Ministry of Health Population Health Branch

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1 Ministry of Health Population Health Branch HIV Prevention and Control Report for 2016 saskatchewan.ca

2 Executive Summary The provides an overview of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) surveillance data and a profile of people diagnosed with HIV and AIDS in Saskatchewan. The report is prepared by the and covers the period January to December, The report includes program and financial information, detailed information on HIV and AIDS surveillance data, and testing information. A summary of this information can be found in the HIV/AIDS Annual Report Infographic, located at government-structure/ministries/health/other-reports/ annual-report-archive#step saw more HIV point of care testing sites added and more testing completed. It also saw a 6% increase in the number of people newly diagnosed with HIV. The profile of people newly diagnosed in 2016 was comparable to the peak years of HIV from Other data from 2016 includes: The number of people newly identified with HIV ( cases ) increased to 170 in 2016 compared to 160 individuals in 2015 and 112 individuals in The greatest increases were in the Sunrise region. 79% of cases self-identified as Indigenous, comparable to the peak HIV years % of female cases self-identifying as Indigenous were in the childbearing age range (15 to 45 years). Zero cases of perinatal (mother to child) transmission of HIV were reported. Injection drug use was reported by 60% of cases; and of those, 81% self-identified as Indigenous. 36% of exposures were a result of sexual contact, either men having sex with men or heterosexual. The majority (86%) of people diagnosed with HIV in the past decade are thought to be still alive. Laboratory testing increased by 71% in the past decade; the rate of new cases detected was 2.2 for every 1,000 HIV tests performed in Almost half of persons diagnosed with AIDS in the decade are still living. One in four of the 25 people diagnosed with AIDS in 2016 were identified late in their disease progression. Since 2009 when the Saskatchewan HIV Strategy was implemented following a substantial increase in new HIV cases, the Ministry of Health and the Saskatchewan HIV Collaborative have continued to work toward the goals of reducing HIV rates; addressing risk factors and improving the quality of life for those living with HIV/AIDS. In order to support these goals and targeted efforts to reduce HIV rates in Saskatchewan, the Ministry has provided $27.3M in incremental funding since 2010; annual funding totals $3.984M. The data in our HIV Prevention and Control Report for 2016 points to continued efforts around testing to find new cases early in the disease progression, harm reduction services and cross jurisdictional collaboration to ensure that the needs of our Indigenous population are being met. The report highlights the importance of continued prevention, education, and awareness. The Saskatchewan HIV Collaborative hosted a mobilization event to develop objectives and activities for a multi-year work plan. This was an important step in the strategic planning of future HIV work in the province. 2

3 HIV Prevention and Control Saskatchewan HIV Collaborative The Saskatchewan (SK) HIV Collaborative is a provincial committee, formed in 2014, to provide advice and input on prevention, diagnosis, and care of those living with HIV/AIDS. In 2015, the Committee included representation from the Ministry of Health, First Nations and Inuit Health Branch (FNIHB), Regional Health Authorities (RHAs), Saskatchewan Disease Control Laboratory (SDCL), a Medical Health Officer, a pharmacist, a nurse consultant, and an HIV Strategy Coordinator. In 2016, membership was expanded to include peers with lived experience, a Knowledge Keeper, and the Public Health Agency of Canada. Members provide advice and direction on addressing target populations with common needs, behaviors and risk factors across a broad spectrum of communicable diseases such as HIV, tuberculosis (TB), hepatitis C virus (HCV), and sexually transmitted infections. The Collaborative regularly reviews and revises approaches based on current HIV trends. In 2016, 79% of people diagnosed with HIV self-identified as Indigenous and 60% reported injection drug use as a primary risk factor. The vision of the Collaborative is to support a culturally informed, integrated approach to infectious disease care through partnerships and enhanced and coordinated services, in order to reduce new infections and promote supportive communities for those affected by HIV and other communicable diseases. The HIV Collaborative has established various working groups with broad stakeholder representation to implement programs and develop policies to address risk factors associated with the acquisition of HIV, while supporting timely diagnosis, linkage to and retention in care for those living with HIV. Sharing The Wisdom, 2016 The SK HIV Collaborative hosted an HIV stakeholder mobilization event, Sharing the Wisdom, on October 25, 2016 in Saskatoon. The purpose of the meeting was to provide a forum for collaboration and information sharing among stakeholders, and gather input into a provincial work plan that guides the work to address high HIV rates in the province. A meeting report provides a summary of the input to the SK HIV Collaborative multiyear work plan, from approximately 180 stakeholders, including representatives from Health Authorities, provincial and federal governments, community based organizations (CBO), First Nations communities, frontline service providers and patients. Information on the event and the Collaborative s work plan can be found at As an important step in the development of the new provincial HIV work plan, Sharing the Wisdom facilitated stakeholder discussion and input into the direction of future HIV work in the province. This input will continue to be an important part of HIV strategic planning in Saskatchewan. 3

4 HIV PREVENTION AND CONTROL Saskatchewan HIV Collaborative Work Plan The Saskatchewan HIV Strategy ( ) focused efforts and resources on meeting three goals: reducing HIV rates; addressing risk factors; and improving the quality of life for those living with HIV/AIDS. The Saskatchewan HIV Strategy evaluation (June 2015) indicated that system improvements and increased resources as a result of the HIV Strategy had a positive impact on patient care and outcomes through increased testing and case finding, targeted educational opportunities, an enhanced focus on patient engagement, and improved access to multidisciplinary teams in rural and remote areas, resulting in a decrease in health care utilization. Moving forward, it is critical that support for HIV prevention and control programs be sustained to ensure continuity of the progress made to date. The Strategy evaluation and Sharing the Wisdom provided a foundation for the development of a three-year work plan. Key areas of focus in the work plan include engaging communities to support HIV strategies, increasing public and provider education, strengthening linkages between clinical and community services, promoting collaboration between provincial and federal health systems and addressing barriers to accessing HIV testing and treatment. The SK HIV Collaborative has adopted the International Advisory Panel on HIV Care Continuum Optimization (IAPAC) guidelines as a framework for the multi-year work plan. Objectives include: Optimize the HIV care environment; Increase HIV testing, linkage to care and treatment; Increase retention in care, antiretroviral therapy adherence and viral suppression; and, Develop metrics for monitoring the HIV care continuum (those diagnosed, linked to care, on antiretroviral therapy and virally suppressed). Monitoring Progress The HIV Care Continuum (also known as the HIV Cascade of Care or HIV Treatment Cascade) is a model that outlines the sequential steps, or stages of HIV medical care that people living with HIV will go through, from initial diagnosis to achieving the goal of viral suppression (an undetectable, or very low level of HIV in the blood). A comprehensive continuum of care ensures persons living with HIV receive the support required to achieve viral suppression. The HIV Care Continuum is recognized as a focal point for efforts to maximize individual and public health benefits of antiretroviral therapy. A thorough understanding of the stages in the HIV Care Continuum helps to identify where individuals are lost to care, informs strategies to re-engage individuals to care and subsequently, treatment. Our work toward engaging and retaining people living with HIV in the care continuum informs Saskatchewan s indicators. In July 2014, the Joint United Nations Programme on HIV and AIDS (UNAIDS) set global targets to end the AIDS epidemic; specifically, 90% of people with HIV are diagnosed, 90% of those diagnosed are on treatment, and 90% of those on treatment are virally suppressed. The Saskatchewan 2014 estimates for the indicators are: 69% of people living with HIV are diagnosed; 78% of people diagnosed with HIV are on treatment; and, 79% of people on treatment have a suppressed viral load. The Public Health Agency of Canada is establishing a federal/provincial/territorial working group to enhance and refine the data and methods used to calculate the indicators going forward. 1 AIDS.gov. HIV Care Continuum. Retrieved November 18, 2016 from: 4

5 HIV PREVENTION AND CONTROL 2016 Accomplishments The work of the SK HIV Collaborative aligns with best practice strategies to achieve the indicators. This work, with federal, provincial, community and Indigenous partners, aims to improve access to testing and clinical care; engage, educate and support individuals and communities; and stop the transmission of HIV. There has been a 7% increase per year in HIV testing performed by the Saskatchewan Disease Control Laboratory (SDCL). In addition, the number of HIV Point of Care testing (preliminary results are available immediately) sites has more than doubled, from 20 to 59 sites since Sixty percent (60%) of the people diagnosed with HIV in Saskatchewan in 2016 self-reported injecting drugs as their main exposure to the virus compared to 61% in It is important that people who inject drugs have clean needles to reduce transmission to others and prevent other health complications as a result of unclean needles. Harm Reduction programs are part of a comprehensive public health disease prevention strategy to reduce the spread of HIV, HCV, and other blood-borne infections. The distribution of supplies is intended to reduce the sharing of used needles/syringes and other injecting equipment among people who use injection drugs. Access to harm reduction programs has increased. A new site in a rural location in the province has attributed, in part, to an increase in the number of visits (up 14%) and needles distributed (up 8%) provincially. As of December 31, 2016, the provincially-funded programs include twenty-five fixed and two mobile programs located in eight health regions: Regina Qu Appelle, Five Hills, Saskatoon, Prairie North, Prince Albert Parkland, Sunrise and the North (Mamawetan Churchill River and Keewatin Yatthé). There remain significant gaps in access to these services. There were no babies born with HIV reported in To continue to achieve this, implementation of standardized provincial protocols to reduce HIV transmission from mother to child have been implemented across the province. The number of infants accessing free formula to prevent HIV transmission through breastfeeding has increased by 27%. Under the leadership of a Primary Health Care Capacity Building Task Group, we are engaging more primary care providers in the testing, treatment and ongoing care of people living with HIV. Federal investments have supported significant growth in access to harm reduction programs and testing in First Nation communities. The Ministry provides annualized funding to eight regional health authorities for harm reduction programming to reduce transmission of blood-borne infections and other harms. Services include education and supplies for safer drug use and sexual health. HIV Annual Investments With the HIV Strategy in 2010, came a commitment of $2.5M annually to bolster existing resources. Within a year this had increased to close to $4.0M. As of , $27.3M has been provided since the strategy began in Targeted resources enhanced existing services already being provided to patients through funding to community based organization (CBOs) and the health system including medications and nursing, physician, pharmacist, and laboratory services. Since , annual funding for the strategy increased by 13%. [Table 1] As of , the total incremental funding provided by the Ministry annually totals $3.984M: $3.785M to health regions, and $199K to the Saskatchewan Prevention Institute for clinical and Public Health expertise, peer advisors, administration, website, training and education, and the infant formula program. 5

6 HIV PREVENTION AND CONTROL This funding includes support from Primary Health Services Branch for a Family Physician and outreach services at the Westside Clinic in Saskatoon. Over 30 full-time positions to increase services along the continuum for HIV/AIDS care have been added as a result of the funding. Table 1: HIV Annual Funding Funding provided is used to support: Community development coordinators; Outreach programs/mobile clinics; Social workers; Clinical and administrative staff; Prevention and risk reduction services; Transportation; Peer to Peer programs; and Funding to Community Based Organizations (CBOs). The medication costs to treat one person with antiretroviral therapy ranges from approximately $15K to $20K annually, depending on the treatment regimen. Most drugs used to treat HIV are publicly funded for eligible Saskatchewan residents through the provincial Drug Plan. As with other medications covered under the Drug Plan, drugs used to treat HIV are subject to the patient s deductible and/or co-payment. Therefore, depending on a beneficiary s coverage type, the Drug Plan may pay all or a portion of the prescription cost. Some residents have private drug plan coverage that reduces their out of pocket costs. As shown in Table 2, the Drug Plan currently pays on average 93% of the total cost of prescriptions for the HIV medications listed on the Saskatchewan Formulary. This does not include prescriptions for First Nations residents who are covered under the federal Non-Insured Health Benefits (NIHB) program. Table 2: HIV Prescription Drug Expenditure for Eligible Drug Plan Beneficiaries 6

7 HIV PREVENTION AND CONTROL Encouraging people to know their HIV status is important so they can receive proper care, support and treatment. This also helps reduce the risk of transmission to others. In 2016, more individuals were tested, in more locations throughout the province. There has been a steady increase in HIV testing performed by the Saskatchewan Disease Control Laboratory (SDCL) from 44,779 tests in 2007 to 76,675 tests completed in 2016, representing a 71% increase and reflecting about a 7% increase per year. Table 3 reflects the costs associated with HIV testing. Table 3: Expenditures for HIV Testing 7

8 Overview of people newly diagnosed with HIV & AIDS Table 4 provides a summary of the HIV and AIDS cases for the decade 2007 to Table 5 provides the geographic information for the 2015 and 2016 HIV cases. The number of persons newly identified with HIV ( cases ) increased to 170 cases in 2016 compared to 160 individuals in 2015 and 112 individuals in [Table 4] 79% of cases self-identified as Indigenous. Injection drug use was reported by 60% of cases. 36% of exposures were a result of sexual contact, either men having sex with men or heterosexual. The greatest increase in case counts was seen in Sunrise. There continues to be a notable shift to rural communities. [Table 5] There were 25 newly diagnosed AIDS cases in Table 4: People newly diagnosed with HIV & AIDS in Saskatchewan, HIV Cases Change from previous year (%) 26% 37% 15% 13% 7% 5% 28% 13% 43% 6% SK Rate per 100, Canadian rate per 100, Comparison of SK to Canada 1.7x 2.1x 2.7x 2.4x 2.6x 2.7x 1.9x 1.7x 2.4x 2.3x Self-Identified Ethnicity Age & Gender Indigenous 67% 79% 79% 75% 81% 77% 69% 71% 81% 79% Non-Indigenous & not-specified 33% 21% 21% 25% 19% 23% 31% 29% 19% 21% Mean Age (years) Female 49% 45% 45% 38% 42% 40% 34% 34% 38% 44% Most Commonly Reported Primary Risk Factors AIDS Injection drug use (IDU) 69% 78% 79% 75% 76% 67% 56% 49% 61% 60% Men who have sex with men (MSM) 6% 4% 2% 6% 4% 8% 7% 13% 8% 4% Heterosexual contact 13% 13% 15% 15% 15% 20% 29% 29% 27% 32% Cases *Minor differences in the numbers from previous reports are due to extensive data cleaning efforts in

9 OVERVIEW OF PEOPLE NEWLY DIAGNOSED WITH HIV & AIDS Table 5: People newly diagnosed with HIV by health region (HR), 2015 & 2016 HR Change from previous year (%) Regina Qu Appelle HR (RQHR) (12%) Saskatoon HR (SKHR) (22%) Prince Albert Parkland HR (PAPHR) (12%) Mamawetan Churchill River HR (MCRHR) (11%) Prairie North HR (PNHR) (83%) All other HRs (including Sunrise HR) (127%) Sunrise HR (SHR) <5 18 >13 (>260%) Total (6%) *Information for all other HRs is collapsed due to small numbers As we continue to expand access to testing, it is expected there will be an increase in new cases. The 2016 numbers show the Prince Albert area increased by 6 cases and Prairie North increased by 5 cases compared to Sunrise region showed a considerable increase due to an outbreak (18 cases in 2016). For both 2015 and 2016, the majority of cases came from five areas: Regina, Saskatoon, Prince Albert, Prairie North, and the North. The Regina (down 3 cases) and Saskatoon (down 13) areas reported lower numbers of cases in 2016 compared to 2015, while other areas such as Prince Albert (up 6), Prairie North (up 5) and the North (up 1) saw increases. The 170 cases in 2016 is a 6% increase from 2015 and is above the ten year average of 161 cases ( ). 9

10 Profile of people newly diagnosed with HIV In 2016, 170 individuals were newly diagnosed with HIV, a 6% increase compared to 2015 (160 cases). [Figure 1] The 2016 rate of 14.5 cases per 100,000 population was below the peak rates between 2008 (16.8 cases per 100,000) and 2011 (17.2 cases per 100,000). [Figure 2] 1,608 cases were reported in the decade , compared to 463 in the previous decade Just over 2,200 HIV cases have been reported since reporting began in Of these, 73% were diagnosed in the past 10 years. Newly Diagnosed Cases and Trends Figure 1: People newly diagnosed with HIV by year of diagnosis, The peak of 200 HIV cases in 2009 related, in part, to enhanced efforts to find people who may have been infected for a number of years but had not been tested. The increase again in 2015 and 2016 may also be related to case finding and public education activity resulting in people who had contact with identified HIV cases coming forward for testing. 10

11 PROFILE OF PEOPLE NEWLY DIAGNOSED WITH HIV The national HIV rate declined from 2008 (7.9 cases per 100,000) to 2012 (6.0 per 100,000) and then plateaued. Over the same period, Saskatchewan rates increased from 2006 to 2009 then declined to There was a sharp increase of 43% in 2015 to 160 cases; 2016 saw another increase of 6% to 170 cases. The 2015 and 2016 national rates were 5.8 and 6.4 per 100,000 population respectively. The Saskatchewan 2015 rate of 13.9 per 100,000 population was 2.4 times higher, while the 2016 rate of 14.5 per 100,000 was 2.3 times higher. Figure 2: HIV diagnosis rates, SK versus Canada,

12 PROFILE OF PEOPLE NEWLY DIAGNOSED WITH HIV Of the 170 new cases, 95 were male, down 5% from cases were female, an increase of 25% from [Tables 6 & 7] Over the decade , the proportion of male cases fluctuated from 51-66%, while the proportion of female cases fluctuated from 34-49%. In 2016, the ratio of male to female cases was 1.3:1. The 2016 rate for males was 16.1 cases per 100,000 and the rate for females was 12.9 cases per 100,000. The male rate declined from 2015, while the female rate continued an upward trend from 2014 (6.7 per 100,000). [Figure 3] Gender and Age Characteristics Table 6: Males newly diagnosed with HIV by age group, Table 7: Females newly diagnosed with HIV by age group,

13 PROFILE OF PEOPLE NEWLY DIAGNOSED WITH HIV There was a decline in all age group diagnosis rates among males from 2015 with the exception of the age group, where there was an increase from 24.3 to 35.9 per 100,000. [Figure 4] Female cases comprised 59% of the total cases aged years (24 of 41 cases) and 42% of total cases aged years (22 of 53 cases). In contrast to males, all female age groups saw increased rates except those aged where there was a decrease from 30.4 to 26.8 per 100,000. [Figure 5] 77% (58 cases) of all female cases diagnosed in 2016 were of a childbearing age (15-45 years). This is lower than 2015 at 87%, and comparable to Female cases are generally younger than males. The female rates in the year age group over the decade, , were comparable to male rates in the year age group. Figure 3: HIV diagnosis rates by gender,

14 PROFILE OF PEOPLE NEWLY DIAGNOSED WITH HIV Figure 4: Males newly diagnosed with HIV by age group, Figure 5: Females newly diagnosed with HIV by age group, *Rates for males and females < 20 years and females 50 years and older are not shown because of small numbers. 14

15 PROFILE OF PEOPLE NEWLY DIAGNOSED WITH HIV Newborns infected with HIV 44 HIV positive pregnant women delivered infants in There were no infected newborns. There were a total of ten HIV infected newborns cases in the decade since Table 8 illustrates that between 1987 and 2006 (19 years), there were ten newborn cases; from , there were seven cases; and from , there were three cases. Table 8: Newborns infected and exposed to HIV by year of birth, *Data are not available from 1987 to Data from 2011 to 2014 do not include counts from RQHR and other southern HRs. Data are not collected by the notifiable disease system in Saskatchewan and numbers may be underestimated. The care of HIV positive pregnant women is complex and various factors during pregnancy and delivery contribute to newborns becoming infected. Children infected with HIV One HIV infected child aged years was diagnosed in Four HIV infected children aged 0 to 14 years were diagnosed in the decade since Table 9 illustrates that from 1987 to 2006 (19 years), there were two HIV infected children aged years. From , there were four HIV infected children years of age. Table 9: Children infected with HIV by year,

16 PROFILE OF PEOPLE NEWLY DIAGNOSED WITH HIV Ethnic origin Of the 170 new HIV cases in 2016, 36 or 21% selfidentified as Caucasian, Black, Latin-American, Asian, and South Asian. This does not differ from an average of 36 per year for the previous five years. 134 (79%) of the 170 newly identified cases selfidentified as Indigenous, down slightly from 81% (129/160 cases) in For the 10 years illustrated in Figure 6, the percent of non-indigenous cases ranged from a low of 19% in 2011 and 2015 to a high of 33% in For the same period, the percent of total cases reporting Indigenous ethnicity ranged from a low of 67% in 2007 to a high of 81% in both 2011 and [Table 10] Almost two-thirds of cases self-identifying as Indigenous in 2016 lived in Saskatoon (29 cases) and Prince Albert (52 cases) areas. Males self-identifying as Indigenous made up 72% (68/95 cases) of all male cases in % of cases self-identified as Indigenous Females self-identifying as Indigenous comprised 88% of all female cases (66/75 cases) for Females accounted for 49% of all cases self-identifying as Indigenous, a slight decrease from the average 47% of Indigenous cases in the years 2007 to % (50/66) of female cases self-identifying as Indigenous were in the childbearing age group of years. Figure 6 & Table 10: People newly diagnosed with HIV by self-identified ethnicity, The burden of HIV fell for the greatest part among those people self-identifying as Indigenous. This difference was first recognized in Over the past decade, the number of cases self-identifying as Indigenous ranged from 2-fold to 4-fold the number of non- Indigenous cases. To a small degree, self-reporting of ethnicity accounted for some of this fluctuation. 16

17 PROFILE OF PEOPLE NEWLY DIAGNOSED WITH HIV Geographical distribution The rates in Prince Albert, Sunrise and the three northern health authorities were higher than the provincial rate of 14.5 per 100,000. The remaining areas had rates lower than the province or reported no new infections in 2016 [Figure 7, Tables 11, 12 & 13]. Nearly two-thirds (106/170 or 62%) of new cases in 2016 were residents of Saskatoon (39 cases), Prince Albert (46 cases) or Regina (21 cases). Prince Albert area s HIV diagnosis rate in 2016 was 67.8 per 100,000, a 2.3 fold increase over 2014 (29.1 per 100,000) slightly lower than their peak of 71.3 per 100,000 in Saskatoon area s rate in 2016 was 12.5 per 100,000, less than half of 2009 s rate (31.6/100,000). The majority of people newly diagnosed with HIV were residents of large urban centres Regina area s HIV diagnosis rate dropped to 7.7 per 100,000 in 2016, a continuous decline from 21.8 per 100,000 in Sunrise region showed a considerable increase due to an outbreak (18 cases in 2016). Figure 7: HIV Diagnosis Rates by Health Region,

18 PROFILE OF PEOPLE NEWLY DIAGNOSED WITH HIV Table 11: New HIV cases by Health Region, 2016 * Saskatoon, Regina and Prince Albert **includes people living on First Nations reserves Table 12: People newly diagnosed with HIV by health region, 10-year counts and average, Health region 10 years ( ) Average per year ( ) 2016 Change (%) ( to 2016) Regina Qu Appelle HR (RQHR) % Saskatoon HR (SKHR) % Prince Albert Parkland HR (PAPHR) % Sunrise (SHR) % Prairie North HR (PNHR) % North (MCRHR, KYHR, AHA) % Other regions Total % Table 13: People newly diagnosed with HIV by health region, 2015 & 2016 Health region Change (%) Regina Qu Appelle HR (RQHR) (12%) Saskatoon HR (SKHR) (22%) Prince Albert Parkland HR (PAPHR) (12%) Prairie North HR (PNHR) (83%) North (MCRHR, KYHR, AHA) (8%) Sunrise (SHR) 1 < >13 (>260%) Other regions 8 4 NA 1 Total (6%) 1 Cited into a separate category due to the notable increase in 2016; 2015 numbers are counted within the Other regions category 2 Suppressed due to small numbers 18

19 PROFILE OF PEOPLE NEWLY DIAGNOSED WITH HIV In the years , most cases were found in the cities. As illustrated, there has been a shift in new HIV cases toward rural areas. [Figure 8] The percent of newly diagnosed cases living in small cities and rural communities increased from 17% in 2007 to 40% in 2014, with slight decreases to 39% in 2015 and 38% in [Table 14] The percent of all newly diagnosed cases who lived in Prince Albert varied between 9% and 15% from 2006 to 2014, rose sharply to 23% of newly diagnosed cases in 2015 and increased to 27% in Figure 8 & Table 14: Newly diagnosed persons in the three largest cities versus small urban and rural communities, *Due to rounding, percentages may not total to 100% While most of the HIV cases reside in the three largest cities of Saskatoon, Regina, and Prince Albert, a growing number live in small urban and rural communities. 19

20 PROFILE OF PEOPLE NEWLY DIAGNOSED WITH HIV HIV high risk lifestyle behaviours The risk of getting HIV varies widely depending on the type of exposure or behaviour (such as sharing needles or having sex without a condom). Some exposures to HIV carry a much higher risk of transmission than other exposures. For some exposures, while transmission is biologically possible, the risk is so low that it is not possible to put a precise number on it; however, risks do add up over time. Even relatively small risks can add up over time and lead to a high lifetime risk of getting HIV. In other words, there may be a relatively small chance of acquiring HIV when engaging in a risky behaviour with an infected partner only once; but if repeated many times, the overall likelihood of becoming infected after repeated exposures is actually much higher. Certain lifestyle practices place an individual at a higher risk of acquiring the HIV virus through blood and body fluids. 60% of new HIV cases reported injecting drugs Unprotected heterosexual sex was the third highest risk for acquiring HIV comprising 55/170 or 32% of newly diagnosed people in 2016, an increase from 27% in Over half (33 of 55 cases) engaged in high-risk sexual practices including partnering with injection drug users or partnering with suspected or known HIV positive cases. Only three cases were from endemic countries. Lifestyle activities are presented according to a hierarchy or level of risk of being exposed to HIV (see Technical Notes). Men having unprotected sex with men (MSM) have the highest risk for exposure according to the national HIV risk hierarchy (PHAC). In 2016, 12 of the 95 males newly diagnosed with HIV reported this as a risk factor. Five of these men also injected drugs, the second highest risk for being exposed to HIV. These five individuals were categorized with cases who inject drugs since the pool of HIV infected people who inject drugs is much larger in Saskatchewan than the pool of HIV infected men who practice sex with men. [Table 15 & 16]. The probability of acquiring HIV through injecting drugs, therefore, is much higher. 60% (102 of 170 cases) of newly diagnosed cases injected drugs. 20

21 PROFILE OF PEOPLE NEWLY DIAGNOSED WITH HIV Figure 9 & Table 15: Newly diagnosed people self-reporting primary risk factors for acquiring HIV infection, Table 16: Most common risk factors for acquiring HIV, 2016 *Five (5) MSM-IDU cases included in IDU 21

22 PROFILE OF PEOPLE NEWLY DIAGNOSED WITH HIV The majority of newly diagnosed HIV cases have a lifestyle involving multiple risks for acquiring the HIV virus. Less than 20% reported only one risk factor; some cases reported as many as six risk factors. [Table 17] In 2016, 93 of the 170 people newly diagnosed with HIV (55%) reported three or more risk factors. Not all risks are reviewed by the case investigator. The reported risks represent only those documented in the case record, therefore, the actual number of multiple risks could be higher. Multiple lifestyle risks Heterosexual sex with high risk partners comprised the majority of other lifestyle risks practiced by newly diagnosed individuals, particularly cases having partners who injected drugs (84/170 cases), partners with suspected or confirmed HIV infections (57/170 cases) or partners not disclosing a risk (22/170 cases). Some newly diagnosed individuals also had a past history of sexually transmitted infection (20/170 cases), an indicator for risky sexual practices. Tattooing and exposure to blood through fighting was reported by 46 of 170 newly diagnosed cases. Table 17: Newly diagnosed people with multiple reported risk factors, 2016 Factors that Increase Risk of HIV Transmission Previous sexually transmitted diseases (STIs) Acute and late stage HIV infection High viral loads Factors that Decrease Risk of HIV Transmission Condom use Male circumcision Anti-retroviral treatment Pre-exposure prophylaxis 22

23 PROFILE OF PEOPLE NEWLY DIAGNOSED WITH HIV Injection drug use - the highest self-reported risk A total of 102 (60%) newly diagnosed HIV cases selfreported injection drug use in 2016 compared to a peak of 79% (157 cases) in [Figure 9] The declining trend seen after 2011 in the proportion of new HIV cases reporting injecting drugs was reversed in In 2016, men comprised 60% of cases self-reporting injection drug use and all of those were aged 22 to 59 years. Five of these cases were males who also reported having sex with males. All female cases who reported injection drug use were between 19 and 54 years of age. 1,097 of 1,608 newly diagnosed HIV cases reported injection drug use in the decade (68%) compared to 257 of 463 HIV cases reporting this risk in the previous decade (56%). 85% of cases who reported injection drug use selfidentified as Indigenous (87 out of 102 cases). Among Indigenous female cases, 58% (38/66) reported injection drug use, and all but six of the new cases were in the childbearing age (range years). 80% of males who inject drugs self-identified as Indigenous (49/61). Individuals who inject illicit drugs, because of a compromised health status, typically respond less well to the drug therapies for HIV viral suppression or are more challenged with adherence to the drug regime. Two-thirds of individuals injecting drugs practiced two or more additional activities putting them at risk, albeit a lesser risk, for acquiring the infection. Heterosexual activity - the second most reported risk 55 cases (32%) reported heterosexual activity as the primary risk for infection in 2016, part of an increasing trend since females reported heterosexual activity as the primary risk factor; of these, 25 self-identified as Indigenous. 25 males reported heterosexual activity as the primary risk for infection; of these, 17 self-identified as Indigenous. Though 55 cases stated heterosexual activity was their primary risk for infection, cases with higher risks for acquiring HIV also practiced heterosexual activity. Close to half of the cases practicing heterosexual sex stated their partner had no high risk activities associated with HIV infection. Sex workers Eight new cases reported being sex workers, half the 15 who reported this risk in Sex workers ranged between years; six selfidentified as Indigenous. Five of the eight new sex workers were female. Five of the eight cases practicing sex work also injected drugs. All cases among sex workers reported up to four other risks for acquiring HIV infection. Three cases reported knowing their partner was HIV positive. 23

24 PROFILE OF PEOPLE NEWLY DIAGNOSED WITH HIV Men having sex with Men (MSM) Twelve male cases in total (17% of male cases) reported sex with other men as a risk for HIV infection. Five of these cases also injected drugs and were categorized with cases who injected drugs. Half of the 12 cases self-identified as Caucasian (six cases). The number of MSM cases fluctuates year to year. An annual average of six cases was reported in the decade between 1996 and An average of seven cases was reported each year in the first half of the decade, , compared to 12 cases annually in the latter half. Unlike other jurisdictions in Canada, MSM is not yet a common risk for acquiring HIV in Saskatchewan. The majority of HIV cases practicing MSM in 2016 had two to five other risks, albeit lesser risks, for acquiring an HIV infection. Immigrants from endemic countries Saskatchewan received six previously diagnosed HIV positive immigrants from endemic countries in These are not included among the 170 cases whose infection was diagnosed in this province. The number of HIV cases from endemic countries diagnosed in Saskatchewan ranges from one to three cases annually. From , 17 cases from endemic countries (<1% of HIV positive individuals) were diagnosed after arriving in this province. Co-infection with other blood borne diseases 98 (58%) of the 170 new cases were co-infected with hepatitis C, and of those, 89 (91%) also reported injection drug use. Only one case was co-infected with hepatitis B, and one case with infectious syphilis in The majority of people newly diagnosed with HIV over the past decade were still alive 86% of people diagnosed with HIV in the past decade, 2007 to 2016, were presumed to be still living (1,381/1,608). One-fifth of the cases who died in the past decade died in the year they were diagnosed (44/227 cases). For many this indicates they presented for care late in their infection. For some, the primary cause of death was unrelated to their HIV infection. 24

25 PROFILE OF PEOPLE NEWLY DIAGNOSED WITH HIV Laboratory testing for HIV The number of tests for HIV performed by the Saskatchewan Disease Control Laboratory (SDCL) increased steadily each year. Over 30,000 more tests were performed in 2016 compared to 2007, an overall increase of 71%. [Figure 10 & Table 18] A total of 1,896 point of care (POC) tests were completed in 2016, a 42% increase from 1,332 tests in A confirmatory test is completed on all positive HIV POC tests by sending blood samples to the SDCL. The rate of new HIV infections per 1,000 tests performed fluctuated yearly between 1.6/1,000 tests and 4.1/1,000 tests over the decade, 2007 to 2016, for an average of 2.7 new infections detected for every 1,000 tests performed. 2.2 new infections were confirmed for every 1,000 tests performed in 2016, similar to 2015 but an increase over 1.6/1,000 tests in Figure 10 & Table 18: HIV tests performed at SDCL and new infection rate, ? **Percent change 2007 to 2016 A portion of tests represent individuals with low risk lifestyles but still wishing to know their HIV status. Some tests represent repeat testing requested by individuals with an ongoing high risk lifestyle or by physicians for clinical monitoring of patients. SDCL performs testing on individuals initially diagnosed with HIV in another jurisdiction or residents from other jurisdictions. The rate of new infections represents the initial positive HIV test for Saskatchewan residents only. 25

26 Profile of people newly diagnosed with AIDS 24% of the 25 people newly diagnosed with AIDS in 2016 were diagnosed at the same time as their HIV diagnoses (six cases), half the number in 2015 (12 cases, 41%). The length of time between cases first testing positive for HIV and being diagnosed with AIDS in 2015 ranged from 0 to seventeen years. Four of the 25 cases lived more than ten years since their HIV diagnosis. Males aged years represented a larger proportion of AIDS cases than in previous years (20%, 5/25). Eight of the 11 female AIDS cases in 2016 were in the year age group. Newly Diagnosed Cases and Trends 66% of female AIDS cases in the past decade, , were diagnosed in the latter five years (58/88). 62% of AIDS cases diagnosed from were in the latter half of the decade (149 of 240 cases). (Figure 11) Over 450 people in Saskatchewan are living or have lived with an AIDS defining illness since 1984 when HIV/AIDS became a provincially notifiable disease. (Figure 12) There is an under reporting of AIDS cases. A third (30%) of the AIDS cases diagnosed in the past decade died within a few months of their diagnosis. Others lived between one and eight years after an AIDS diagnosis. Some cases died from causes other than AIDS. Figure 11: People newly diagnosed with AIDS by year and gender,

27 PROFILE OF PEOPLE NEWLY DIAGNOSED WITH AIDS Figure 12: Life status* of people newly diagnosed with AIDS by year of diagnosis *Life status as of August 15, 2017 Individuals diagnosed concurrently with HIV and AIDS typically present late in their disease progression. All six cases diagnosed concurrently with HIV and AIDS in 2016 are still alive. The number of AIDS cases among females will predictably increase in the coming years as a reflection of the increasing numbers of female HIV cases beginning in

28 Appendix Technical Notes and Data Limitations All HIV and AIDS cases have been confirmed positive by laboratory testing. All HIV testing is done at the Saskatchewan Disease Control Laboratory (SDCL). Notification of HIV and AIDS cases to the local Medical Health Officer and the Saskatchewan Ministry of Health is mandated by the Disease Control Regulations under The Public Health Act, Data in this report are based on information extracted from the EpiData HIV database and the Integrated Public Health Information System (iphis) on August 15, 2017 by the Ministry of Health. Delays occur in the reporting of HIV and AIDS data. As updated information becomes available, case data may be reassigned based on this information. As such, numbers may differ from previous reports or at the time of next year s report. HIV cases counts are based on the year of the first positive lab result; therefore they do not necessarily represent the number of new infections that year since individuals can be first tested years after their infection. The exception is infant cases born to infected mothers where date of diagnosis is assigned by the infant s year of birth. Delays occur in the reporting of HIV and AIDS data, specifically for ethnicity and risk exposure categories, as well as for AIDS cases and death information. As updated information becomes available, case data may be reassigned based on this information. Thus, numbers may differ from previous reports or at the time of next year s report. Ethnicity is self-identified. For this report, persons selfidentifying as Indigenous comprise Inuit, Métis, and First Nations. The non-indigenous classification includes individuals self-identifying as Caucasian, Black, Latin- American, Asian, South Asian and other ethnicities. Risk exposure information is self-reported, thus limiting the accuracy and completeness of the data. HIV and AIDS cases were assigned to a single exposure category based on a national hierarchy of risk for acquiring the virus. When more than one risk factor is provided, cases are classified as the exposure category that is highest in the hierarchy: MSM Men having sex with men MSM/IDU Men reporting both injection drug use and having sex with men IDU Injection Drug Use The childbearing age of women includes ages 15 to 45 years. HIV rates cited in this report are crude rates. Rates were calculated by dividing the total number of HIV cases by the Saskatchewan covered population, expressed as the number of cases or events per 100,000 population. Only first-time HIV diagnoses are included in this report. All repeat positive and follow-up tests are removed. The data do not include HIV cases currently living in Saskatchewan who were initially diagnosed outside of the province. Individuals lab-confirmed by the SDCL must be resident in the province six months to be included in the annual case count, otherwise they are referred to the jurisdiction where they resided and are counted there. Individuals tested by Immigration, Refugees and Citizenship Canada, as part of the immigration process, are not included in the provincial statistics. First Nations individuals known to be living on reserve at the time of HIV diagnosis are included in figures for the health regions where the First Nations reserve is located. Het-Exposure Heterosexual exposure includes partnering with an individual at risk for HIV, including those from an endemic country, or partners who have no known risk for HIV. This category also includes individuals where heterosexual contact is the only exposure activity reported Endemic Origin from an HIV endemic country where heterosexual transmission is the main exposure. Cases from endemic countries under 15 years of age are not included in the count of heterosexual cases Perinatal Infected newborns of an HIV positive mother NIR No identified risk, unknown risk and less likely sources of infection The incidence pattern of AIDS cases does not necessarily reflect the year in which the client was infected, but rather the year in which the individual was diagnosed with an AIDS defining illness. Individuals reported with AIDS may have been diagnosed with HIV in jurisdictions outside of Saskatchewan. 28

29 Figure 1: People newly diagnosed with HIV by year of diagnosis,

30 Figure 2: HIV diagnosis rates, SK versus Canada,

31 Figure 3: HIV diagnosis rates by gender,

32 Figure 4: Males newly diagnosed with HIV by age group,

33 Figure 5: Females newly diagnosed with HIV by age group,

34 Figure 6 & Table 10: People newly diagnosed with HIV by self-identified ethnicity,

35 Figure 7: HIV Diagnosis Rates by Health Region, 2016

36 Figure 8 & Table 14: Newly diagnosed persons in the three largest cities versus small urban and rural communities,

37 Figure 9 & Table 15: Newly diagnosed people self-reporting primary risk factors for acquiring HIV infection,

38 Figure 10 & Table 18: HIV tests performed at SDCL and new infection rate, ** Percent change from 2006 to 2015

39 Figure 11: People newly diagnosed with AIDS by year and gender,

40 Figure 12: Life status* of people newly diagnosed with AIDS by year of diagnosis