About the campaign

Despite progress made in recent decades, gay men still experience stigma and discrimination. In reaction to these social prejudices, many men who have sex with men keep their distance from the gay community and consequently are not sufficiently reached by prevention and safer sex messages. Some men also keep their sexual orientation hidden. According to a number of studies, this can have negative repercussions on self-esteem, wellness, and psychological health and can often be associated with sexual risk-taking.

Over the years, there has been a significant decrease in the overall proportion of HIV infections that can be attributed to men who have sex with men. During the early 1980s, according to the Canadian AIDS Society, nearly 80% of AIDS cases in Canada occurred among men who had sex with men. In 1995, 81% of new cases of HIV infection occurred within this group. More recently, statistics from the Public Health Agency of Canada (PHAC) indicate that men who have sex with men still account for the highest number of new HIV infections in Canada. However, the proportion of new infections that can be attributed to this group has greatly decreased. At the end of 2005, men who have sex with men represented 45% of new HIV infections. This decrease suggests that, in the years since the start of the epidemic, a majority of men have modified their sexual practices so as not to have unprotected anal sex with partners of unknown HIV status. 

Nonetheless, rates of HIV/AIDS among men who have sex with men remain a cause for concern. According a report published by the Centre for Infectious Disease Prevention and Control (CIDPC) in 2007, a total of 20,669 AIDS cases have been reported in Canada since the start of the epidemic, of which 18 560 occurred in adult men. Among men, 80.8% of reported AIDS cases have occurred among men who have sex with men. In 2005, 29 600 men who have sex with men were estimated to be living with HIV in Canada. That same year, 3 400 new HIV infections were diagnosed within this group, a higher incidence than in any other segment of the Canadian population. Between 2002 and 2005, new HIV infections increased by 13% among men who have sex with men in Canada.  

The situation regarding other sexually transmitted infections (STIs) is also worrisome. Rates of syphilis and gonorrhoea among men who have sex with men are on the rise. In 2004, for example, rates of syphilis among men who have sex with men in Canada were nine times higher than in 1997 (3.5/100,000 compared with 0.4/100,000). From 1997 to 2002, rates of gonorrhoea among men who have sex with men increased by 106% and this group represented more than half of all cases. Because STIs are subject to mandatory reporting in Canada, rising rates of these infections are key indicators that suggest high risk sexual practices have also increased. 

Factors associated with risk-taking in vulnerable populations 

Results from the British Columbia Vanguard prospective cohort study, the Ontario Men’s Survey longitudinal study, and the Omega cohort study carried out Montreal have all pointed to an increase in high risk sexual practices among men who have sex with men. These studies have provided information on some of the factors that contribute to the risk of contracting HIV and other STIs within this group.  

The changing reality of living with HIV 

As a result of major progress in research and pharmacology, life expectancy and quality of life among people living with HIV has indisputably improved. The antiretroviral treatments that are now available are able to slow the progression of HIV infection, and most people diagnosed with HIV can anticipate a near-normal life expectancy because of these treatments. HIV/AIDS has generally been reclassified as a chronic rather than terminal illness, and most people living with HIV/AIDS are now able to lead relatively normal working, social, and sex lives. This has significantly changed how populations vulnerable to HIV infection perceive the risks associated with HIV/AIDS. The level of fear that HIV/AIDS evokes today is clearly not as high as it was in the 1980s or early 1990s. Some men who have sex with men may have become less vigilant about HIV prevention based on the belief that they can maintain their lifestyle and quality of life even if they contract HIV. This may, in part, explain an increase in high risk sexual practices. These new realities mean that important changes are needed in how HIV prevention and health promotion are undertaken among men who have sex with men. Among other things, prevention strategies, activities, and messages now need to account for the realities and experiences of HIV-positive men who have active sexual and emotional lives.

Co-infection

During a forum on HIV held in Ottawa in April 2007, Dr. Alix Adrien presented statistics that suggest most people who contract syphilis are also living with HIV. Co-infection with HIV and another STI among men who have sex with men is an indicator that some men living with HIV engage in high risk sexual practices. Increasing rates of STI and HIV co-infection, as well as the development drug resistant strains of these infections, provide important evidence that high risk practices associated with these infections are a very real phenomenon. The presence of a co-infection such as syphilis or lymphogranuloma venereum (LGV) can increase the degree to which a person living with HIV is contagious. People who are HIV-negative but have another STI are also more vulnerable to HIV infection. 

The Internet as a social setting

The Internet has become very popular as a way to meet other people, yet finding sexual partners in this manner can carry certain risks. A sense of trust can often be established prematurely among people who meet online. Users of Internet “hook-up” sites may be under the false impression that they already know what they need to know about a potential partner and this may curtail further discussion of HIV status and safer sex. The “barebacking” phenomenon points to additional challenges linked to Internet use currently faced by those working in HIV prevention. Studies of some gay Internet sites have shown that a significant number of user profiles mention a preference for unprotected anal sex with partners who are HIV-positive or of unknown HIV status.  

Unprotected anal sex

According to certain studies, unprotected anal sex and a large number of casual partners are key risk factors associated with to HIV transmission. Men who practise unprotected anal sex with casual partners have a risk of contracting HIV that is five times higher than those who do not.  

Results of the MAYA longitudinal study on health, quality of life, and prevention practices among people living with HIV has shown that there is link between the HIV status of partners and unprotected anal sex. During the six months preceding the survey, 22% of respondents reported having unprotected anal sex with at least one HIV-negative partner. This percentage doubles to 45% for partners of unknown HIV status, and a further increase was noted with regards to sex with partners who are HIV-positive. In other studies, high risk sexual practices have been associated with “sero-sorting” (i.e., choosing sexual partners and sexual practices based on the HIV status) and boredom with safer-sex norms. Unprotected anal sex among people living with HIV may increase the risk of “super-infection” (infection with more than one strain of HIV) and the development of drug resistant viral mutations. 

Media coverage related to HIV/AIDS

Media coverage of advances in scientific knowledge related to HIV/AIDS is also an important factor to consider. Television and newspaper reporting, as well as the ease with which people can now access large amounts of health-related information via the Internet, has tended to increase the public’s overall level of knowledge about HIV transmission but may also have had a detrimental influence on sexual behaviour.  

For example, some media reports have underscored the fact that HIV is 8 to 10 times more aggressive during primary infection (the first year of an HIV infection) than at later stages, and that more than half of all new infections can be attributed to unprotected sex with a person who is newly infected with HIV (and who is often unaware of his or her HIV status). Depending on the quality of these media reports, people may have difficulty fully understanding the implications of such information or applying it in an appropriate way to their own sexual practices. For example, an HIV-negative man who has had unprotected anal sex with an HIV-positive partner over an extended period may mistakenly come to believe that he is unlikely to contract HIV.  

Media coverage of the issue of “undetectable” viral load raises similar questions. Much has been written about the announcement by a group of Swiss physicians, notably Dr. Bernard Hirschel, on World AIDS Day in 2007 to the effect that HIV-positive people who have an undetectable viral load as a result of being on antiretroviral treatment cannot transmit HIV to their sex partners and therefore do not need to use condoms. This announcement was based on a limited number of studies, contains many “grey areas,” and will require much further research before it can be considered in any way conclusive, but it was widely circulated by many newspapers and on the Internet with very little mention of these limitations and caveats. Such media coverage could communicate the overly simplistic message to some HIV-positive men that if they are on treatment and have an undetectable viral load the danger of HIV transmission has disappeared. This, in turn, could affect decisions about whether to use condoms during sex.

Venues where sex takes place on the premises

Studies undertaken in Montreal and Vancouver have recently been combined and analyzed to compare the sexual practices of gay and bisexual men, both HIV-positive or and HIV-negative, in the 16- to 30-year age bracket. In both cities, unprotected anal sex was associated with having sex in public and commercial venues. Men who express a preference for intense sexual experiences also tend to have sex in venues such as saunas, sex clubs, backrooms, parks, and peep shows and to find sexual partners on the Internet. These venues may serve to encourage high risk practices to the extent that they make it possible to have sex with a large number of casual partners. Research data as well as information gathered informally during outreach work suggest that many of the men who frequent these venues are have an interest in experiencing strong sensations during sex. Some of them may have just recently come out of the closet and as a result may not be well informed about the gay community, HIV, and other STIs. Others may be assertive men for whom wearing a condom can represent an obstacle to sexual performance (erectile difficulties, diminished sensation, etc.). 

People living with HIV who are unaware of their status

According to the Public Health Agency of Canada, an estimated 27% of people living with HIV in Canada did not think that they were HIV-positive at the time they received their diagnosis. No data of this kind exist for Canada as a whole with regards to men who have sex with men. However, the 2005 ARGUS study of gay and bisexual men living in Montreal, during which blood samples were collected on a voluntary and anonymous basis, found that one in eight study participants were HIV-positive and of these, nearly one out of five (23.2%) reported they were HIV-negative. Similarly, the 2007 Lambda study of men who have sex with men Ontario found that 20% of study participants whose blood sample tested positive for HIV reported being HIV-negative. We can thus assume that to a certain extent, the increase in HIV incidence among men who have sex with men may be attributable to people who believe they are HIV-negative or are unaware of their HIV-positive status and as a result do not take the necessary precautions when having sex. 

Substance use

Data from the Public Health Agency of Canada indicates that the use of drugs and alcohol is often associated with high risk sexual practices among men who have sex with men. In a general way, people with substance-use problems tend to be more vulnerable to deteriorating levels of health and wellness. The use of drugs appears common among men who have sex with men in Canada. Data from studies in Vancouver and Montreal reveal that in both cities, unprotected anal sex was closely associated with the use of inhaled nitrites (poppers). The use of other drugs that heighten sexual sensation (including marijuana, cocaine, amphetamines, ecstasy) was also reported in these studies as being a factor connected to high risk sexual practices. In Montreal, the use of speed (amphetamines) among men who have sex with men varies from 1.4% to 9.8% depending on the time of year. In 2007, the Canadian AIDS Society noted that increasing use of crystal (methamphetamine) in Canada is also cause for concern. Psychotropic drugs can significantly alter judgment, resulting in changes in perception and behaviour and, as such, can lead to risk-taking among men who have sex with men who use these drugs. In Vancouver, methamphetamine use has been directly associated with receptive unprotected anal sex with casual partners. 

Ethno-cultural context

Canada is one of the few countries in the world that admits refugees on the basis of persecution related to sexual orientation. While no data are available on the proportion of immigrants to Canada who are men who have sex with men, Canada’s refugee policy has no doubt had an influence in this regard and has contributed to an increase in the population of men who have sex with men who are relative newcomers to Canada and are members of visible and cultural minorities.

Although Canada is a culturally diverse country, being a newcomer can increase vulnerability to HIV and make diagnosis of HIV infection difficult for various reasons. People who are members of cultural minorities may be less likely to seek HIV testing because they are fearful of stigma, in particular if HIV is perceived to be a “curse” within their community of origin. In addition, some individuals may not be registered for the health plan in the province where they reside and thus do not have access to health services such as HIV testing for which a provincial health card is required. These factors may lead to a higher possibility of being infected with HIV without knowing it.

In some cultural communities and within some religious traditions, homosexuality may be considered a “western” phenomenon and diversity with regards to sexual orientation may not be well accepted. For some individuals, lack of acceptance of homosexuality within family and social networks can reinforce clandestine practices in venues such as saunas and peep shows where it is possible to have anonymous sex. This, as well as factors such as language barriers and internalized homophobia, can make communication with sex partners complex and have a detrimental impact on a person’s ability to negotiate safer sex.