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HIV infections are a growing problem in Canada, according to recent data. In November, the Public Health Agency of Canada reported an alarming 25% increase in new HIV cases during 2022. The largest numbers of diagnoses were seen in Saskatchewan and Manitoba.

Although COVID and the halt of services during the pandemic may still be having residual effects, Julio Montaner, MD, executive director of the British Columbia Centre for Excellence, Vancouver, British Columbia, Canada, in HIV/AIDS, told Medscape Medical News that the global community, and especially Canada, has moved on to other challenges. The result has been a resurgence of HIV.

“There’s no political will, no medical leadership, no focus,” said Montaner. “The socioeconomic profile of HIV today has drifted in such a way that the well-off, educated, gay men who were so vocal in the early days of the epidemic have moved on.”

Misdirected Messaging

In Canada in 2022, 51% of patients with HIV and 36% of new HIV cases were gay, bisexual, and other men who have sex with men (MSM). Although MSM remain an at-risk group, there has been a significant demographic shift in new HIV diagnoses to populations who lack the means to organize like MSM previously did.

“The other populations where we are seeing a rise in HIV cases are racialized communities, equity-seeking communities, and First Nations patients, who are already dealing with discrimination from society at large, in workplaces, and in the medical system,” said Charu Kaushic, PhD, scientific director for the Institute of Infection and Immunity at the Canadian Institutes of Health Research.

Though advocacy groups have made attempts to take up the gauntlet on behalf of these populations, messaging is a huge issue, said Ken Miller, executive director of the Canadian AIDS Society. “For decades, messaging has not been tailored outside of gay, cisgender males. And now we’re seeing the result of not including anyone else.”

Miller is especially concerned about the lack of attention to homelessness and injection drug use, which data have shown often go together. Between 2018 and 2021, as much as 48% of women and 34% of men with newly diagnosed HIV were homeless, according to the Manitoba HIV Program. More recently, the province reported a 40.7% increase in new cases (age-standardized rate of 20.2 cases per 100,000 population) in 2023, compared with the previous year. Patients who inject drugs were the largest driver of transmission, accounting for 81.2% of cases in women and 64.0% of cases in men.

Messaging that misses the vulnerable population may not be the only problem in Canada’s emerging HIV crisis. The way that funding for HIV/AIDS is grouped with funding for other sexually transmitted and blood-borne infections (STBBIs) is inappropriate, said Miller. He contended that without funding that is specifically allocated to community-based advocacy, HIV advocacy groups won’t be able to hold the government to its promises or fill the gaps in messaging and access.

“There are two proposals in front of Minister of Health Mark Holland right now. They were submitted by over 20 organizations,” said Miller. “One is a bilateral agreement where the federal government would provide funding to each province with caveats (eg, x amount needs to go to HIV, etc.), and the other is to prop up the HIV and Hepatitis C Community Action Fund (CAF), which diversifies community-funded projects,” he said. In addition to HIV and hepatitis C, CAF addresses other STBBIs. “We need [the Ministry] to make a decision soon on whether or not they will accept one of these proposals.”

More Efficient Spending?

Citing the increase in rates of heterosexual transmission of HIV and other sexually transmitted infections (STIs), Kaushic emphasized that these diseases influence each other and are often comorbid.

She said that sexually transmitted HIV is on the rise, and the key at-risk populations for HIV and STBBI are the same (ie, people who inject drugs, sex workers, Indigenous populations, African-Caribbean-Black populations, and incoming migrant populations). “We’re not dividing the money; we are making more efficient use of money because the delivery programs, underlying research, and the drivers are the same for HIV and other STIs,” she said. “By combining all of that, we are actually delivering better care, better prevention, better surveillance, and better therapeutics.”

Realizing a return on the investments also takes time. “We just announced about $20 million for community-based research teams for a distinction-based, distinction-focused approach, so there is dedicated, allocated funding…for all key populations that are affected,” said Kaushic. “We know from our successful programs that this is a ground-up effort. The people we are funding are community-based researchers and community-based programs.” These organizations can partner not only on research but also on the delivery of surveillance and testing.

Kaushic said that the Canadian Institutes of Health Research will be meeting to assess how well they are doing and discuss priorities for addressing HIV. The group uses the same process for other STIs, too. “This knowledge mobilization exchange is embedded into our processes,” said Kaushic.

Saskatchewan is taking its own initiatives, as well. In a written statement to Medscape Medical News, the Saskatchewan Ministry of Public Health said that its “2024-2025 budget includes an increase of $1.5 million to improve provincial testing capacity and expand testing for all STBBIs, including HIV.” This money is in addition to the $7 million in annual provincial funding to support HIV services (including 100% coverage of HIV drugs for patients who meet medical criteria) and community-based organizations.

Solution Without Support?

While advocacy groups and the federal and provincial governments have explained the reasons for the surge in HIV rates, Montaner contended that the means for reducing HIV infections is readily available. Research published in July in The Lancet HIV demonstrated that providing antiretroviral therapy (ART) to all patients with HIV, along with pre-exposure prophylaxis (PrEP) — an approach that Montaner referred called “treatment as prevention” coupled with PrEP — would reduce HIV/AIDS-related mortality by 95% and new infections by 91%.

The strategy suppresses current infections to almost undetectable levels, while treatment as prevention expands access to free ART immediately after diagnosis. The addition of PrEP further decreases HIV incidence by reducing the number of people, especially in key at-risk groups, who can transmit HIV.

Except for British Columbia, Canada has not met the global targets for HIV testing and treatment, said Montaner. “In the last 2 years, we’ve had a rebound, basically as the result of migratory pressure, and today, the vast majority of people that we diagnose in British Columbia are migrants.”

The aforementioned strategy’s cost-effectiveness also has been demonstrated, said Montaner. “We’ve shown that if you measure the return on the investment of treating people with ART and then add treatment as prevention, the return becomes exponential because the chain of transmission has stopped.”

But so far, meetings with federal and provincial ministries have yielded little interest or support.

Montaner reported that his institution has received support for Treatment as Prevention research from the British Columbia Ministry of Health, Health Canada, the Canadian Institutes of Health Research, the Public Health Agency of Canada, Genome Canada, Genome BC, Vancouver Coastal Health, and the Vancouver Hospital Foundation. Institutional grants have been provided by Gilead Sciences, Janssen Pharmaceuticals, Merck Sharp & Dohme, and ViiV Healthcare. Miller and Kaushic reported having no relevant financial relationships.

Liz Scherer is an independent, US-based journalist who frequently writes on HIV and other infectious diseases.