important aspect of the global HIV response strategy. On November 2, 2020, Health Canada approved bioLytical’s INSTI HIV self-test, which expands the suite of testing approaches available in Canada. As the newest testing approach available in Canada, HIV self-testing has the potential to reach people who currently do not or are unable to engage with HIV services, including individuals who may avoid testing in a healthcare setting out of concern about stigma and discrimination.^{Footnote 7} Of note however, self-testing does not replace conventional HIV testing, as those who test positive through an HIV self-test must seek follow-up confirmatory lab-based testing. As such, leveraging community-based strategies will be an important complementary step for reaching the undiagnosed in Canada, but ensuring that those who self-test are able to fully access treatment, care, and support will be essential.

Despite making progress, the national estimate for the second 90 target (proportion of those diagnosed who are on treatment) remained the lowest of the three targets. As countries globally have moved to treating all PLHIV as close to diagnosis as possible, it is critical to understand reasons for non-initiation, since persons not yet on treatment are at higher risk for HIV-related morbidity, mortality, and onward transmission of the virus. A systematic review of reasons for non-initiation of treatment showed that socio-economic characteristics, health status, emotional factors such as HIV-related stigma and anxiety, as well as beliefs about HIV and treatment were all connected to decisions not to start HIV treatment.^{Footnote 8} People with HIV who feel well or do not have symptoms may not feel ready to start taking lifetime treatment, or may feel that taking medication will make them feel worse. Financial burdens such as medication costs, transportation costs and unstable housing were reported in many studies. In all reviewed studies, HIV-related stigma was mentioned as a main barrier affecting decisions not to initiate treatment.^{Footnote 8} These results demonstrate the need for early counselling and support, and increasing awareness of the health benefits of timely treatment. Results from the Tracks survey of people who inject drugs in Canada,^{Footnote 9} demonstrated that existing structural and social barriers across the care continuum in Canada present challenges for successful linkage to care and initiation of HIV treatment. Nearly half of all participants who were aware of their HIV-positive status reported avoiding HIV services because of stigma and discrimination in the 12 months prior to the interview.

Since the mid-1990s, the availability of antiretroviral therapy (ART) has led to decreased HIV-related mortality and morbidity. For people living with HIV who are aware of their infection and can access and adhere to treatment, ART has transformed HIV from a fatal disease into a manageable chronic illness. After starting HIV treatment, many patients remain engaged in ongoing care for HIV and have follow-up services to monitor the effectiveness of therapy. The effectiveness of such follow-up may explain why the third 90-90-90 target is the highest of all three targets, which is also observed in other western countries. Achieving and maintaining HIV viral suppression can improve health outcomes and limit transmission to others.^{Footnote 10Footnote 11} This makes monitoring viral suppression an important aspect of HIV care as well as disease prevention efforts. Identifying predictors and groups at increased risk of non-suppression can enhance intervention efforts.^{Footnote 12} Among respondents who were aware of their HIV-positive status in the Tracks survey of people who inject drugs in Canada,^{Footnote 9} almost all of them (97.2%) had taken ART at some point, however less than 90% (87.7%) were currently taking ART at the time of the interview. Treatment adherence among this population (measured as no missed doses in the month prior to the interview) was less than 50% (42.5%). Among participants taking ART at the time of the interview, two-thirds (62.8%) reported an undetectable HIV viral load.^{Footnote 9} In comparison, among Canadian gbMSM respondants from the European Men-who have-sex-with-men Internet survey (EMIS), 99.1% of the HIV-positive participants reported current use of antiretroviral therapies and of these, 96.7% reported an undetectable viral load.^{Footnote 6} These differences, as well as the higher proportion of people who have been diagnosed but who are not on treatment, suggest that there are social, economic and environmental factors such as the experience of stigma and discrimination, poverty, housing instability, or social isolation that can influence whether or not a person achieves a suppressed viral load.

Rather than focus on a single number, such as the number of people receiving HIV treatment, the 90-90-90 targets recognize the need to focus more broadly on testing, on the quality and outcomes of antiretroviral therapy, and on the degree to which programmes are meeting their ultimate goal of viral suppression. Continuum of HIV care data reported for 2018 highlight the need for greater efforts if Canada is to achieve the 90-90-90 targets and viral suppression rates above 73%. As well, these data highlight losses at each stage of the continuum, and the need to use continuum data to identify where these losses are occurring and take steps to minimise them. Improvements to the 90-90-90 measures can be achieved by enhancing our understanding of the knowledge, behaviours, attitudes and experiences related to stigma, discrimination and barriers to services, and by reviewing policies that affect the determinants of health.

90-90-90 estimates in federal correction facilities

All Inmates

All inmates in federal correctional facilities are offered a health assessment on admission, and are also referred for, or can request, HIV testing anytime during incarceration. At the end of 2018, 88% of all inmates knew their status.^{Footnote a} This includes those who were tested for HIV prior to incarceration, those who accepted voluntary testing on admission, and those who were referred for, or requested HIV testing during incarceration. Among the 141 inmates living with diagnosed with HIV at the end of 2018, 94% were on treatment, and 93% of those on treatment had a suppressed viral load (Figure 5).

Figure 5 - Text description

This graph shows the estimate percentage of inmates who tested for HIV on admission, the percentage of inmates who were diagnosed on treatment and the percentage of inmates on treatment who were virally suppressed in Federal correctional facilities on December 2018.

Estimated percentage of inmates who knew their status, on treatment, virally suppressed, federal correctional facilities, 2018

Indicators	Point estimate
Percent of inmates tested for HIV on admission	88%
Percent of inmates living with diagnosed HIV who were on treatment	94%
Percent of inmates on treatment who were virally suppressed	93%

Indigenous Ancestry among inmates

In 2018, 43% of inmates with HIV were of Indigenous ancestry. HIV prevalence was higher among those with Indigenous ancestry compared to non-Indigenous Ancestry (1.48% vs 0.82%). As of December 2018, among all inmates of Indigenous ancestry, 90% knew their status.^{Footnote a} Of the Indigenous inmates known to be living with HIV, 94% were on treatment, and 92% of those on treatment had a suppressed viral load (Figure 6).

Figure 6 - Text description

This graph shows the estimate percentage of Indigenous inmates who were aware their HIV status, the percentage of inmates diagnosed with HIV who were on treatment and the percentage of inmates on treatment who were virally suppressed in Federal correctional facilities as of December 2018.

Estimated percentage of inmates of Indigenous ancestry who knew their status, on treatment, and virally suppressed, federal correctional facilities, 2018

Indicators	Point estimate
Percent of indigenous inmates aware their HIV status	90%
Percent of indigenous inmates living with diagnosed HIV who were on treatment	94%
Percent of indigenous inmates on treatment who were virally suppressed	92%

90-90-90 estimates for on-reserve First Nations communities in Saskatchewan

PHAC is working with provinces, territories and community groups to try to provide more community-specific measures of the progress on the 90-90-90 targets, and an example from Saskatchewan is included below.

Data from all First Nations on-reserve communities in Saskatchewan, which represent 82 communities, showed that at the end of 2018, of the individuals known to be living with diagnosed HIV, 79% were on treatment and 81% of those on treatment had achieved viral suppression (Figure 7).

These percentages represent slight improvements since 2016 when it was estimated that 77% of people living with diagnosed HIV were on treatment, and 75% of those on treatment had a suppressed viral load.

Figure 7 - Text description

This graph shows estimated proportion of persons living with diagnosed HIV who were on treatment, and had a suppressed viral load among First Nations on-reserve communities, Saskatchewan, 2018.

Estimated percentage of persons living with HIV, diagnosed, on treatment, and virally suppressed, First Nations Peoples living on-reserve, Saskatchewan, 2018

Indicators	Point estimate
Percent of First Nation on-reserve living with diagnosed HIV who were on treatment	79%
Percent of First Nation on-reserve on treatment who were virally suppressed	81%

Estimates number of new HIV infections

The Agency estimates that 2,242 new infections (range between 1,080 – 3,850) occurred in Canada in 2018. This estimate is a slight increase from the estimate for 2016 (1,960; range between 1,160 and 2,770) (Table 3, Figure 8).

The resulting estimated incidence rate in Canada for 2018 was 6.0 per 100,000 population (range between 2.9 and 10.4 per 100,000 population) which is a slight increase from the estimate for 2016 (5.4/100,000 population; range between 3.2 and 7.7 per 100,000 population).

Figure 8 - Text description

This graph shows the point estimates of new HIV infections by year with each associated plausible ranges for point estimates. The vertical axis shows the estimated number of new HIV infections per year, with the low and high ranges. The horizontal axis shows the calendar years.

Estimated annual number of new HIV infections in Canada

Year	Low estimate	Point estimate	High estimate
1975	0	0	0
1976	0	3	30
1977	1	58	119
1978	30	167	283
1979	53	243	536
1980	224	572	1083
1981	992	1858	2636
1982	2416	3836	5140
1983	3284	5077	7260
1984	2846	5042	7540
1985	2496	4394	6412
1986	2047	3732	5701
1987	1776	3267	5072
1988	1820	2971	4381
1989	1837	2738	3903
1990	1570	2523	3963
1991	1288	2321	4219
1992	973	2134	3982
1993	840	1993	3677
1994	722	1900	3416
1995	644	1830	3373
1996	650	1790	3073
1997	726	1795	2935
1998	971	1842	2882
1999	1214	1953	3028
2000	1479	2119	3104
2001	1656	2301	3158
2002	1621	2447	3383
2003	1646	2520	3488
2004	1548	2529	3658
2005	1525	2496	3764
2006	1447	2428	3508
2007	1360	2344	3312
2008	1301	2256	3172
2009	1249	2136	3087
2010	1170	2054	2816
2011	1125	1888	2616
2012	1020	1771	2430
2013	985	1714	2429
2014	1000	1742	2412
2015	1093	1853	2596
2016	1160	1960	2770
2017	1134	2122	3170
2018	1080	2242	3850

Figure 9 - Text description

This pie chart shows the estimated percentage of new HIV infections by key population in 2018.

Estimated percentage of new HIV infections by key population, Canada, 2018

Risk group	Percentage
Gay, bisexual and other men who have sex with men (gbMSM)	49.5%
People who inject drugs (PWID)	13.9%
Heterosexual contacts	34.0%
gbMSM-PWID	2.7%

Among the estimated new infections in 2018, an estimated 1,109 were among gay, bisexual and other men who have sex with men (gbMSM), representing just under half (49.5%) of all new HIV infections in 2018, despite representing approximately 3-4% of the Canadian adult male population. Although the gbMSM population continues to be over-represented in new HIV infections in Canada, the proportion of new infections among this population has decreased compared to 2016. (Table 3 and Figure 9).

Three hundred and twelve (312) of the estimated new infections in 2018 were among people who inject drugs (PWID), accounting for 13.9% of new infections. The proportion of new infections attributed to heterosexuals increased slightly to 34.0% from 31.7% in 2016.

An estimated 314 new HIV infections in 2018 occurred among Indigenous people (Table 3) which represented 14.0% of all new infections in 2018, whereas Indigenous Peoples represented 4.9% of the total Canadian population (according to the 2016 Census). This is an increase since 2016, when 12.3% of new infections were estimated to be among Indigenous Peoples. One quarter of new infections were estimated to be among females, which is a slight increase compared to the 2016 estimate of 22.2%.

Table 3. HIV incidence: Estimated number of new HIV infections and associated ranges of uncertainty in Canada in 2018 and 2016, by key population, sex and Indigenous origin.

Category	2018			2016
	Point estimate	RangeFootnote *	Percentage	Point estimate	RangeFootnote *	Percentage
Key Population
gbMSM	1,109	540-1,900	49.5%	1,036	610-1,470	52.9%
gbMSM-PWID	60	30-100	2.7%	59	30-90	3.0%
PWID	312	150-540	13.9%	243	140-350	12.4%
Heterosexuals	761	370-1,300	34.0%	622	360-880	31.7%
Other	<5	0-10	<0.2%	<5	0-10	<0.2%
Sex
Female	566	270-970	25.2%	435	250-620	22.2%
Male	1,676	810-2,870	74.8%	1,525	900-2,160	77.8%
Indigenous Origin
Indigenous	314	150-540	14.0%	241	140-340	12.3%
Non-Indigenous	1,928	930-3,310	86.0%	1,719	1,010-2,440	87.7%
Total	2,242	1,080-3,850	100%	1,960	1,160-2,770	100%
Footnote * Range estimates are rounded to the nearest ten. Return to footnote * referrer

Estimated number of people living with HIV

The Agency estimates that approximately 62,050 people were living with HIV (including AIDS) at the end of 2018 (range between 54,600 and 70,500). This estimate represents a 3% increase from the estimated 58,291 (range between 51,700 – 65,900) at the end of 2016 (Table 4, Figure 10).

The estimated prevalence rate in Canada at the end of 2018 was 167 per 100,000 population (range between 147 and 189 per 100,000 population).

Figure 10 - Text description

This graph shows estimated number of people living with HIV by year. The vertical axis shows point estimates for number of people living with HIV, along with the associated low estimate and high estimate. The horizontal axis shows the calendar years.

Estimated annual number of people living with HIV in Canada

Year	Low estimate	Point estimate	High estimate
1975	0	0	0
1976	0	0	30
1977	0	60	120
1978	70	220	350
1979	210	450	770
1980	580	1,000	1,520
1981	1,960	2,780	3,700
1982	5,120	6,450	7,920
1983	8,980	11,290	13,720
1984	12,770	16,050	19,540
1985	15,440	20,090	24,920
1986	18,150	23,330	28,800
1987	20,250	25,900	31,880
1988	22,120	28,000	34,590
1989	23,220	29,660	36,480
1990	24,250	30,940	37,480
1991	25,260	31,770	38,260
1992	26,210	32,230	38,310
1993	26,670	32,300	37,890
1994	26,650	32,140	37,580
1995	26,310	31,780	37,600
1996	26,360	31,870	37,950
1997	26,760	32,560	39,150
1998	27,090	33,670	40,570
1999	28,400	34,860	41,750
2000	29,330	36,170	43,370
2001	30,650	37,770	45,390
2002	32,470	39,500	47,040
2003	34,180	41,270	48,230
2004	35,820	43,030	49,930
2005	38,070	44,760	51,640
2006	40,260	46,440	53,610
2007	41,860	48,010	55,330
2008	43,310	49,430	57,160
2009	44,780	50,750	58,530
2010	45,890	52,020	59,610
2011	46,500	53,140	61,010
2012	47,270	54,100	61,910
2013	48,310	55,040	62,380
2014	49,310	56,030	63,440
2015	50,360	57,080	64,830
2016	51,700	58,290	65,900
2017	53,410	60,160	68,060
2018	54,600	62,050	70,500

Of the estimated 62,050 people living with HIV (PLHIV) in Canada at the end of 2018:

• Nearly half (48.9%) were among gay, bisexual and other men who have sex with men. (Figure 11).
• 14.0% were people who inject drugs, and 33.4% were heterosexuals.
• About one in four PLHIV was female (23.4%) and this proportion has been consistent over the past 6 years.
• One in ten (10.0%) was Indigenous. This proportion remained stable compared to the 2016 estimates.

Figure 11 - Text description

This pie chart shows the estimated percentage of people living with HIV by key population in 2018.

Estimated percentage of people living with HIV by key population, Canada, 2018

Key population	Percentage
Gay, bisexual and other men who have sex with men (gbMSM)	48.9%
People who inject drugs (PWID)	14.0%
Heterosexuals	33.4%
gbMSM-PWID	2.8%
Others	0.9%

Table 4. HIV prevalence: Estimated number of people living with HIV and associated ranges of uncertainty in Canada at the end of 2018 and 2016, by key population, sex and Indigenous origin.

Category	2018			2016
	Point estimate	RangeFootnote *	Percentage	Point estimate	RangeFootnote *	Percentage
Key Population
gbMSM	30,316	26,500-34,600	48.9%	28,409	25,000-32,300	48.7%
gbMSM-PWID	1,728	1,500-2,000	2.8%	1,628	1,430-1,850	2.8%
PWID	8,690	7,600-9,920	14.0%	8,328	7,340-9,460	14.3%
Heterosexuals	20,750	18,200-23,600	33.4%	19,355	17,050-22,000	33.2%
Other	566	490-650	0.9%	571	500-650	1.0%
Sex
Female	14,545	12,700-16,600	23.4%	13,647	12,000-15,500	23.4%
Male	47,505	41,500-54,200	76.6%	44,644	39,400-50,700	76.6%
Indigenous Origin
Indigenous	6,180	5,400-7,050	10.0%	5,742	5,050-6,550	9.9%
Non-Indigenous	55,870	48,900-63,700	90.0%	52,549	46,300-59,700	90.1%
Total	62,050	54,600-70,500	100%	58,291	51,700-65,900	100%
Footnote * Range estimates are rounded to the nearest ten or hundred. Return to footnote * referrer

Conclusion

This national HIV estimates report for 2018 provides updated insight into the trends of HIV in Canada. At the end of 2018, an estimated 62,050 individuals were living with HIV in Canada. Since HIV treatment has reduced HIV-related mortality, and new infections are occurring at a rate greater than the number of deaths, the overall number of people living with HIV in Canada will likely continue to increase. This will mean increased demand for HIV-related care and treatment.

Challenges remain in reaching the most marginalized people impacted by STBBIs. Of the 62,050 individuals living with HIV in Canada, an estimated 18,700 people were lost from the continuum of care, being either undiagnosed (13% or 8,300 people), diagnosed but not on treatment (7,840), or on treatment but not virally suppressed (2,560). These groups represent opportunities to expand the provision of effective HIV care and support and reduce the onward transmission of infection. Community-based testing strategies, such as self-testing, provide new opportunities to reach the undiagnosed, which can lead to better health outcomes and fewer new HIV transmissions. However, linkage to prevention and health care services will be an important consideration for ensuring those who self-test access prevention services (for those with a negative result), and access treatment, care, and support (for those with a positive result). The slow progress on the 2^nd and 3^rd 90-90-90 targets may be related to the experience of intersecting health challenges such as socio-economic characteristics, health status, emotional aspects such as HIV-related stigma and anxiety, as well as beliefs about HIV and treatment remaining as barriers to accessing and adhering to HIV treatment. Opportunities to address these gaps will require complex responses, potentially including further reductions to barriers for accessing treatment, such as improving treatment coverage, referral or connection mechanisms to health and support services, and addressing stigma and discrimination, including among health professionals, and should ultimately result in improved 90-90-90 measures.

Estimated HIV incidence in Canada has been slightly increasing since 2014. Additional years of data are needed to determine whether the increase in 2018 represents a true increase in HIV incidence (considering the wide plausible ranges around the estimate for the most recent period). One component of this possible increase in estimated HIV incidence could be an artefact due to increases in HIV testing initiatives such as ‘Know Your Status’. This is because increased testing for HIV leads to an increase in new HIV diagnoses, which in turn can influence the modelled estimate of HIV incidence.

The most important consideration is that the recent trend in HIV incidence does not appear to be decreasing. This has also been shown for other STBBIs such as hepatitis C, where the number of reported cases increased from 10,553 in 2010 to 12,447 in 2018, with a corresponding rate increase from 31.0 to 33.6 per 100,000 population.^{Footnote 13} Additionally, a shift in the distribution of new HIV infections is beginning to be observed in Canada, with the proportion of cases among gay, bisexual and other men who have sex with men decreasing slightly since 2016, and the proportion of new infections increasing slightly among Indigenous Peoples, heterosexuals, and females. Similar findings have been noted among reported syphilis cases as well, where in 2018, the proportion of cases among women and people reporting heterosexual sex increased. Among reported cases of syphilis, the proportion of female cases doubled in Canada since 2014.^{Footnote 14} These data suggest an overlap between other STBBIs and HIV that may be contributing to increased health burden for individuals or communities,^{Footnote 15} since the same behaviours and circumstances that put a person at risk for getting other STBBIs also increase the risk for getting HIV. This also highlights the need to focus on the key populations that are affected by overlapping epidemics to address the unique aspects of these populations and communities.^{Footnote 16}

Pre-exposure prophylaxis (PrEP) is a relatively recent biomedical intervention that can reduce the risk of sexual transmission of HIV for people at high risk of HIV infection, and its more widespread use may help reduce HIV incidence at the population level.^{Footnote 17Footnote 18Footnote 19} Health Canada approved PrEP in February 2016, and a recent analysis of Canadian pharmaceutical data found an increasing trend in the estimated number of persons prescribed PrEP from 2014 to 2018.^{Footnote 20} However, PrEP awareness and uptake or use varies across and within key populations. Among the Tracks – PWID survey participants, less than 15% were aware of PrEP, but less than 1% of HIV negative participants were taking PrEP.^{Footnote 9} Eighty-six percent of Canadian EMIS participants had heard of PrEP, but less than 10% had ever used or were currently taking PrEP.^{Footnote 6} More than half of Canadian EMIS participants reported being likely to use PrEP if it was available and affordable, which is consistent with other previous studies, suggesting affordability and accessibility as barriers to uptake.^{Footnote 6}

Despite current efforts, Canada has not seen a decrease in new HIV infections in recent years and further work is needed to meet all of the 90-90-90 targets. The Public Health Agency of Canada will continue to work closely with provinces and territories (PTs) to enhance data sources to improve the ability to measure and assess progress on achieving the 90-90-90 targets. In particular, the Agency will work with PTs and community groups on the feasibility of producing estimates for key populations such as gbMSM, PWID and racialized communities such as the African, Caribbean and Black communities, which would help improve programs for these populations.

These estimates will be used to support the Measuring Impact commitment within the Government of Canada five-year action plan on sexually transmitted and blood-borne infections, with the goal of accelerating prevention, diagnosis and treatment to reduce the health impacts of STBBI in Canada by 2030.

Appendix 1. Additional detail related to Canada’s modelling method

Reference: Yan, Ping; Zhang, Fan; and Wand, Handan (2011). Using HIV Diagnostic Data to Estimate HIV Incidence: Method and Simulation. Statistical Communications in Infectious Diseases: Vol. 3: Iss. 1, Article 6.

The statistical modelling method that was used to estimate the number of new HIV infections in Canada is based on a back-calculation method that combines HIV and AIDS diagnostic data (from national routine HIV/AIDS surveillance) with data on the proportions of recent infections among newly diagnosed individuals (from specialized recent-infection laboratory testing algorithms). The model estimates the time trend in the number of past HIV infections, up until the present time (2018 in this case) since surveillance data can only record the date of diagnosis and not the date of infection (which is some time before diagnosis). From this trend in past HIV infections, the model then projects forward to calculate the expected number of HIV diagnoses (using a mathematical formulation of the time between HIV infection and diagnosis based on the recent-infection algorithm data and model assumptions). The back-calculation method used for incidence estimation in Canada is similar to methods used in the European Union, the USA, and Australia.

Once the time trend in past HIV infections has been estimated, cumulative HIV incidence is calculated by adding up the incidence estimates for all years up to and including the most recent year (2018 in this case). Prevalence for the most recent year is then calculated as the cumulative incidence minus estimated total mortality among HIV-infected persons. For this, total mortality needs to be estimated (using data from Statistics Canada, provincial/territorial vital statistics, national reports of AIDS deaths, and Canadian research studies) since vital statistics data only record mortality among persons who died of HIV-related causes. Note that there are additional details not discussed here, such as accounting for HIV cases who had been previously diagnosed, who were likely infected in another province/territory or country, or who migrated out of the province / territory.

Appendix 2. Key populations used for the national estimates of HIV incidence and prevalence

Key Population	Type of exposure
Gay, bisexual and other men who have sex with men (gbMSM)	Exposure during male-to-male sexual contact
People who inject drugs(PWID)	Exposure during the use of injection drugs
gbMSM-PWID	Exposure during either male-to-male sex and/or the use of injection drugs (used in instances where both exposures were reported for one person)
Heterosexuals	Exposure during heterosexual sex
Other	Persons who were exposed during: receipt of transfusion of blood or clotting factor, perinatal exposure, or occupational exposure

In previous reports, the heterosexual category was separated into an “endemic” group (persons born in a so-called HIV-endemic country, mainly sub-Saharan Africa and the Caribbean) and a “non-endemic” group (born elsewhere). This separation is no longer considered appropriate, for reasons of increasing data incompleteness. The Public Health Agency of Canada is working with communities and with provinces and territories to find ways to better reflect the HIV situation in these communities.