Experiences and needs of Canadian men-who-have-sex-with-men, 2017 survey results

CCDR

Volume 45–11, November 7, 2019: Sexually transmitted infections among MSM

Survey

Canadian results from the European Men-who-have-sex-with-men Internet survey (EMIS-2017)

N Brogan1, DM Paquette1, NJ Lachowsky2, M Blais3, DJ Brennan4, TA Hart5, B Adam6,7

Affiliations

1 Public Health Agency of Canada, Ottawa, ON

2 University of Victoria, Victoria, BC

3 Université du Québec à Montréal, Montréal, QC

4 University of Toronto, Toronto, ON

5 Ryerson University and University of Toronto, Toronto, ON

6 University of Windsor, Windsor, ON

7 Ontario HIV Treatment Network, Toronto, ON

Correspondence

dana.paquette@canada.ca

Suggested citation

Brogan N, Paquette DM, Lachowsky NJ, Blais M, Brennan DJ, Hart TA, Adam B. Canadian results from the European Men-who-have-sex-with-men Internet survey (EMIS-2017). Can Commun Dis Rep 2019;45(11):271–82. https://doi.org/10.14745/ccdr.v45i11a01

Keywords: HIV, sexually transmitted infections, sexual risk practices, gay bisexual and other men who have sex with men, gbMSM, preexposure prophylaxis, postexposure prophylaxis

Abstract

Background: In 2017, the international European Men-who-have-sex-with-men Internet Survey (EMIS-2017) collected data from 50 countries, including Canada for the first time.

Objective: To provide an overview of the Canadian EMIS-2017 data to describe the sexually transmitted and other bloodborne infection (STBBI) related needs of gay, bisexual and other men who have sex with men (gbMSM).

Methods: The EMIS-2017 questionnaire was an updated version of EMIS-2010. It included self-reported sociodemographic data, experience of discrimination, mental health and substance use, knowledge of preexposure prophylaxis (PrEP) for HIV, sexual practices and history of STBBI testing and diagnosis. Analysis was largely descriptive.

Results: Of the 6,059 respondents from Canada, 5,165 participants met the inclusion criteria for this analysis. The majority of participants were born in Canada (79.3%); and over half of the respondents (56.7%) were under the age of 39. In terms of discrimination related to their attraction to other men, participants reported high levels of intimidation (31.9%), verbal abuse (22.1%) and physical violence (1.5%) in the previous year. Regarding mental health, 23.9% had a moderate to severe depression/anxiety score. Almost two-thirds (64.1%) indicated substance use and one-fifth (21.5%) reported chemsex (or the use of stimulant drugs to make sex more intense or last longer). Only 8.4% of participants reported use of PrEP for HIV; however, 51.7% reported being likely to use PrEP if it was available and affordable. Sexual practices, such as condom use, varied by PrEP use with 91.3% of men using PrEP reporting condomless anal intercourse (CAI) compared with 71.5% of men not on PrEP. In terms of STBBI testing, 1.5% reported being diagnosed with hepatitis C and 9.0% reported an HIV diagnosis. Of those with an HIV diagnosis, most were on treatment (99.1%) and had an undetectable viral load (96.7%).

Conclusion: gbMSM in Canada experienced stigma, discrimination and mental health problems; substance use was high as were high-risk sexual practices, such as CAI, among some groups of men. There was a gap between the proportion of men who were interested in PrEP and those who actually used it; and comprehensive STBBI testing was low.

These findings can inform public health action and provide a baseline to examine the impact of current and new interventions.

Introduction

In 2017, the second iteration of the European Men-who-have-sex-with-men Internet Survey (EMIS-2017) was launchedFootnote 1. This survey collected data from gay, bisexual and other men who have sex with men (gbMSM) living in 50 countries, with the aim of generating data useful for planning HIV and sexually transmitted infection (STI) prevention and care programs, and monitoring of progress in these areasFootnote 1. Canada participated in this survey for the first time.

In Canada, gbMSM continue to be particularly affected by sexually transmitted and bloodborne infections (STBBIs). In 2016, it was estimated that gbMSM make up more than half (52.5%) of the population living with HIV infection in CanadaFootnote 2. Rates of syphilis and gonorrhea have increased over the past several years, with the increase among men largely in the gbMSM population in CanadaFootnote 3Footnote 4Footnote 5 and internationallyFootnote 6Footnote 7. Hepatitis C is also on the rise among gbMSM who are HIV-positiveFootnote 8.

The reasons for this are multifactorial. Among HIV-negative men, new preventive interventions like preexposure prophylaxis (PrEP) in combination with reduced use of condoms may, in part, contribute to the rise in STIs other than HIVFootnote 3Footnote 4. Among HIV-positive men, serosorting and knowledge of an undetectable viral load may lead to minimizing the risk of HIV transmission, which can lead to a concurrent decreased use of condoms, thus increasing the risk of other STBBIsFootnote 3Footnote 4. Other factors that could be influencing rates of STBBIs include changing community norms and the use of illicit drugs to enhance sexual experiences (i.e. party and play/chemsex)Footnote 9. Structural factors, such as stigma related to sexual orientation and to HIV infection, a lack of provider knowledge and training in gbMSM sexual health risks and needs, and issues related to cost and access to PrEP and HIV treatment may also be contributing to the STBBI burden among gbMSMFootnote 10.

Gathering national-level information on risk and prevention behaviours, health service needs and health outcomes is crucial for understanding the current trends and for guiding the planning and evaluation of public health interventions to prevent STBBIs among gbMSM. The objective of this report is to provide an overview of the EMIS-2017 data from Canada.

Methods

EMIS-2017 was undertaken by Sigma Research at the London School of Hygiene and Tropical Medicine in association with the Robert Koch Institute in Berlin. The survey was funded by the European Union Health Programme 2014–2020 for Europe. The survey ran from October 2017 to January 2018, inclusively, across 50 countries. In Canada, the Public Health Agency of Canada (PHAC) funded the promotion of the survey to Canadian gbMSM. Community-involved researchers (NJL, MB, DJB, TAH and BA), along with two PHAC representatives, provided feedback on the questionnaire and recruitment methods and a review and interpretation of the results.

While EMIS uses the term “men who have sex with men (MSM)”, the authors use the term “gbMSM“ to describe the same population as the latter is commonly used in Canada. A more detailed description of the methods can be found elsewhereFootnote 11.

Questionnaire

The EMIS-2017 survey was based on the questionnaire successfully used in EMIS-2010. Updates were based on a review of evidence of the epidemiology of HIV infection and STIs; the STBBI-related risk and precautionary behaviours of gbMSM; a policy and practice mapping exercise; a scoping exercise of available gbMSM questionnaires published since EMIS-2010; and three rounds of consultations with partner countries, including Canada.

The final version of the questionnaire included questions on:

  • Sociodemographic characteristics of EMIS participants
  • Experiences of discrimination, mental health and substance use
  • Knowledge and use of postexposure prophylaxis (PEP) and PrEP
  • Sexual practices – information on chemsex was captured by asking about the use of stimulant drugs (including ecstasy/MDMA, cocaine, amphetamine, crystal methamphetamine, mephedrone and ketamine to make sex feel more intense or last longer)
  • STBBI testing and diagnosis

The survey was available in 33 languages simultaneously, including 22 of the 23 official languages of the European Union; Canadian researchers provided edits to both the French and English version and the questionnaire was piloted among a small group of Canadian gbMSM. The EMIS-2017 questionnaire can be found onlineFootnote 12.

Recruitment

Sigma staff commissioned advertising from 10 multi-country “dating” platforms including PlanetRomeo, Grindr, Hornet, Qruiser, RECON, Scruff, Gaydar, Manhunt/Jack’d, GROWLr and Bluesystem. Within Canada, advertisements and banners on social media, gay news websites and sexual networking apps were posted. Electronic and offline promotional materials were provided to community-based organizations across Canada, such as the Health Initiative for Men, for distribution to their networks.

All online promotions of EMIS, paid or unpaid, were allocated a specific URL to direct potential participants to the EMIS landing page. Here they could make their language selection and proceed to the survey; this page also captured data on the recruitment source. Unfortunately, the Grindr Source codes were erroneously labelled in Canada; during data cleaning, these were rectified as much as possible using the timeline for participation invitations sent out by Grindr.

Consent and inclusion criteria

Before proceeding to the survey, participants in Canada had to confirm that they had read and understood the nature and purpose of the study, wanted to participate and were aged 16 years or older. Inclusion criteria included:

  • Living in one of 50 countries participating in the study
  • Identifying as a man, including cisgender men (i.e. individuals assigned male at birth who identify as men) and transgender men (i.e. individuals assigned female at birth who identify as men)
  • Being sexually attracted to men and/or ever having had sex with men

For the purposes of this analysis, participants needed to provide the first part of their postal code so they could be assigned to a province or territory. Three discrepancy flags were created with regard to age, steady male partners and non-steady partners. Participants with inconsistent data were excluded from this analysis.

Analysis

Descriptive analyses (frequencies and proportions) were conducted. Participants’ characteristics were described by province and territory. Due to sample sizes less than 10, men who resided in Yukon were combined with those living in British Columbia, those from Northwest Territories with Alberta and those from Nunavut with Ontario. Similarly, participants from Manitoba and Saskatchewan were combined as were those from the four Atlantic Provinces.

A combined measure of anxiety and depression was calculated using a validated brief screening scale for anxiety and depression, the Patient Health Questionnaire-4Footnote 13. The CAGE 4-item questionnaire was used as an indicator of alcohol dependencyFootnote 14.

To monitor the uptake and effect of new HIV prevention strategies, the following indicators were derived:

  • Anal intercourse with casual partners
  • Condom use with casual partners
  • Any condomless anal intercourse (CAI) with casual partners in the last 12 months by HIV-positive men on HIV treatment and with an undetectable viral load
  • Any CAI with casual partners in the last 12 months by HIV-negative men on PrEP
  • Any CAI with casual partners in the last 12 months by HIV-positive men not on HIV treatment or with a detectable viral load
  • Any CAI with casual partners in the last 12 months by HIV-negative or untested men not on PrEPFootnote 15. Casual partners were defined in the questionnaire as non-steady partners: “men you have had sex with once only, and men you have sex with more than once but who you don’t think of as a steady partner”

“Full STI screening” was a composite variable indicating testing for HIV infection, a blood test, an anal swab and a urethral swab (or a vaginal swab or a urine test) in non-HIV-diagnosed respondents in the previous 12 months. Only non-HIV-diagnosed respondents were included in this indicator to ensure that it was not influenced by counts from HIV-diagnosed men who typically have regular routine STI checks as part of their clinical follow-up. This variable was developed for cross-country comparison of STI testing and treatment services coverage in the Dublin Declaration MonitoringFootnote 16. Although pharyngeal swabs are recommended in CanadaFootnote 17, EMIS-2017 did not collect this information.

Numbers and proportions were suppressed when the numerator was less than five and the denominator was less than 100.

Results

A total of 6,059 Canadian gbMSM participated in EMIS-2017. Of these, 894 (14.8%) were removed because they had discrepant data or did not provide a forward sortation area (i.e. first three characters of their postal code) and so could not be categorized by province/territory. The remaining 5,165 participants from Canada were included in this analysis.

Characteristics of EMIS participants

All provinces and territories were represented, with 23.1% from British Columbia and Yukon, 13.7% from Alberta and the Northwest Territories, 6.6% from Saskatchewan and Manitoba, 33.0% from Ontario and Nunavut, 15.3% from Quebec and 8.3% from the Atlantic Provinces. Nationally, the majority of participants completed the survey in English (91.0%), with 7.4% completing it in French and the 1.6% completing it in one of 19 other languages.

Over 50% of participants were under the age of 39 (56.7%) (Table 1). The median age of the population was 36 years of age. The majority of the participants identified as gay (76.0%), and the remaining participants identified as bisexual (17.5%), straight (0.9%) or with another term or no term (5.7%). Of the participants, 2.4% identified as transgender men. In terms of ethnicity, 3.8% identified as Indigenous, 3.8% as Latin American, 3.1% identified as Asian, 2.8% as East or Southeast Asian, 1.9% as South Asian, 1.7% as Black and 1.4% as Arab/West Asian. One-fifth (20.7%) of the participants were born outside of Canada.

Table 1: Sociodemographic characteristics of Canadian participants in the EMIS-2017 (N=5,165)
Characteristics British Columbia + Yukon
(n=1,191)Footnote a of Table 1
Alberta + Northwest Territories
(n=710)Footnote a of Table 1
Saskatchewan + Manitoba
(n=339)Footnote a of Table 1
Ontario + Nunavut
(n=1,707)Footnote a of Table 1
Quebec
(n=789)Footnote a of Table 1
Atlantic Provinces
(n=429)Footnote a of Table 1
Total
(N=5,165)Footnote a of Table 1
n % n % n % n % n % n % n %
Age category
16–24 160 13.4 148 20.8 63 18.6 281 16.5 165 20.9 89 20.7 906 17.5
25–39 492 41.3 295 41.5 137 40.4 607 35.6 334 42.3 161 37.5 2,026 39.2
40–54 326 27.4 166 23.4 83 24.5 526 30.8 179 22.7 96 22.4 1,376 26.6
55–69 193 16.2 90 12.7 53 15.6 250 14.6 102 12.9 77 17.9 765 14.8
70+ 20 1.7 11 1.5 3 0.88 43 2.5 9 1.1 6 1.4 92 1.8
Sexual identity
Gay or homosexual 975 82.0 503 70.8 223 65.8 1,294 75.8 627 79.5 302 70.4 3,924 76.0
Bisexual 138 11.6 156 22.0 98 28.9 297 17.4 116 14.7 96 22.4 901 17.5
Straight or heterosexual 4 0.3 12 1.7 6 1.8 17 1.0 4 0.5 2 0.5 45 0.9
Other 72 6.1 39 5.5 12 3.5 99 5.8 42 5.3 29 6.8 293 5.7
Gender identity
Cisgender man 1,158 97.2 690 97.2 331 97.6 1,675 98.1 772 97.8 413 96.3 5,039 97.6
Transgender man 33 2.8 20 2.8 8 2.4 32 1.9 17 2.2 16 3.7 126 2.4
Proportion of friends, family who know about attraction to men
All, almost all 652 55.1 291 41.7 139 41.5 819 48.6 432 55.0 203 47.4 2,536 49.6
More than half 227 19.2 125 17.9 52 15.5 318 18.9 124 15.8 60 14.0 906 17.7
Less than half 136 11.5 80 11.5 44 13.1 182 10.8 74 9.4 54 12.6 570 11.1
Few 131 11.1 135 19.3 71 21.2 255 15.1 100 12.7 79 18.5 771 15.1
None 38 3.2 67 9.6 29 8.7 110 6.5 55 7.0 32 7.5 331 6.5
Born in Canada
No 307 25.8 99 14.0 38 11.2 396 23.2 190 24.1 40 9.3 1,070 20.7
Yes 881 74.2 610 86.0 301 88.8 1,309 76.8 598 75.9 388 90.7 4,087 79.3
Ethnicity
White 795 74.2 507 80.9 237 78.0 1,151 76.5 524 78.9 306 87.7 3,520 77.9
Indigenous 46 4.3 34 5.4 24 7.9 35 2.3 20 3.0 11 3.2 170 3.8
Latin American 39 3.6 16 2.6 10 3.3 53 3.5 41 6.2 1 0.3 160 3.5
Asian 47 4.4 17 2.7 8 2.6 53 3.5 12 1.8 3 0.9 140 3.1
East/Southeast Asian 57 5.3 16 2.6 5 1.6 36 2.4 8 1.2 4 1.1 126 2.8
South Asian 22 2.1 10 1.6 4 1.3 45 3.0 5 0.8 2 0.6 88 1.9
BlackFootnote b of Table 1 10 0.9 6 1.0 5 1.6 43 2.9 7 1.1 6 1.7 77 1.7
Arab/West Asian 13 1.2 5 0.8 2 0.7 22 1.5 19 2.9 4 1.1 65 1.4
Other 42 3.9 16 2.6 9 3.0 67 4.5 28 4.2 12 3.4 174 3.8
Years of education past 16 years of age
None 113 9.5 70 9.9 37 10.9 174 10.2 50 6.3 39 9.1 483 9.4
1–3 156 13.1 124 17.5 49 14.5 168 9.8 66 8.4 65 15.2 628 12.2
4–6 322 27.0 210 29.6 116 34.2 479 28.1 193 24.5 136 31.7 1,456 28.2
7+ 600 50.4 306 43.1 137 40.4 886 51.9 480 60.8 189 44.1 2,598 50.3
Occupation
Employed full-time 664 55.8 394 55.5 206 60.8 944 55.5 422 53.6 228 53.1 2,858 55.4
Employed part-time 80 6.7 59 8.3 17 5.0 109 6.4 58 7.4 41 9.6 364 7.1
Self-employed 110 9.3 53 7.5 26 7.7 154 9.0 66 8.4 29 6.8 438 8.5
Unemployed 70 5.9 45 6.3 22 6.5 101 5.9 31 3.9 21 4.9 290 5.6
Student 125 10.5 88 12.4 40 11.8 214 12.6 155 19.7 60 14.0 682 13.2
Retired 84 7.1 41 5.8 18 5.3 105 6.2 41 5.2 34 7.9 323 6.3
Other 56 4.7 30 4.2 10 2.9 75 4.4 14 1.8 16 3.7 201 3.9
Comfort level with current income
Living really comfortably 190 16.0 108 15.2 50 14.7 250 14.7 144 18.3 64 14.9 806 15.6
Living comfortably 374 31.4 207 29.2 116 34.2 572 33.6 281 35.7 118 27.5 1,668 32.3
Neither comfortable nor struggling 387 32.5 244 34.4 106 31.3 530 31.1 234 29.7 145 33.8 1,646 31.9
Struggling 170 14.3 102 14.4 42 12.4 235 13.8 105 13.3 76 17.7 730 14.2
Really struggling 69 5.8 49 6.9 25 7.4 115 6.8 23 2.9 26 6.1 307 6.0

Over three-quarters (78.5%) of the participants reported having four or more years of education past the age of 16. Almost three-quarters (71.0%) reported that they were employed (including full-time, part-time and self-employed) whereas 13.2% identified as students, and the remaining 15.8% reported being unemployed, retired (including medically), on long-term sick leave or other. Almost half (47.9%) of the participants reported being comfortable in their financial situation, 31.9% reported being neither comfortable nor struggling, and one-fifth (20.2%) reported being uncomfortable.

Experiences of discrimination, mental health and substance use

In the year previous to the survey, 31.9% of participants reported experiencing intimidation, 22.1% reported experiencing verbal abuse and 1.5% reported experiencing physical violence related to knowledge or presumption of attraction to men (Table 2).

Table 2: Experiences of discrimination related to knowledge or presumption of attraction to men, mental health and substance use of Canadian participants in the EMIS-2017 (N=5,165)
Characteristics British Columbia + Yukon
(n=1,191)Footnote a of Table 2
Alberta + Northwest Territories
(n=710)Footnote a of Table 2
Saskatchewan + Manitoba
(n=339)Footnote a of Table 2
Ontario + Nunavut
(n=1,707)Footnote a of Table 2
Quebec
(n=789)Footnote a of Table 2
Atlantic Provinces
(n=429)Footnote a of Table 2
Total
(N=5,165)Footnote a of Table 2
n % n % n % n % n % n % n %
Homophobic intimidation and assault started at or intimidatedFootnote b of Table 2
Within last six months 172 14.5 94 13.3 43 12.7 233 13.7 67 8.5 38 8.9 647 12.6
Six months to a year ago 249 20.9 145 20.5 69 20.4 306 18.0 135 17.2 89 20.7 993 19.3
1–5 years ago 190 16.0 96 13.5 36 10.6 240 14.1 115 14.6 60 14.0 737 14.3
5+ years ago 257 21.6 104 14.7 49 14.5 351 20.6 184 23.4 80 18.6 1,025 19.9
Never 321 27.0 270 38.1 142 41.9 570 33.5 286 36.3 162 37.8 1,751 34.0
Verbal insultsFootnote b of Table 2
Within last six months 77 6.5 57 8.1 19 5.6 98 5.8 35 4.5 18 4.2 304 5.9
Six months to a year ago 223 18.8 113 16.0 62 18.3 289 17.0 83 10.6 64 15.0 834 16.2
1–5 years ago 265 22.3 117 16.5 60 17.7 332 19.5 149 19.0 73 17.1 996 19.4
5+ years ago 323 27.2 137 19.4 70 20.6 460 27.1 219 27.9 122 28.5 1,331 25.9
Never 301 25.3 283 40.0 128 37.8 520 30.6 299 38.1 151 35.3 1,682 32.7
Punched, hit, kicked or beatenFootnote b of Table 2
Within last six months 4 0.3 8 1.1 1 0.3 4 0.2 1 0.1 4 0.9 22 0.4
Six months to a year ago 17 1.4 10 1.4 5 1.5 11 0.6 7 0.9 6 1.4 56 1.1
1–5 years ago 40 3.4 40 5.6 13 3.8 50 2.9 23 2.9 13 3.0 179 3.5
5+ years ago 216 18.2 83 11.7 34 10.0 292 17.2 125 15.9 71 16.6 821 15.9
Never 913 76.7 568 80.1 286 84.4 1,342 79.0 630 80.2 334 78.0 4,073 79.1
Anxiety and Depression ScaleFootnote c of Table 2
Normal 472 40.0 276 39.1 137 40.7 731 43.4 321 41.3 188 44.7 2,125 41.6
Mild 393 33.3 249 35.3 116 34.4 546 32.4 308 39.6 149 35.4 1,761 34.5
Moderate 176 14.9 92 13.0 41 12.2 245 14.5 87 11.2 44 10.5 685 13.4
Severe 139 11.8 88 12.5 43 12.8 164 9.7 61 7.9 40 9.5 535 10.5
Suicidal ideation in previous two weeks
Not at all 885 74.4 510 71.8 237 70.1 1,268 74.7 592 75.2 311 72.5 3,803 73.8
Some days 200 16.8 129 18.2 70 20.7 305 18.0 148 18.8 87 20.3 939 18.2
More than half the days 51 4.3 33 4.6 10 3.0 63 3.7 20 2.5 16 3.7 193 3.7
Nearly every day 54 4.5 38 5.4 21 6.2 62 3.7 27 3.4 15 3.5 217 4.2
Alcohol dependencyFootnote d of Table 2
Not alcohol dependent 936 79.1 553 78.4 262 77.7 1,345 79.7 629 80.5 363 85.6 4,088 79.9
Alcohol dependent 248 20.9 152 21.6 75 22.3 343 20.3 152 19.5 61 14.4 1,031 20.1
Ever taken recreational or illicit drugs
No 367 31.1 254 35.9 151 44.7 597 35.3 294 37.4 176 41.6 1,839 35.9
Yes 812 68.9 454 64.1 187 55.3 1,092 64.7 492 62.6 247 58.4 3,284 64.1
Illicit drugs used in previous yearFootnote e of Table 2
Cannabis 609 51.7 326 46.0 131 38.8 797 47.2 333 42.5 192 45.4 2,388 46.6
Cocaine 192 16.3 98 13.9 39 11.5 222 13.2 123 15.6 40 9.5 714 14
Ecstasy pills 152 12.9 53 7.5 15 4.4 147 8.7 77 9.5 16 3.8 458 8.9
Ecstasy in the form of a crystal or powder 146 12.4 65 9.2 19 5.6 132 7.8 59 7.5 23 5.5 444 8.7
GHB or GBL 136 11.5 46 6.5 9 2.7 119 7.1 58 7.4 8 1.9 373 7.3
Crystal methamphetamine 80 6.8 43 6.1 16 4.7 129 7.6 29 3.7 13 3.1 310 6.1
Ever injected any drugsFootnote f of Table 2
No, never 1,139 96.0 679 95.8 328 96.8 1,640 96.6 770 98.1 413 96.3 4,969 96.5
Yes 48 4.0 30 4.2 11 3.2 58 3.4 15 1.9 16 3.7 178 3.5

Almost one-quarter (23.9%) of participants were classified as moderate to severe on a combined measure of anxiety and depression, and 26.1% of participants reported some suicidal ideation ranging from on occasion to nearly every day in the previous two weeks.

With regard to substance use, 64.1% indicated ever using any illicit substance. The most frequently reported drugs used included cannabis (46.6%), which was not yet legal at the time of the survey, cocaine (14.0%) and ecstasy pills (8.9%) (Table 2). Substances used in the previous year by less than 5% of participants overall were as follows: amphetamine (4.4%), ketamine (4.0%), LSD (3.9%), synthetic cannabinoids (2.1%), crack cocaine (1.5%), heroin (0.9%), mephedrone (0.4%) and synthetic stimulants other than mephedrone (0.5%). Only 3.5% of participants reported ever injecting drugs.

Knowledge and use of PEP and PrEP

Most participants had heard of PrEP (86.4%); a slightly smaller proportion had heard of PEP (74.3%), and 8.4% of all the participants, regardless of HIV status, had taken or were currently taking PrEP (Table 3). Of HIV-negative or untested men, 51.7% reported being likely to use PrEP if it was available and affordable.

Table 3: Awareness and use of PEP and PrEP, and healthcare provider knowledge of sexual attraction to men of Canadian participants in the EMIS-2017 (N=5,165)
Characteristics British Columbia + Yukon
(n=1,191)Footnote a of Table 3
Alberta + Northwest Territories
(n=710)Footnote a of Table 3
Saskatchewan + Manitoba
(n=339)Footnote a of Table 3
Ontario + Nunavut
(n=1,707)Footnote a of Table 3
Quebec
(n=789)Footnote a of Table 3
Atlantic Provinces
(n=429)Footnote a of Table 3
Total
(N=5,165)Footnote a of Table 3
n % n % n % n % n % n % n %
Heard of PEP
No 157 13.4 175 24.8 76 22.6 265 15.7 167 21.3 117 27.8 957 18.7
Yes 958 81.5 465 65.9 222 66.1 1,323 78.6 560 71.5 268 63.7 3,796 74.3
Not sure 61 5.2 66 9.3 38 11.3 96 5.7 56 7.2 36 8.6 353 6.9
Ever taken PEPFootnote b of Table 3
No, have not tried to get it 923 89.4 634 95.5 304 94.4 1,395 91.8 629 87.1 386 95.5 4,271 91.6
No, tried, but could not get it 20 1.9 12 1.8 8 2.5 29 1.9 14 1.9 9 2.2 92 2.0
No, had the opportunity but decided not to 14 1.4 5 0.8 4 1.2 19 1.3 13 1.8 1 0.2 56 1.2
Yes, one or more courses 76 7.4 13 2.0 6 1.9 77 5.1 66 9.1 8 2.0 246 5.3
Confidence in ability to access PEPFootnote b of Table 3
Very confident 322 31.2 145 21.9 71 22.0 470 30.9 262 36.2 69 17.0 1,339 28.7
Quite confident 268 25.9 149 22.5 66 20.5 344 22.6 231 31.9 70 17.2 1,128 24.1
A little confident 173 16.7 126 19.0 64 19.9 287 18.8 98 13.5 93 22.9 841 18.0
Not at all confident 118 11.4 107 16.1 56 17.4 192 12.6 49 6.8 79 19.5 601 12.9
I don’t know 152 14.7 136 20.5 65 20.2 230 15.1 84 11.6 95 23.4 762 16.3
Heard of PrEP
No 88 7.5 96 13.7 53 15.8 146 8.7 93 11.9 79 18.8 555 10.9
Yes 1,063 90.7 576 82.1 265 79.1 1,506 89.3 669 85.7 326 77.6 4,405 86.4
Not sure 21 1.8 30 4.3 17 5.1 34 2.0 19 2.4 15 3.6 136 2.7
Ever taken PrEP
No 1,099 92.4 674 95.5 325 95.9 1,532 90.3 664 84.7 415 97.6 4,701 91.6
Yes 90 7.6 32 4.6 14 4.1 165 9.7 120 15.3 10 2.4 431 8.4
Likelihood of using PrEP if available and affordableFootnote c of Table 3
Very unlikely 117 11.3 46 6.9 30 9.3 143 9.4 88 12.2 36 8.9 460 9.9
Quite unlikely 111 10.7 50 7.6 39 12.1 134 8.8 99 13.7 32 7.9 465 10.0
Not sure 277 26.8 185 27.9 79 24.5 440 29.0 200 27.7 143 35.5 1,324 28.4
Quite likely 185 17.9 156 23.6 74 23.0 319 21.0 145 20.1 88 21.8 967 20.7
Very likely 343 33.2 225 34.0 100 31.1 483 31.8 190 26.3 104 25.8 1,445 31.0

Sexual practices

Over half of participants (62.1%) always or almost always had sober sex in the previous 12 months (Table 4). One-fifth (21.5%) of the participants reported participation in chemsex, and 5.8% participated in chemsex in the past six months.

Table 4: Sexual practices of Canadian participants in the EMIS-2017 (N=5,165)
Characteristics British Columbia + Yukon
(n=1,191)Footnote a of Table 4
Alberta + Northwest Territories
(n=710)Footnote a of Table 4
Saskatchewan + Manitoba
(n=339)Footnote a of Table 4
Ontario + Nunavut
(n=1,707)Footnote a of Table 4
Quebec
(n=789)Footnote a of Table 4
Atlantic Provinces
(n=429)Footnote a of Table 4
Total
(N=5,165)Footnote a of Table 4
n % n % n % n % n % n % n %
Nonsober sex (last 12 months)Footnote b of Table 4
None of it 362 33.1 252 41.0 125 41.7 533 35.0 253 35.8 160 44.3 1,685 36.6
Almost none of it 278 25.4 174 28.3 81 27.0 380 25.0 171 24.2 87 24.1 1,171 25.5
Less than half 141 12.9 71 11.6 26 8.7 209 13.7 92 13.0 42 11.6 581 12.6
About half 115 10.5 42 6.8 21 7.0 122 8.0 67 9.5 24 6.6 391 8.5
More than half 74 6.8 27 4.4 9 3.0 111 7.3 49 6.9 16 4.4 286 6.2
Almost all of it 97 8.9 31 5.0 31 10.3 121 8.0 58 8.2 23 6.4 361 7.8
All of it 28 2.6 17 2.8 7 2.3 46 3.0 17 2.4 9 2.5 124 2.7
Recency of chemsexFootnote c of Table 4
Within six months 95 8.1 26 3.7 11 3.3 105 6.2 47 6.0 14 3.3 298 5.8
Six months to a year 76 6.5 56 7.9 14 4.1 127 7.5 50 6.4 20 4.7 343 6.7
1–5 years ago 50 4.2 37 5.2 10 3.0 62 3.7 31 3.9 12 2.8 202 3.9
5+ years ago 77 6.5 31 4.4 8 2.4 84 5.0 40 5.1 20 4.7 260 5.1
Never 879 74.7 558 78.8 295 87.3 1,311 77.6 617 78.6 357 84.4 4,017 78.5
Anal intercourse with casual partners (participants of any HIV status)Footnote d of Table 4
No anal intercourse 420 36 258 36.7 125 37.3 632 37.8 308 39.6 181 42.9 1,924 37.9
Any anal intercourse 748 64 444 63.3 210 62.7 1,038 62.2 470 60.4 241 57.1 3,151 62.1
Consistent condom use with casual partners (participants of any HIV status)Footnote e of Table 4
Non-consistent condom use 561 75.0 327 73.6 160 76.2 765 73.8 320 68.2 185 76.8 2,318 73.6
Consistent condom use 187 25.0 117 26.4 50 23.8 272 26.2 149 31.8 56 23.2 831 26.4
Any CAI by HIV-negative men, on PrEPFootnote f of Table 4
No CAI - - - - - - - - - - - - 30 8.7
Any CAI - - - - - - - - - - - - 314 91.3
Any CAI among HIV-negative or HIV-unknown men not on PrEPFootnote g of Table 4
No CAI 180 26.5 114 27.4 50 25.1 265 29.5 134 36.1 54 23.4 797 28.5
Any CAI 498 73.5 302 72.6 149 74.9 632 70.5 237 63.9 177 76.6 1,995 71.5
Any CAI by HIV-positive men, on treatment, undetectable viral loadFootnote h of Table 4
No CAI - - - - - - - - - - - - 22 7.3
Any CAI - - - - - - - - - - - - 278 92.7
Any CAI among HIV-positive men not on treatment and detectable viral loadFootnote i of Table 4
No CAI - - - - - - - - - - - - 12 85.7
Any CAI - - - - - - - - - - - - 2 14.3
Paid a man to have sex
Within 12 months 57 4.9 33 4.8 24 7.4 108 6.6 51 6.8 14 3.5 287 5.8
1–5 years 61 5.3 27 4.0 15 4.6 89 5.4 34 4.5 16 4.0 242 4.9
5+ years 78 6.7 31 4.6 19 5.9 113 6.9 38 5.1 18 4.4 297 6.0
Never 961 83.1 590 86.6 266 82.1 1,333 81.1 626 83.6 357 88.1 4,133 83.3
Paid by a man to have sex
Within 12 months 40 3.5 30 4.4 7 2.2 67 4.1 36 4.8 20 4.9 200 4.0
1–5 years ago 44 3.8 22 3.2 12 3.7 72 4.4 44 5.9 17 4.2 211 4.3
5+ years ago 114 9.9 43 6.3 24 7.4 153 9.3 33 4.4 25 6.2 392 7.9
Never 959 82.9 586 86.0 281 86.7 1,353 82.2 637 84.9 344 84.7 4,160 83.8

With regard to sexual practices, 62.1% of the participants reported any anal intercourse with casual partners; of these men, 73.6% were inconsistent in their condom use in the previous year (ranging from one to multiple condomless acts).

Of the HIV-negative men using PrEP who had anal intercourse with one or more casual partners in the past year (n=344), 91.3% participated in any CAI with casual partners in the past year. Of those who were HIV-negative or did not know their status, who had anal intercourse with one or more casual partners in the past year and were currently not using PrEP (n=2,792), 71.5% participated in any CAI with casual partners in the past year. Of the HIV-positive participants who had anal intercourse with one or more casual partners in the past year and who had an undetectable viral load (n=300), 92.7% participated in any CAI with casual partners in the past year. Of the men who were HIV-positive who had anal intercourse with one or more casual partners in the past year, were not taking antiretroviral therapy and had a detectable viral load (n=14), 14.3% had engaged in CAI with casual partners in the past year.

In the past year, 5.8% of participants bought sex and 4.0% sold sex with male partners.

STBBI testing and diagnosis

Although almost two-thirds of participants (62.5%) had tested for HIV in the previous year, only one-quarter (24.9%) reported full STI screening in the last 12 months (Table 5). This proportion was higher (37.7%) among participants who engaged in any CAI in the previous year.

Table 5: Sexually transmitted and bloodborne infection testing and diagnoses of Canadian participants in the EMIS-2017 (N=5,165)
Characteristics British Columbia + Yukon
(n=1,191)Footnote a of Table 5
Alberta + Northwest Territories
(n=710)Footnote a of Table 5
Saskatchewan + Manitoba
(n=339)Footnote a of Table 5
Ontario + Nunavut
(n=1,707)Footnote a of Table 5
Quebec
(n=789)Footnote a of Table 5
Atlantic
Provinces
(n=429)Footnote a of Table 5
Total
(N=5,165)Footnote a of Table 5
n % n % n % n % n % n % n %
Received full STI screen in last 12 monthsFootnote b of Table 5
No 698 66.7 480 71.6 246 76.4 1,270 82.5 473 64.9 377 92.0 3,544 75.1
Yes 348 33.3 190 28.4 76 23.6 269 17.5 256 35.1 33 8.0 1,172 24.9
Healthcare provider’s knowledge of sex with menFootnote c of Table 5
Definitely/Probably knew 718 91.8 358 86.1 153 86.4 883 91.3 451 93.8 155 78.7 2,718 90.0
Did not know or Don’t know if they knew 64 8.2 58 13.9 24 13.6 84 8.7 30 6.2 42 21.3 302 10.0
HIV testing historyFootnote d of Table 5
Within six months 213 20.6 94 14.2 39 12.1 224 14.7 131 18.1 26 6.4 727 15.5
Six months to a year 507 49.0 311 46.8 150 46.6 731 47.9 327 45.2 173 42.6 2,199 47.0
1–5 years 151 14.6 91 13.7 36 11.2 219 14.4 103 14.2 67 16.5 667 14.3
5+ years 45 4.4 26 3.9 22 6.8 83 5.4 28 3.9 25 6.2 229 4.9
Never 118 11.4 142 21.4 75 23.3 269 17.6 135 18.6 115 28.3 854 18.3
Last syphilis diagnosis
Within 12 months 50 4.2 21 3.0 8 2.4 53 3.2 25 3.2 5 1.2 162 3.2
1–5 years ago 71 6.0 24 3.4 16 4.8 93 5.5 47 6.1 20 4.7 271 5.3
5+ years 44 3.7 22 3.1 9 2.7 84 5.0 19 2.5 14 3.3 192 3.8
Never 1,015 86.0 635 90.5 301 90.1 1,447 86.3 684 88.3 387 90.8 4,469 87.7
Last gonorrhea diagnosis
Within 12 months 110 9.3 43 6.1 19 5.7 99 5.9 77 10.0 11 2.6 359 7.1
1–5 years ago 147 12.5 60 8.5 22 6.6 135 8.0 72 9.3 17 4.0 453 8.9
5+ years ago 131 11.1 60 8.5 22 6.6 180 10.7 65 8.4 32 7.5 490 9.6
Never 790 67.1 540 76.8 268 81.0 1,268 75.4 559 72.3 365 85.9 3,790 74.4
Last chlamydia or LGV diagnosis
Within 12 months 105 9.0 35 5.1 14 4.3 106 6.4 60 7.8 7 1.7 327 6.5
1–5 years ago 109 9.3 57 8.2 26 7.9 140 8.4 67 8.7 18 4.3 417 8.2
5+ years ago 94 8.0 43 6.2 24 7.3 127 7.6 42 5.4 21 5.0 351 6.9
Never 865 73.7 558 80.5 265 80.5 1,293 77.6 604 78.1 375 89.1 3,960 78.3
Ever diagnosed with hepatitis C
No 1,135 95.3 672 94.9 331 97.9 1,648 96.8 765 97.2 408 95.8 4,959 96.3
Yes 26 2.2 13 1.8 0 0.0 23 1.4 11 1.4 3 0.7 76 1.5
I don’t know 30 2.5 23 3.2 7 2.1 31 1.8 11 1.4 15 3.5 117 2.3
Ever diagnosed with HIV
No 1,034 87.4 664 94.1 322 95.0 1,526 89.8 724 92.0 406 95.5 4,676 91.0
Yes 149 12.6 42 5.9 17 5.0 174 10.2 63 8.0 19 4.5 464 9.0
Currently taking ARTFootnote e of Table 5
No - - - - - - - - - - - - 4 0.9
Yes - - - - - - - - - - - - 436 99.1
Detectable at last viral loadFootnote f of Table 5
Undetectable - - - - - - - - - - - - 440 96.7
Detectable - - - - - - - - - - - - 15 3.3

Most of the participants (90%) who had been tested for STIs other than HIV infection in the previous year stated that their healthcare provider knew they had sex with other men.

With regard to bloodborne infections, 1.5% of participants were ever diagnosed with hepatitis C and 9% reporting being diagnosed with HIV infection. Of those with an HIV diagnosis, 99.1% of the HIV-positive participants reported current use of antiretroviral therapies; of those, 96.7% reported an undetectable viral load. For other STBBIs, 3.2% of the participants had received a syphilis diagnosis within the previous year. The proportions of participants diagnosed in the previous year with gonorrhea and chlamydia (including lymphogranuloma venereum) were 7.1% and 6.5%, respectively.

Discussion

EMIS-2017 identified that Canadian participants experienced high levels of intimidation, as well as verbal abuse and physical violence related to their attraction to other men. Moderate to severe anxiety or depression were present in almost 25% of participants. Substance use was high and, for the first time, there are national data showing that over 20% of participants engaged in chemsex. There was a significant gap between the proportion of participants who reported using PrEP and the proportion who reported they would use PrEP if it was readily available: 8.4% versus 51.7%. Although virtually all HIV-diagnosed respondents were undergoing treatment and had undetectable viral loads, less than 25% stated that they had received full STI testing in the previous year.

Strengths and limitations

The strength of the Canadian EMIS-2017 survey was the use of a global, validated questionnaire that will facilitate cross-country comparisons, a large sample size and participation from all regions of Canada.

A number of limitations need to be considered when interpreting the findings. Since the EMIS-2017 was based on self-reported data and included sensitive topics such as sexual practices and substance use, some degree of underreporting of higher-risk behaviours may have occurred. However, any underreporting was likely limited given the self-administered nature of the survey. EMIS-2017 made use of non-probability sampling methods, including the use of social and sexual networking mobile applications for recruitment, and, as a result, it more likely represents sexually active nonmonogamous gbMSM. However, this is a main target population for both behavioural surveys and public health interventions.

Implications

Many of the findings are consistent with previous studies. For example, a Canadian survey of gbMSM found a higher risk of suicidal ideation and related behaviour among gbMSM than among heterosexual menFootnote 17. A review of the international literature found a higher prevalence of substance use among gbMSM than heterosexual menFootnote 18. The reported use of chemsex (21.5%) in the Canadian portion of the EMIS-2017 was higher than found by regional Canadian studies (6% and 18%)Footnote 19Footnote 20 and may reflect regional variation. Other studies have also found that mental health challenges and substance use are associated with gbMSM engaging in higher-risk sexual practicesFootnote 21Footnote 22Footnote 23. The tendency of these issues to coincide has been conceptualized as a syndemic, defined as co-occurring epidemics that results in a higher disease burden in marginalized populationsFootnote 24. Previous studies have indicated that in some cities between 10.5% and 12.5% of gbMSM are using PrEPFootnote 25, and that 50% to 60% of gbMSM are interested and willing to use PrEPFootnote 26Footnote 27, suggesting affordability and accessibility are barriersFootnote 28Footnote 29. A low proportion of participants reporting full STI testing have been found in other surveys of gbMSM in CanadaFootnote 30 and internationallyFootnote 31Footnote 32. The finding that almost all participants diagnosed with HIV infection were undergoing treatment and had undetectable viral loads is similar to recent regional surveys of gbMSMFootnote 33Footnote 34.

Next steps

The EMIS-2017 findings point to the need for implementation research to determine best practices to address the high levels of discrimination, poor mental health and substance use harms that gbMSM experience. The EMIS-2017 study also provides useful baseline data on PrEP. In light of changes to provincial formularies and recent guidelines on PrEP prescribing, we anticipate an uptake of this effective prevention technology. Further research would be useful in determining the role of PrEP on sexual risk practices and on the subsequent rates of infection with HIV and other STBBIs. As this survey likely captured a specific and important subgroup of gbMSM regarding STBBIs, triangulating these data with information generated from future surveys using alternative sampling methods would lead to a more comprehensive understanding of this population as a whole.

Conclusion

gbMSM in Canada experienced high levels of stigma, discrimination, mental health problems, and substance use. Furthermore, a low prevalence of condom use was found among them. The gap between the proportion of men who were interested in PrEP and those who actually used it is significant and comprehensive STBBI testing was low. These findings can inform public health action and provide a baseline to examine the impact of current and new interventions.

Authors’ statement

  • NB — Conceptualization, data curation, formal analysis, writing (original draft and review and editing)
  • DMP — Funding acquisition, project administration, conceptualization, data curation, formal analysis,
    writing — review and editing
  • NJL — Conceptualization, formal analysis, writing (review and editing)
  • MB — Conceptualization, formal analysis, writing (review and editing)
  • DJB — Conceptualization, formal analysis, writing (review and editing)
  • TAH — Conceptualization, formal analysis, writing (review and editing)
  • BA — Conceptualization, formal analysis, writing (review and editing)

Conflict of interest

None.

Acknowledgements

European Men-who-have-sex-with-men Internet Survey (EMIS-2017) was undertaken by Sigma Research at the London School of Hygiene and Tropical Medicine in association with the Robert Koch Institute in Berlin. The EMIS core team is made up of F Hickson, D Reid, AJ Schmidt and P Weatherburn at the London School of Hygiene and Tropical Medicine and U Marcus and SB Schink at the Robert Koch Institute. We especially thank AJ Schmidt for his continued and strong support of Canadian participation in EMIS-2017.

We thank all of the men who took part in EMIS-2017 and our nongovernmental organization (NGO) partners, particularly the Health Initiative for Men, Rézo, the Gay Men’s Sexual Health Alliance of Ontario and Canadian AIDS Treatment Information Exchange (CATIE), who recruited participants through activities on Facebook and/or other social media and by placing EMIS banners on their websites. We thank all our partners for being part of something huge. We also would like to thank C Archibald for his advice prior to and throughout data collection and for his review of the manuscript.

Funding

As part of European Surveys and Trainings to Improve MSM Community Health project, EMIS-2017 was carried out under the service contract 2015 71 01 with the Consumers, Health, Agriculture and Food Executive Agency (Chafea), acting under powers delegated by the Commission of the European Union. Other financial contributions came from the Public Health Agency of Canada (PHAC) for recruitment in Canada. NJL is supported by a Scholar Award from the Michael Smith Foundation for Health Research (#16863). TAH is supported by an Endgame Leader Chair Award from the Ontario HIV Treatment Network. Promotion of the survey and recruitment of Canadian participants in EMIS-2017 was funded by the PHAC.

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