The epidemiology of HIV infection among MSM in Ontario: The situation to 2009

Transcription

1 The epidemiology of HIV infection among MSM in Ontario: The situation to 2009 Robert S. Remis, Juan Liu Ontario HIV Epidemiologic Monitoring Unit Dalla Lana School of Public Health University of Toronto January 2010

2 LIST OF TABLES Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Number and proportion of HIV diagnoses (adjusted) among MSM and MSM-IDU by year of diagnosis, Ontario, 1985 to 2008 Cumulative number of HIV diagnoses (adjusted) among MSM by health region, Ontario, 1985 to 2008 HIV diagnoses among MSM by age group and 5-year period of HIV diagnosis, Ontario, 1985 to 2008 Number of HIV tests (adjusted) among MSM by year and health region, Ontario, 1992 to 2008 Cumulative number of HIV diagnoses (adjusted) among MSM by Local Health Integration Network (LHIN) region, Ontario, 1985 to 2008 Number and proportion of AIDS cases (adjusted) among MSM and MSM-IDU by year of HIV diagnosis, Ontario, 1981 to 2007 Table 7 Cumulative number of AIDS cases among MSM by health region, Ontario, 1981 to 2007 Table 8a Table 8b Table 9 Table 10 Table 11 HIV diagnoses by race/ethnicity and exposure category, Laboratory Enhancement Program (LEP), Ontario, January-August 2009 Proportion of HIV diagnoses by race/ethnicity and exposure category, LEP, Ontario, January-August 2009 Modeled HIV incidence and prevalence among MSM by year, Ontario, 1997 to 2008 Modeled HIV prevalence and number diagnosed by exposure category, Ontario, 2008 Modeled HIV prevalence and incidence among MSM by public health unit and health region, Ontario, 2007 Table 12 Modeled HIV prevalence among MSM by LHIN region, Ontario,

3 LIST OF FIGURES Figure 1 Figure 2 Figure 3 Figure 4 Figure 5a Figure 5b Number HIV diagnoses (adjusted) by selected exposure categories and year of diagnosis, Ontario, 1985 to 2008 Number of HIV diagnoses (adjusted) among MSM by year of diagnosis and health region, Ontario, 1985 to 2008 Number of HIV tests (adjusted) among MSM by year of test and health region, Ontario, 1992 to 2008 HIV positivity rate among MSM by year of diagnosis and health region, Ontario, 1992 to 2008 Number of HIV diagnoses (adjusted) among MSM by year of diagnosis and LHIN region, Ontario, 1985 to 2008 Number of HIV diagnoses (adjusted) among MSM by year of diagnosis and LHIN region, Ontario, 1985 to 2008 Figure 6 Reported HIV cases by race/ethnicity among MSM, Toronto, 1980 to 2005 Figure 7 Figure 8 Proportion White race/ethnicity of reported HIV cases among MSM, Toronto, 1980 to 2005 Proportion other race/ethnicity of reported HIV cases among MSM, Toronto, 1980 to 2005 Figure 9 Reported HIV cases by race/ethnicity among MSM, Ottawa, 1983 to 2003 Figure 10 Figure 11 Figure 12 Figure 13 Proportion White race/ethnicity of reported HIV cases among MSM, Ottawa, 1983 to 2003 Proportion other race/ethnicity of reported HIV cases among MSM, Ottawa, 1983 to 2003 Number of reported AIDS cases (adjusted) by selected exposure category, Ontario, 1981 to 2007 Number of reported AIDS cases (adjusted) among MSM by year of diagnosis and health region, Ontario, 1981 to 2007 Figure 14 AIDS cases by race/ethnicity among MSM, Ontario, 1981 to 2005 Figure 15 Proportion White race/ethnicity of AIDS cases among MSM, Ontario, 1981 to 2005 Figure 16 Proportion other race/ethnicity of AIDS cases among MSM, Ontario, 1981 to 2005 Figure 17 Modeled HIV incidence among MSM, Ontario, 1977 to 2008 Figure 18 Modeled HIV prevalence among MSM, Ontario, 1977 to

4 EXECUTIVE SUMMARY From October1985 to December 2008, 29,787 persons were newly diagnosed with HIV infection in Ontario, of whom 61% were MSM. While MSM constituted a decreasing proportion of HIV diagnoses - from ~90% in the 1980s to ~50% in recent years - MSM continue to be the population most affected by HIV infection in Ontario. The age group most affected by HIV/AIDS continues to be those years old, though in recent years younger and older men constitute an increasing proportion of new HIV diagnoses. The pattern of reported AIDS cases mirrors that of HIV rates with 68% of AIDS cases reported in Ontario since 1981 being among MSM. Though AIDS incidence among MSM has decreased by over 70% from its peak in 1993, after correcting for delayed reporting, incidence was relatively stable at about 100 cases reported per year from 2000 to 2006 and increased about 60% in MSM from ethnoracial populations, and in particular Black, Latin American and Southeast Asian MSM, comprise an increasing proportion of HIV diagnoses in recent years. This phenomenon is reflected in data from HIV diagnoses from Toronto and Ottawa, reported AIDS cases and the Laboratory Enhancement Program. This trend is concerning and may indicate a more rapid increase in HIV infections in these ethnoracial groups. However, some of the observed trends may due to factors such as the changes in the policy of HIV testing for immigration and changing patterns of testing in general. According to our statistical model, 15,068 MSM in Ontario were infected with HIV as of 2008, with more than one-forth of HIV-infected MSM have not been diagnosed. In 2007, overall, we estimated that 16.8% of Ontario MSM were HIV-positive. 10,880 MSM in Toronto were infected, constituting 71% of the Ontario total. Based on our model, HIV incidence among MSM increased 68% since 1996, from 438 to 738 new infections in HIV prevalence increased by 64% during the same period. Despite dramatic improvement in survival related in large part to the advent of HAART in 1996, the epidemic of HIV infection among MSM in Ontario is still not effectively controlled. 3

5 1. INTRODUCTION The HIV epidemic continues to have a profound impact on men who have sex with other men in Ontario. The report presents the updated situation with respect to the epidemiologic characteristics of HIV infection among MSM in Ontario, using available surveillance data, research findings and the results of epidemiologic modeling. 2. METHODS In this section, we briefly describe the databases used to prepare this report, the selection of cases within each database and the analytic methodology. Each data source includes cases diagnosed among the Ontario population, from which cases among MSM were selected for more detailed analyses. Further details on the methodology used may be found in our annual HIV/AIDS surveillance report. We analyzed trends in reported AIDS cases among MSM using data on reported AIDS cases diagnosed from January 1981 to December 2007 and reported to mid-january 2009 provided by the Public Health Division, Ontario Ministry of Health and Long-Term Care (OMHLTC). HIV diagnostic data from 1985 to 2008 was provided by the HIV Laboratory, Ontario Agency for Health Protection and Promotion (OAHPP) and used to examine trends in HIV diagnoses (persons with a first-time HIV-positive test) among MSM in Ontario. We analyzed data on race/ethnicity of reported AIDS cases in Ontario (available to December 2005) and reported HIV-positive tests in Toronto (available to 2005) and Ottawa (to April 2004), based on data provided by these two public health units. Approximately 60% of reported HIV cases included information on ethnicity. We also analyzed data on ethnicity of HIV diagnoses entered into the Laboratory Enhancement Program (LEP) from January to August We attempted to estimate as precisely as possible the incidence, cumulative incidence and prevalence of HIV infection and AIDS among MSM from 1977 to 2008 using a modeling approach. To accomplish this, we used data from several sources, including HIV diagnoses and detuned assay results(hiv Laboratory, OAHPP), AIDS case reports (Public Health Division, OMHLTC) and AIDS mortality (Office of the Registrar General). 3. RESULTS Table 1 and Figure 1 present the number of HIV diagnoses adjusted for unknown exposure category by selected exposure categories form October 1985 to December ,787 HIV infections were diagnosed in Ontario during this period, including 18,096 (60.8%) diagnoses among MSM and 1,102 (3.7%) among MSM-IDU. The number of HIV diagnoses among MSM remained high, with 1,200 to 1,600 new diagnoses per year from 1986 to The number of diagnoses gradually decreased to its lowest level at 409 in 2001 and then increased to about 500 diagnoses per year in subsequent years. Table 2 shows the cumulative HIV diagnoses among MSM by health region from 1985 to % of HIV-infected MSM were from Toronto, followed by Ottawa (8.5%), the Southwest (6.7%) and Central West (4.6%) health regions. The rate of MSM diagnosed with HIV among the adult male population was 1,121.0 per 100,000 persons in Toronto, followed by in Ottawa, in 4

6 the Southwest Health Region. The lowest rate was in the Northern Health Region at 36.6 per 100,000 persons. Figure 2 shows the adjusted number of HIV diagnoses among MSM by year and health region. HIV diagnoses increased from 1986 to its highest level in 1990 and 1991 and then gradually decreased to the lowest level in 1998 for Toronto and 2000 for Ottawa. Following that, the number of HIV diagnoses was relatively stable at about 350 per year in Toronto from 1999 to 2008 and 55 per year in Ottawa from 2001 to Table 3 presents the number of HIV diagnoses among MSM by age group and five-year period of HIV diagnosis. The majority of MSM were aged 25 to 44 years at the time of HIV diagnosis. The proportion of MSM younger than 25 years increased from 5.7% in to 12.3% in The proportion of MSM who were 45 years of age or older also increased, from 10.7% in to 21.2% in the latest period. Table 4 and Figure 3 present the number of HIV tests among MSM by year of test and health region from 1992 to Toronto accounted for the largest number of HIV tests among MSM, representing about 50% of tests in Ontario over the 17-year period. The trend in HIV tests remained relatively stable from 1992 to 2000 then gradually increased for most health regions. Compared to 2000, HIV tests in 2008 increased by 133.7% in the Northern region, 107.5% in Ottawa, 95.2% in the Southwest, 84.7% in the Central East, Other, 82.2% in Toronto, 68.6% in the Central West, and 26.0% in the Eastern, Other health region. Figure 4 presents the HIV positivity rate among MSM by year of diagnosis and health region from 1992 to The positivity rate among MSM decreased over the period examined for most health regions. Table 5 shows cumulative HIV diagnoses among MSM by LHIN region from 1985 to Nearly 80% of HIV diagnoses among MSM were from the Toronto Central, Central, Central East and Champlain LHIN regions. The rate of MSM diagnosed with HIV among the adult male population was highest in the Toronto Central LHIN at 1,141.5 per 100,000 male population, highintermediate in the Central (408.2), Central East (384.1) and Champlain (297.9) and lowintermediate in Central West (240.7), South West (195.6), Mississauga Halton (164.4) and Erie St. Clair (119.2) LHIN regions. The rates were 34 to 103 per 100,000 in the six other regions. Figure 5a and 5b show the number of HIV diagnoses among MSM by year of HIV diagnosis and LHIN region from 1985 to HIV diagnoses increased from 1986 to the highest point at 1990 and 1991 and then gradually decreased to the lowest point at 1996 to 1998 for most LHIN regions. Following that, the number of HIV diagnoses was relatively stable at about 300 per year in Toronto Central and 55 per year in Champlain LHIN region. Figures 6 to 8 present the distribution by race/ethnicity of reported HIV cases among MSM in Toronto by race/ethnicity from 1980 to Among 7,294 HIV-infected MSM with known race/ethnicity, 83.8% were White, followed by Black (4.8%), Latin American (4.4%) and Southeast Asian (3.0%). While the proportion of White persons decreased, the proportion of other ethnic groups, including Black, Southeast Asian, South Asian, Arab/West Asian and Latin American increased. Figures 9 to 11 present the distribution by race/ethnicity of reported HIV cases among MSM in Ottawa by race/ethnicity from 1983 to Among 367 HIV-infected MSM with known race/ethnicity, 87.2% were White, followed by Black (6.3%), Latin American (3.5%) and Southeast 5

7 Asian (1.1%). The proportion of White MSM decreased and the proportion of other ethnic groups, including Black, Southeast Asian and Latin American, increased. Table 6 and Figure 12 present the number of reported AIDS cases adjusted for reporting delay and unknown exposure category for selected exposure categories from 1981 to For MSM, AIDS incidence increased steeply, from a low of 15 cases in 1983 to a peak of 563 in 1993 and decreased since then. AIDS incidence was relatively stable at about 100 reported cases per year from 2000 to 2006 and then increased about 60% in Table 7 shows the cumulative reported AIDS cases among MSM by health region from 1981 to % of HIV-infected MSM were from Toronto, 7-8% from each of Ottawa, the Southwest, Central East, Other and Central West health regions. The rate of MSM diagnosed with AIDS among the adult male population was 329 per 100,000 persons in Toronto, followed by in Ottawa, and per 100,000 persons in the rest of health regions. Figure 13 shows the number of reported AIDS cases among MSM by year and health region. Reported AIDS cases increased from 1981 to the highest point at 1992 and 1994, then gradually decreased and then remained relatively stable since 2000 for most health regions. Figures 14 to 16 present the distribution of reported AIDS cases among MSM in Ontario by race/ethnicity from 1981 to Overall, the majority (88.5%) of MSM with AIDS were White, followed by Black (3.5%), Latin American (2.9%) and Southeast Asian (2.6%). However, the distribution of ethnicity among reported AIDS cases changed over time. The proportion of MSM classified as White decreased, while the proportion of AIDS cases among other ethnic groups increased markedly, in particular Black, Latin American and Southeast Asian MSM. Table 8a and 8b show the number and proportion of HIV diagnoses entered into Laboratory Enhancement Program (LEP) from January to August 2009 by race/ethnicity and exposure category. During this period, 47.1% of HIV diagnoses were MSM. 65.9% of MSM diagnosed with HIV were white, followed by Latin American (9.8%), Black (8.1%) and Southeast Asian (8.1%). Table 9, Figure 17 and Figure 18 present modeled HIV incidence and prevalence among MSM in Ontario from 1977 to We estimate that 15,068 MSM were living with HIV infection in Ontario as of December The estimated annual HIV incidence rate among MSM was 0.95% in 2008, with 740 persons being newly infected. HIV incidence increased dramatically from 1977, reaching a peak of about 1,500 cases in 1984, then decreased about 50% in 1988 and continued to decrease to its lowest level in However, from 1997 to 2004, it gradually increased about 55% compared to the rate in 1996 but has remained relatively stable at 1.0% since then. The number and rate of new HIV infections among MSM in 2008 was 68.3% and 50.4% higher, respectively than in HIV prevalence (Figure 18) appeared to follow three distinct phases, a sharp increase from 1977 to 1989, relatively stable from 1990 to 1998 and a steep increase after The first phase likely represents the first wave of infection in MSM, the second phase a relative equilibrium between new infections and AIDS deaths and the third phase, a marked increase in prevalence due to improved survival related to new more effective therapies and to the continued high rate of new HIV infections. Table 10 shows the modeled HIV prevalence and the proportion of infections diagnosed by exposure category as of December At that time, we estimated 15,068 MSM were infected with HIV. Among them, 73.8% have been diagnosed, i.e. more than one-fourth of HIV-infected MSM have not been diagnosed. 6

8 Table 11 presents the modeled HIV prevalence and HIV incidence numbers and rates among MSM by public health unit and health region as of In Ontario, the overall HIV prevalence rate among MSM was 16.8% and annual HIV incidence rate was 1.0%. There were variations among the public health units (PHUs), however, in HIV prevalence and incidence. HIV prevalence varied from a low of 2.4% in the North Bay-Parry Sound PHU to a high of 22.5% in Toronto and HIV incidence from a low of 0.11% in the Haliburton-Kawartha-Pine Ridge PHU to a high of 1.4% in Toronto. Table 12 presents the modeled HIV prevalence among MSM by LHIN region as of end MSM accounted for more than 60% of HIV-infected persons in Toronto Central, Central and Central East LHIN regions, but only 27% in the North East and North West LHIN regions. Among 15,300 HIVinfected MSM in Ontario, 75.7% were from the Toronto Central, Central, Central East and Champlain LHIN regions. 4. STUDY LIMITATIONS There are several methodologic limitations to our analyses. HIV data were adjusted for unknown exposure category, gender and region using the results of the Laboratory Enhancement Program. Also, AIDS cases were adjusted for underreporting and delayed reporting. These adjustments are subject to uncertainty. Populations of MSM are not well characterized in size, behavioural patterns and regional variations. Limited data on HIV incidence and biases in available data could account for uncertainty in our HIV model. The model in 2008 is preliminary since updated data on reported AIDS cases and the results of the detuned assay in 2008 are not yet available. Despite these challenges, with triangulation we believe our estimates for HIV incidence and prevalence among MSM in Ontario are plausible. The results of the Lambda Study in Toronto and Ottawa carried out in 2007 were highly consistent with our modelled estimates of HIV prevalence among MSM in these regions. 5. CONCLUSIONS In this report, we analyzed available surveillance and research data to 2008 to characterize the evolution of the HIV epidemic among MSM in Ontario. MSM in Ontario continue to be severely affected by the HIV epidemic. In 2008, the estimated preliminarily HIV prevalence among MSM was 16.3%. About MSM were newly infected with HIV annually in the most recent five years. Reasons for persisting high HIV incidence are unclear. Due to continued high incidence and increased survival, HIV prevalence continues to increase dramatically, having increased 64% from 1996 to Despite the limitations associated with the available data, we believe that MSM in Ontario continue to be severely affected by the HIV epidemic. Thus, implementing and evaluating effective primary and secondary preventive interventions among MSM men are needed. 7

9 GLOSSARY OF EPIDEMIOLOGIC INDICATORS FOR HIV INFECTION USED IN THIS REPORT Incidence is the number or rate of new HIV infections in a population. It is usually expressed on an annual basis (i.e. the number or rate of new infections in the course of a calendar year). Incidence is important because it indicates the success with which transmission of HIV infection is being prevented and, therefore, is a reflection of the effectiveness of our prevention programs. Prevalence is the number or rate of infections in a population at a given time. It is usually expressed as an absolute number or a proportion (i.e. the number or rate of HIV-infected persons on a given date, usually at end year). Prevalence is important because it indicates the burden of disease in a population and, in turn, is an indicator of the potential need for treatment and support services. HIV diagnoses are first-time HIV positive tests. To the extent possible, follow-up HIV tests on a person who already tested HIV-positive in the past are excluded from these analyses. However, we know there are residual duplicates and the duplicate rate is taken into account in the modeling of HIV infection in Ontario. After correcting for deaths, the cumulative number of HIV diagnoses provides an indicator of the number of HIV-infected persons who have been diagnosed and, therefore, likely to seek treatment services. HIV diagnosis is not the same as HIV incidence as there can be people who have HIV infection who have not been tested and diagnosed with HIV. Therefore, trends in HIV diagnosis do not necessarily reflect trends in HIV incidence. Reported AIDS cases are cases reported by a treating physician to any of the 36 public health units and, in turn, transmitted to the Ontario Ministry of Health and Long-Term Care. A person is considered to have developed AIDS if they are HIV-infected and have been diagnosed with any one of 26 infections, cancers or other conditions indicative of severe immune deficiency. 8

10 ACKNOWLEDGEMENTS This report was made possible with the assistance of a number of colleagues to whom we owe our sincere thanks and appreciation: Frank McGee, Coordinator, AIDS Bureau, Ontario Ministry of Health and Long-Term Care, for providing core funding to our program to monitor the HIV epidemic in Ontario; Michael Whelan, Public Health Division, Ontario Ministry of Health and Long-Term Care for providing AIDS data; Carol Swantee, HIV Laboratory, Ontario Agency of Health Protection and Promotion for testing diagnostic specimens with the detuned assay; and Ottawa and Toronto Public Health units for providing us with data on HIV diagnoses to 2004 and 2005, respectively; Lisa Santangelo, HIV Laboratory, Ontario Agency of Health Protection and Promotion for coordinating the Laboratory Enhancement Program. Claudia Rank, Field Surveillance Officer assigned to the HIV Laboratory, Ontario Agency of Health Protection and Promotion for providing a custom output from the Laboratory Enhancement Program for

11 Table 1 Number and proportion 1 of HIV diagnoses (adjusted 2 ) among MSM and MSM-IDU by year of diagnosis, Ontario, 1985 to 2008 MSM MSM-IDU Other exposure categories Year No. % No. % No. % Total % % % , % % % 1, , % % % 1, , % % % 1, , % % % 1, , % % % 2, , % % % 1, , % % % 1, % % % 1, % % % 1, % % % 1, % % % 1, % % % % % % % % % % % % % % % % % % 1, % % % 1, % % % 1, % % % 1, % % % 1, % % % 1, % % % 1,121 Total 18, % 1, % 10, % 29, Percentage of MSM or MSM-IDU cases among all new HIV diagnoses in Ontario 2. According to the proportion of known exposure that year and results of the LES (see text for more details), thus, totals may differ due to rounding Data source: HIV Laboratory, Laboratories Branch, Ontario Ministry of Health and Long-Term Care 10

12 Figure 1 Number HIV diagnoses (adjusted) by selected exposure categories and year of diagnosis, Ontario, 1985 to 2008 Number of HIV diagnoses 1,800 1,500 1, MSM MSM-IDU Other exp cat Year of diagnosis Table 2 Cumulative number of HIV diagnoses (adjusted) among MSM by health region, Ontario, 1985 to 2008 Health region Number Proportion Rate 1 Toronto 13, % Ottawa 1, % Southwest 1, % Central West % 80.3 Eastern, Other % 79.8 Central East, Other % 49.5 Northern % 36.6 Total 18, % Per 100,000 male population Data source: HIV Laboratory, Laboratories Branch, Ontario Ministry of Health and Long-Term Care 11

13 Figure 2 Number of HIV diagnoses (adjusted) among MSM by year of diagnosis and health region, Ontario, 1985 to 2008 Number of HIV diangoses 1,400 1,200 1, Toronto Ottawa Southw est Central West Central East, other Eastern, other Northern Year of diagnosis 12

14 Table 3 HIV diagnoses among MSM by age group and 5-year period of HIV diagnosis, Ontario, 1985 to 2008 Age group Total No. % No. % No. % No. % No. % No. % < % 1 0.0% % 0 0.0% % 4 0.0% % % % % % % % % % % % % % % % % % 1, % % % % % % 2, % % % % % % 1, % % % % % % 1, % % % % % % % % % % % % % % % % % % % % % % % % % Unknown Total 3, % 2, % 1, % 1, % 1, % 9, % 13

15 Table 4 Number of HIV tests (adjusted) among MSM by year and health region, Ontario, 1992 to 2008 Year of test Northern Eastern, Other Ottawa Central East, Other Toronto Central West Southwest Total ,985 1,178 8,923 1,128 2,225 16, ,041 1,082 7, ,673 14, ,150 1,002 7, ,097 13, ,325 1,002 7, ,600 14, ,304 1,095 7,690 1,029 1,674 14, ,252 1,182 7,190 1,067 1,610 14, ,895 1,285 6,936 1,060 1,568 13, ,030 1,284 6,571 1,023 1,422 13, ,857 1,352 7,148 1,049 1,340 13, ,168 1,513 7,193 1,058 1,445 14, ,860 1,783 8,562 1,271 1,721 17, ,946 1,837 11,417 1,295 1,816 20, ,374 2,067 12,316 1,441 2,183 22, ,326 2,167 12,884 1,606 2,393 23, ,587 2,427 11,156 1,696 2,268 22, ,623 2,573 10,405 1,813 2,026 22, ,853 2,497 13,064 1,769 2,614 25,407 Total 7,037 13,293 44,574 27, ,716 21,024 30, ,644 14

16 Figure 3 Number of HIV tests (adjusted) among MSM by year of test and health region, Ontario, 1992 to ,000 12,000 Toronto Southw est Central East, other Northern Ottawa Central West Eastern, other Number of HIV tests 9,000 6,000 3, Year of HIV test Figure 4 HIV positivity rate among MSM by year of diagnosis and health region, Ontario, 1992 to % 8.0% Toronto Southwest Central East, other Northern Ottawa Central West Eastern, other Positivity rate (%) 6.0% 4.0% 2.0% 0.0% Year of HIV diagnosis 15

17 Table 5 Cumulative number of HIV diagnoses (adjusted 1) among MSM by Local Health Integration Network (LHIN) region, Ontario, 1985 to 2008 Number Proportion Rate 2 Erie St. Clair % South West % Waterloo Wellington % 47.6 Hamilton Niagara Haldimand Brant % Central West % Mississauga Halton % Toronto Central 7, % 1,414.5 Central 2, % Central East 2, % South East % 92.5 Champlain 1, % North Simcoe Muskoka % 33.9 North East % 44.8 North West % 41.5 Total 18, % Adjusted for unknown LHIN region, sex and exposure category (see text for more details), thus, total may differ due to rounding; the total adjusted number by exposure category was different from the number adjusted by health region, since weights of allocation of unknown exposure category for the 14 LHIN regions were the weights from seven health regions 2. Per 100,000 male population, using 2001 census population Data source: HIV Laboratory, Laboratories Branch, Ontario Ministry of Health and Long-Term Care 16

18 Figure 5a Number of HIV diagnoses (adjusted) among MSM by year of diagnosis and LHIN region, Ontario, 1985 to Number of HIV diagnoses Toronto Central Central East South West Mississauga Halton Central Champlain Central West 0 Year of HIV diagnosis Figure 5b Number of HIV diagnoses (adjusted) among MSM by year of diagnosis and LHIN region, Ontario, 1985 to 2008 Number of HIV diagnoses Ham ilton Niagara Haldim and Brant Erie St. Clair South East Waterloo Wellington North Simcoe Muskoka North East North West Year of HIV diagnosis 17

19 Figure 6 Reported HIV cases by race/ethnicity among MSM (n=7,294), Toronto, 1980 to % White Black Southeast Asian South Asian Arab/w est Asian Latin American Aboriginal Other 1.5% 0.8% 4.4% 0.4% 1.3% 3.0% 4.8% Figure 7 Proportion White race/ethnicity of reported HIV cases among MSM, Toronto, 1980 to % Porportion of reported HIV cases 80% 60% 40% 20% 0%

20 Figure 8 Proportion other race/ethnicity of reported HIV cases among MSM, Toronto, 1980 to 2005 Porportion of reported HIV cases 15% 12% 9% 6% 3% Black Southeast Asian South Asian Arab/West Asian Latin American Aboriginal Other 0% Figure 9 Reported HIV cases by race/ethnicity among MSM (n=367), Ottawa, 1983 to % White Black Southeast Asian South Asian Arab/w est Asian Latin American Aboriginal Other 0.5% 6.3% 1.1% 3.5% 0.0% 0.3% 1.1% 19

21 Figure 10 Proportion White race/ethnicity of reported HIV cases among MSM, Ottawa, 1983 to % Porportion of reported HIV cases 80% 60% 40% 20% 0% Figure 11 Proportion other race/ethnicity of reported HIV cases among MSM, Ottawa, 1983 to 2003 Porportion of reported HIV cases 20% 16% 12% 8% 4% Black Southeast Asian South Asian Arab/West Asian Latin American Aboriginal Other 0%

22 Table 6 Number and proportion 1 of AIDS cases (adjusted 2 ) among MSM and MSM-IDU by year of AIDS diagnosis, Ontario, 1981 to 2007 MSM MSM-IDU Other exposure categories Total Year No. % No. % No. % No % 0 0.0% % % 0 0.6% % % % % % 4 7.0% 4 7.6% % 6 3.9% % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % 7 2.4% % % 7 2.7% % % 7 3.2% % % 7 3.8% % % 4 1.8% % % 4 2.0% % % 7 3.1% % % 9 4.1% % % 3 1.4% % % % % % 6 1.8% % 323 Total 6, % % 2, % 9, Percentage of MSM or MSM-IDU cases among all AIDS cases in Ontario 2. Adjusted unknown exposure category according to proportion among the known cases stratified by sex, health region and year and diagnosis and as well as reporting delay Data source: Ontario AIDS Surveillance Program, Public Health Branch, Ontario Ministry of Health and Long-Term Care (cases reported to January 2009) 21

23 Figure 12 Number of reported AIDS cases (adjusted) by selected exposure category, Ontario, 1981 to 2007 Number of AIDS cases MSM MSM-IDU Other exp cat Year of diagnosis Table 7 Cumulative number of AIDS cases among MSM by health region, Ontario, 1981 to 2007 Health region Number Proportion Rate 1 Toronto 3, % Ottawa % Southwest % 61.5 Central West % 47.4 Eastern, Other % 34.1 Central East, Other % 34.5 Northern % 28.7 Total 5, % Per 100,000 male population Data source: Ontario AIDS Surveillance Program, Public Health Branch, Ontario Ministry of Health and Long-Term Care (cases reported to January 2009) 22

24 Figure 13 Number of reported AIDS cases (adjusted) among MSM by year of diagnosis and health region, Ontario, 1981 to 2007 Number of HIV diangoses Toronto Ottawa Southwest Central West Central East, other Eastern, other Northern Year of diagnosis Figure 14 AIDS cases by race/ethnicity among MSM (n=3,954), Ontario, 1981 to % White Black Southeast Asian South Asian Arab/West Asian Latin American Aboriginal Other 1.0% 0.7% 3.5% 2.9% 0.1% 0.7% 2.6% 23

25 Figure 15 Proportion White race/ethnicity of AIDS cases among MSM, Ontario, 1981 to % Porportion of AIDS cases 80% 60% 40% 20% 0% Figure 16 Proportion other race/ethnicity of AIDS cases among MSM, Ontario, 1981 to 2005 Porportion of AIDS cases 10% 8% 6% 4% 2% Black Southeast Asian South Asian Arab/West Asian Latin American Aboriginal Other 0%

26 Table 8a HIV diagnoses by race/ethnicity and exposure category, Laboratory Enhancement Program (LEP), January-August 2009 Race/ethnicity MSM MSM- IDU IDU Hetero Other/ unknown Total White Black Southeast Asian South Asian Arab/West Asian Latin American Aboriginal Other Total Proportion 47.1% 2.7% 5.4% 21.1% 14.9% 8.8% 100% Table 8b Proportion of HIV diagnoses by race/ethnicity and exposure category LEP, January-August 2009 Race/ethnicity MSM HIVendemic MSM- IDU IDU HIVendemic Hetero Other/ unknown Total White 65.9% 57.1% 57.1% 0.0% 46.2% 82.6% 49.8% Black 8.1% 14.3% 14.3% 96.4% 12.8% 0.0% 27.2% Southeast Asian 8.1% 0.0% 0.0% 1.8% 12.8% 0.0% 6.1% South Asian 4.1% 0.0% 0.0% 0.0% 12.8% 4.3% 4.2% Arab/West Asian 3.3% 0.0% 0.0% 0.0% 0.0% 13.0% 2.7% Latin American 9.8% 0.0% 7.1% 1.8% 12.8% 0.0% 7.3% Aboriginal 0.0% 28.6% 21.4% 0.0% 2.6% 0.0% 2.3% Other 0.81% 0.0% 0.0% 0.0% 0.0% 0.0% 0.38% Total 100% 100% 100% 100% 100% 100% 100% 25

27 Table 9 Modeled HIV incidence and prevalence among MSM by year of infection, Ontario, 1977 to 2008 Year HIV incidence rate HIV incidence number HIV prevalence HIV prevalence (%) % % % % % % % % % 599 1, % % 977 2, % % 1,049 3, % % 1,495 4, % % 1,370 6, % % 1,179 7, % % 888 7, % % 712 8, % % 690 8, % % 664 8, % % 638 9, % % 559 9, % % 526 9, % % 491 9, % % 474 9, % % 438 9, % % 462 9, % % 502 9, % % 569 9, % % , % % , % % , % % , % % , % % , % % , % % , % % , % 26

28 Figure 17 Modeled HIV incidence among MSM, Ontario, 1977 to % 2,000 Annual incidence rate 2.5% 2.0% 1.5% 1.0% Incidence rate Incidence number 1,500 1,000 HIV incidence number % 0.0% Year Figure 18 Modeled HIV prevalence among MSM, Ontario, 1977 to % 20,000 Prevalence % Proportion HIV infected 15.0% 10.0% 5.0% Prevalence num ber ,000 10,000 5,000 Number of HIV-infected men % 0 Year 27

29 Table 10 Modeled HIV prevalence and number diagnosed by exposure category, Ontario, 2008 HIV prevalence Proportion Ontario HIV diagnosed Proportion diagnosed MSM 15, % 11, % MSM-IDU % % IDU 1, % 1, % HIV-endemic 4, % 2, % Heterosexual 3, % 2, % Clotting factor % % Transfusion % % Total 26, % 17, % 28

30 Table 11 Model HIV prevalence and incidence among MSM by public health unit and health region, Ontario, 2007 HIV prevalent number HIV prevalence rate (%) Annual HIV incident number Annual HIV incidence rate (%) PHU/health region Durham Regional % % Haliburton-Kawartha-Pine Ridge % % Peel Regional % % Peterborough County-City % % Simcoe-Muskoka % % York Regional % % Central East, Other, total % % Brant County % % Haldimand-Norfolk Regional % % Halton Regional % % Hamilton-Wentworth Regional % % Niagara Regional % % Waterloo % % Wellington-Dufferin % % Central West, total 1, % % Eastern Ontario % % Hastings & Prince Edward % % Kingston, Frontenac, Len & Add % % Leeds,Grenville-Lanark % % Renfrew County and District % % Eastern, Other, total % % Algoma % % North Bay-Parry Sound % % Northwestern % % Porcupine % % Sudbury & District % % Thunder Bay District % % Timiskaming 4 3.6% % Northern, total % % Ottawa 1, % % Chatham-Kent % % Elgin-ST Thomas % % Grey-Bruce % % Huron % % Middlesex-London % % Oxford County % % Perth District % % Sarnia-Lambton % % Windsor-Essex County % % Southwest, total % % Toronto 10, % % Ontario, total 15, % % 29

31 Table 12 Modeled HIV prevalence among MSM by LHIN region, Ontario, 2007 LHIN region HIV prevalent Proportion Number Proportion 1 Total 2 MSM Erie St. Clair % % South West % 1, % Waterloo Wellington % % Hamilton Niagara Haldimand Brant % 1, % Central West % 1, % Mississauga Halton % 1, % Toronto Central 4, % 7, % Central 2, % 4, % Central East 2, % 4, % South East % % Champlain 1, % 3, % North Simcoe Muskoka % % North East % % North West % % Total 15, % 26, % 1. Column percent 2. Total HIV prevalence in each LHIN region 30