Thank you, Madam Chair.
On behalf of the BC Centre for Excellence in HIV/AIDS and our Executive Director, Dr. Julio Montaner, I would like to thank the committee for the opportunity to speak today. My name is David Moore. I'm a Research Scientist at the BC-CfE in Vancouver and a professor in the Faculty of Medicine at UBC.
I'd like to start by acknowledging that I am presenting from the unceded traditional territory of the Musqueam, Squamish and Tsleil-Waututh first nations.
The BC-CfE is a provincial agency dedicated to improving the health of British Columbians living with HIV and AIDS. The BC-CfE works in partnership with the B.C. Ministry of Health, health authorities, municipalities and community groups in B.C. to promote evidence-based programs and policies to improve the quality of life for those living with HIV and to protect people from acquiring the virus.
As you've already heard, gay, bisexual and other men who have sex with men—hereafter referred to as “gbMSM”—are disproportionately affected by HIV and other sexually transmitted and blood-borne infections in Canada. Despite great advances in our scientific knowledge, gbMSM continue to experience the largest number of new HIV diagnoses each year amongst all populations at risk. In 2016 they accounted for 48% of new HIV diagnoses in Canada, despite comprising only 3% to 5% of the adult male population. Nationally, the number of new diagnoses amongst gbMSM has remained largely unchanged over the last 10 years. HIV remains a fundamental threat to the health of gbMSM and results in significant costs to the Canadian health care system.
However, recent advances in HIV treatment and prevention have generated great optimism for the potential elimination of HIV as a public health threat among gbMSM. The BC-CfE was at the forefront of developing modern HIV treatment as a highly effective means of preventing the development of AIDS and premature death amongst people living with HIV. More recently, research has shown that effective HIV treatment is 100% effective in preventing HIV transmission. As such, the close to 90% of gbMSM in metropolitan Vancouver who are receiving HIV treatment and have achieved virologic suppression can now be assured that they will have near-normal life expectancy; equally important, they will not transmit HIV to their sexual partners.
The B.C. experience has shown that facilitated access to HIV testing and immediate access to free treatment amongst people living with HIV, or treatment as prevention, known as “TasP”, is the key to controlling the epidemic. TasP has now been adopted globally as part of the BC-CfE's proposed 90-90-90 targets for the global rollout of antiretroviral therapy. These targets propose that by 2020, at least 90% of people living with HIV will have been diagnosed, at least 90% of these will be receiving HIV treatment, and 90% of these will have achieved virologic suppression. It's estimated that meeting the 90-90-90 targets will lead to a 90% decrease in AIDS mortality by 2020 and a decrease in HIV infections of 90% by 2030. The 90-90-90 targets have now been formally adopted by the United Nations and by the Government of Canada, yet the implementation of TasP in Canada has been uneven. There is a growing concern that we will fail to meet the 90-90-90 targets on time.
More recently, it has been shown that taking a combination of two antiretroviral medications, or HIV pre-exposure prophylaxis, which is known as “PrEP”, is at nearly 90% effective in preventing HIV acquisition amongst gbMSM at high risk of infection. However, PrEP access across Canada remains suboptimal. Since January 2018 in B.C., PrEP has been available free of charge through BC-CfE for B.C. residents at high risk of acquiring HIV. Since full public funding for PrEP began in B.C., uptake has been very high, with more than 4,000 individuals, of whom 98% are gbMSM, initiating PrEP through the program as of the end of March 2019. As a result, B.C. is currently experiencing the lowest rates of new HIV diagnoses since the mid-1990s. We therefore call on the federal government to secure equitable and effective access to HIV testing and prevention programs, with support for and access to TasP and PrEP at no charge for people living with HIV or those at risk of HIV infection.
While the issues above highlight the great optimism felt about the control of the HIV epidemic, this is not the case for other sexually transmitted infections, blood-borne infections, or STBBIs. As we've heard from Dr. Gilbert, diagnosis rates of hepatitis C, syphilis, gonorrhea, and chlamydia continue to grow each year across the country, and again, gbMSM are heavily overrepresented in these epidemics. Therefore, we support the development and implementation of the government's STBBI action plan, coupled with significant new funding for programming, monitoring, evaluation and research. Without additional funding, our efforts will be diluted and will result in very limited impact for affected communities.
As mentioned by Dr. Gilbert, it's now understood that the syndemics of mental health and substance use disorders play a large role in increasing the vulnerability to STBBIs amongst gbMSM. Public policies developed over the last decades have likely reduced some of the stigma and discrimination faced by gbMSM in Canada. However, frequent and pervasive exposure to stigma and discrimination within the school, home, community and online environments due to one's sexual and/or gender minority status are still common and result in what has been termed “minority stress”. This minority stress is then reflected in much higher rates of substance use and mental health disorders. Compared with heterosexual men, sexual minority men are four times more likely to attempt suicide, two to three times more likely to develop depression and anxiety, and are twice as likely to develop drug dependencies. In order to have a sustainable impact on minority stress experienced by gbMSM, additional attention must be paid towards implementing evidence-based mental health and substance-use disorder services at the community level. We therefore recommend that the federal government work with provincial, territorial and indigenous partners to bridge the gaps in mental health and substance use services for gbMSM.
Another factor that has likely contributed to the continuing stigmatization of HIV, and by extension gbMSM, has been the over-criminalization of HIV exposure in Canada. While steps were taken federally to address this issue in late 2018, these had limited impact across the country. Therefore, we recommend that legislation be put forward to eliminate the over-criminalization of HIV exposure in Canada. We also recommend that the federal government unequivocally endorse the notion that undetectable equals untransmittable as it relates to the transmission of HIV.
As we've also heard, many gbMSM also use substances to cope with mental health challenges related to persistent societal stigma and discrimination. While cigarette smoking and hazardous alcohol use have not received as much attention in the press as illicit substances, they are highly prevalent amongst gbMSM, thus gbMSM are at greater risk of developing a host of illnesses related to tobacco and alcohol use, including cardiovascular disease, cancers, respiratory, kidney and liver diseases. Access to evidence-based smoking and alcohol cessation programming by gbMSM is quite low across the country and needs to be improved. The burden of smoking and hazardous alcohol use and the risks for developing diseases associated with these conditions are multiplied for HIV-positive gbMSM. Therefore, we support the inclusion of LGBTQ+ people as a key population in the federal tobacco control strategy, but recommend that additional funding for that strategy be secured to support community-based approaches to smoking prevention and cessation among LGBTQ+ people.
As well, the use of methamphetamine and other stimulants is highly prevalent among gbMSM. Among participants in our cohort study in Vancouver, 44% of HIV-positive and 10% of HIV-negative gbMSM report methamphetamine use in the previous six months. Participants who reported recent methamphetamine use were more likely to have been diagnosed with an anxiety disorder or depression and scored higher for symptoms for both anxiety and depression in comparison with individuals who did not report recent use. Therefore, we also recommend that additional funding be secured to support research and evidence-based programming to provide treatment and support for gbMSM who are affected by substance use disorders, particularly methamphetamine use and hazardous alcohol use.
In summary, in order to improve the health of gay, bisexual and other men who have sex with men in Canada, we recommend that the federal government take steps to realize the potential for HIV elimination among gbMSM in Canada and better control of other STBBIs. However, we must also work with provincial, territorial and indigenous partners to ensure that we are also addressing the syndemic problems of mental health and substance use disorders, which are important drivers of these epidemics.