Sizes-up the Gaps A sexual health survey of gay men in Vancouver Every second day in BC, another gay man is diagnosed with HIV. 150-190 new cases, year after year over the last decade. Between 2000 and 2010 as many as 1,800 gay men were added to the ranks of those living with HIV in BC today. 2 Introduction City of White Rock. Surveys conducted by the Community Based Research Centre (CBRC) ince it first came to public attention over the last decade have attempted to gain in the early 1980s, HIV has had an an understanding of the gay population immeasurable impact, affecting certain and dynamics affecting HIV prevention. By groups more than others, chief among surveying thousands of men at Pride Festivals them gay men. According to estimates and on the Internet between 2002 and 2008 the Sfor 2008 from the Public Health Agency of Sex Now survey helped to gain an appreciation Canada (PHAC) 51% of existing HIV cases of the extent of HIV infection among BC’s nation wide were among gay men and other gay men, at least in those diagnosed. HIV men who have sex with men (MSM). prevalence in Vancouver’s gay men was Every second day in BC, estimated at 16% in 2008. another gay man is diagnosed These studies also disclosed with HIV. 150-190 new cases, ManCount Sizes up sweeping changes to the way year after year over the last the Gaps gay men meet new partners decade. Between 2000 and • Biological evidence of with the influence of the 2010 as many as 1,800 gay HIV prevalence Internet, changes that may be men were added to the ranks • Individual awareness affecting HIV transmission. of those living with HIV in BC of HIV status Until ManCount, however, today. such findings had no • Testing practices corroboration with biological Throughout these years • HIV transmission risks evidence. community efforts have been • Behavioural links to deliberate but daunting. ManCount is a second- biological samples Knowledge and experience generation HIV surveillance with changing conditions have study linked to M-Track, a grown. Resources have been national monitoring program reorganized. But significant gaps continue organized by PHAC. In studies of this type, to exist, particularly around community researchers systematically collect biological prevention. While it is widely assumed that samples and information on transmission risks prevention efforts directed toward BC’s gay to interpret, track and describe dynamics in the population are well resourced, the reality of epidemic over time. ManCount collected dried continuing transmission leaves considerable blood samples and questionnaires from 1,139 doubt that the response has been adequate for men visiting Vancouver’s gay venues to assess the size and scope of the problem. the prevalence of HIV infection, differences No-one knows the true size of the gay between HIV negative and positive men and male population of Greater Vancouver but the gap between those aware and unaware of conservative estimates suggest at least having an HIV infection. It was the first study 20,000–a population larger than the suburban of its kind for Vancouver and may well be repeated to track change over time. 3 Key Findings 2.5% ManCount men: n = 1,139 18.1% were HIV positive by blood sample 2.5% were unaware of being HIV positive 18.1% About these results: HIV positive blood samples are commonly calculated as a proportion of the whole survey population and those “unaware of their infection” as a proportion of positive blood samples. Analysis disclosed that 14% of ManCount’s HIV positive blood samples were from men who were unaware of being positive. This figure is often used to estimate undiagnosed infection, but it is difficult to visualize proportions-within-proportions in the community. In this text we have described the group of HIV positive unaware men as a proportion of the whole population – 2.5 % – to demonstrate what it may mean in terms of a typical night club scene in Vancouver: a ratio of 1 in 40. Men unaware of being HIV positive were 3 times more likely to engage in unprotected sex than known negative men and highly likely to be seeking negative partners. 4 Similar surveys have been conducted Findings from ManCount will help to in Montreal, Ottawa, Toronto, Winnipeg and clarify current circumstances and point toward Victoria. The questionnaire investigates sexual renewed prevention objectives. The outline of experiences over the previous six months. the evidence describes a troubling situation Each respondent’s blood sample is linked to of unacceptably high HIV prevalence and their questionnaire. Respondents receive an chronically high rates of HIV infection. honorarium for their participation. ManCount also asked a subsample of men to participate 51% tested in an additional study, unique to Vancouver, by providing an anal swab for Human in the last year Papillomavirus (HPV) screening. 51% 86%86 % 23% 23% under age 86% had tested for HIV 86 % 30 had never tested for HIV 21% had unprotected sex 21% with unknown or different status partners in the previous 6 months 5 Who got Counted? rom August 2008 to February 2009, ManCount used time-space sampling– ManCount approached 3,324 men in varying recruitment times at prime locations–to Vancouver’s popular gay venues. Any ensure a diverse sample of men in Vancouver’s man over the age of 19 who had had gay venues. While every effort was made sex with another man was eligible. to obtain an unbiased sample, recruiting F1,169 completed the survey and 1,139 provided in popular venues ultimately consults only blood samples. Some of those approached the population that attends them. Surveys at had already participated which made the final Pride Festivals or the Internet, for example, participation rate 42%. produce moderately different views of the gay population due to the respective appeal of those settings to different members of the population. Participation by Venue 54% Bar (635) 37.4% 19-29 25% Event (293) 39.8% 30-44 12% Business (135) 22.9% 45 plus 5% Association (57) * Median age 33 4% Bathhouse (49) Participation by Age 54% Bar (635) 37.4% 19-29 25% Event (293) 39.8% 30-44 12% Business (135) 22.9% 45 plus 5% Association (57) * Median age 33 4% Bathhouse (49) 6 Participation by Orientation 81% Gay 75% European 11% Bisexual 14% Mixed others 3% Two-spirited 7% Asian 2% Queer 4% Aboriginal 2% Straight Participation by Ethnicity 81% Gay 75% European 11% Bisexual 14% Mixed others 3% Two-spirited 7% Asian 2% Queer 4% Aboriginal 2% Straight The majority of ManCount men were from population. The results are representative of Vancouver and the Greater Vancouver Region. Vancouver’s gay venues but may vary when A 12% portion were visitors from nearby considering men from the region apart from cities like Bellingham, Calgary and Seattle, visitors. For example, ManCount showed and other Canadian cities like Montreal and HIV prevalence to be slightly higher among Toronto. There was also representation from Vancouver residents and Sex Now surveys cities much further away such as Amsterdam, have shown slightly lower prevalence in Auckland, Brisbane, Paris and Mexico City. All other regions of BC. In general, all the results of these men were considered part of the sexual reported here should be taken as estimates marketplace of Vancouver’s gay venues and which may vary by plus or minus a few were thus included in ManCount. percentage points depending on the context and who got counted in ManCount. The primary One of ManCount’s main contributions purpose of these results is to provide reliable– was its use of blood samples to assess the though arguably imperfect–indicators on the prevalence of HIV, STI’s and Hepatitis C in the road to a community response. 7 ManCount blood samples showed that at least 2.5% (1 in 40) were unaware of their HIV positive status. Biological Results lood sample results are an effective way to demonstrate the extent of HIV in the community with biological evidence. ManCount results showed that 18.1% of the men in the sample 18.1 % Bwere HIV positive–suggesting almost 1 in 5 in Vancouver’s gay venue population were HIV 1 in 5 were positive by blood sample positive at the time of the survey. Considering only men from the Greater Vancouver Region, ManCount found that 20.8% were HIV positive by blood sample. This evidence indicates that HIV prevalence is very high among Vancouver’s gay men–so high that the level of infection in the community alone would be a major influence in any gay man’s likelihood of getting infected. Answers to specific questions in the survey broadened this finding to show the proportion “aware” and “unaware” of their status. About 14% of blood-sample positive men thought they were HIV negative. In other words, 2.5% or 1 in 40 of all ManCount men 2.5 % were unaware of being HIV positive. 1 in 40 were unaware they were HIV+ 8 This evidence indicates that HIV prevalence is very high among Vancouver’s gay men – so high that the level of infection in the ManCount blood samples showed that at least 2.5% (1 in 40) were community alone would be a unaware of their HIV positive status. major influence in any gay man’s likelihood of getting infected. ManCount results showed that HIV prevalence increased with age which means there were increasingly more positive men in HIV Prevalence by Age Group older age groups. Greater opportunity for HIV transmission appears to occur with the passage 100 of time over the lifespan.