This fact sheet provides a snapshot of the HIV epidemic in Canada. All epidemiological information is approximate, based on the best available data. Most of the data contained in this fact sheet come from the latest estimates from the Public Health Agency of Canada, which are for the year 2020.
What is HIV?
HIV stands for human immunodeficiency virus. HIV is a virus that can weaken the immune system, the body’s built-in defence against disease and illness. With proper treatment and care, people with HIV can live long and healthy lives and avoid passing HIV to others. There is no vaccine to prevent HIV but there are ways to avoid passing or getting HIV.
What statistics are available in Canada to inform programming?
There are two main types of numbers available, HIV estimates and HIV surveillance data (reported HIV diagnoses).
HIV estimates are developed by the Public Health Agency of Canada through statistical modelling, using a variety of data sources. There are two main types of estimates:
- Prevalence estimates tell us how many people are living with HIV at a given point in time. They include estimates for the number of people who are undiagnosed and take into account the number of people with HIV who have died.
- Incidence estimates tell us how many people got HIV in a given year, including those who had not yet been diagnosed.
HIV surveillance data are published by the Public Health Agency of Canada and tell us how many people were diagnosed with HIV in a given year. This information does not tell us when they got HIV, just when the diagnosis was made. People may have had HIV for many years before diagnosis.
How many people are living with HIV in Canada (prevalence)?
According to national HIV estimates, there were an estimated 62,050 Canadians living with HIV at the end of 2020. This means that for every 100,000 Canadians, 167 were living with HIV (prevalence rate).
How many people are living with HIV but don’t know it (undiagnosed) in Canada?
According to national HIV estimates, 8,300 people were living with HIV but didn’t know it (undiagnosed) at the end of 2020. This represents 13% of the estimated number of people with HIV.
How many new HIV infections are there in Canada each year (incidence)?
According to national HIV estimates, there were 2,242 new HIV infections in Canada in 2020. This means that for every 100,000 Canadians, six people became HIV positive in 2018 (incidence rate of 6 per 100,000 people).
There was a small increase in the number of new HIV infections in 2020 compared with 2018, when there were an estimated 1,960 new HIV infections.
Is Canada reaching the global 90-90-90 targets?
The Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO) have established a global health sector strategy on HIV to help eliminate AIDS as a public health threat by 2030. Canada has endorsed this strategy. The strategy can be encapsulated in the phrase “90-90-90” and consists of the following targets for the year 2020:
- 90% of people with HIV know their infection status
- 90% of people diagnosed with HIV receive HIV treatment
- 90% of people taking treatment have an undetectable viral load
Canada is approaching the 90% goal for awareness of HIV status and the 90% goal for treatment and has surpassed the 90% goal for achieving viral suppression. Of the estimated 62,050 people with HIV in Canada in 2020, an estimated:
- 87% were diagnosed and aware they had HIV (53,750 people)
- 85% of those who were diagnosed were on treatment (45,910 people)
- 94% of those on treatment had achieved viral suppression (43,350 people)
This means that 70% of all Canadians with HIV had achieved viral suppression in 2020. If all 90-90-90 measures had been reached, 73% of all Canadians with HIV would have achieved viral suppression.
HIV among gbMSM
How many gay, bisexual and other men who have sex with men (gbMSM) are living with HIV in Canada (prevalence)?
According to national HIV estimates, 32,044 gbMSM were living with HIV in Canada in 2020. This represents 51.7% of all people with HIV in Canada. The estimate included 30,316 men who had sex with men and 1,728 men who had both injected drugs and had sex with men.
How many new HIV infections (incidence) are there in gbMSM in Canada each year?
According to national HIV estimates, 1,169 new HIV infections in Canada were in gbMSM in 2020. This represents 52.2% of all new HIV infections. This estimate included 1,109 new HIV infections in men who had sex with men and 60 new infections in men who had both injected drugs and had sex with men.
GbMSM are over-represented in new HIV infections in Canada. They represent 52.2% of all new HIV infections but only represent 3 to 4% of the adult male population in Canada.
How is Canada doing at reaching the global targets of 90-90-90 for gbMSM?
According to several surveillance studies conducted with gbMSM in Canada in 2019–20:
- 96.7% of gbMSM with HIV were aware of their status in 2019–20
- between 96.8% and 99.1% of gbMSM diagnosed with HIV were on treatment in 2019–20*
- between 93.7% and 96.7% of gbMSM on HIV treatment reported an undetectable viral load in 2019–20*
*There is a range because there are multiple surveillance studies providing different estimates.
HIV among PWID
How many people who inject drugs (PWID) are living with HIV in Canada (prevalence)?
According to national HIV estimates, 10,418 people who have injected drugs (PWID) were living with HIV in Canada in 2020. This represents 16.8% of all people with HIV in Canada. The estimate included 8,690 people who had injected drugs and 1,728 men who had both injected drugs and had sex with men.
How many new HIV infections (incidence) are there in PWID in Canada each year?
According to national HIV estimates, 372 new HIV infections in Canada were in PWID in 2020. This represents 16.6% of all new HIV infections. This estimate included 312 new HIV infections in people who had injected drugs and 60 new infections in men who had both injected drugs and had sex with men.
How is Canada doing at reaching the global targets of 90-90-90 for PWID?
According to a surveillance study conducted with people who inject drugs (PWID) in Canada between 2017 and 2019:
- 82.9% of PWID with HIV were aware of their status in 2017–2019
- 87.7% of PWID diagnosed with HIV were on treatment in 2017–2019
- 62.8% of PWID on HIV treatment reported an undetectable viral load in 2017–2019
HIV among people who acquire HIV through heterosexual sex
How many people living with HIV in Canada acquired HIV through heterosexual sex?
According to national HIV estimates, 20,750 people living with HIV in Canada acquired HIV through heterosexual sex in 2020. This represents 33.4% of all people with HIV in Canada.
In 2016, the Public Health Agency of Canada separated heterosexual transmission into two categories – those born in an HIV-endemic country (primarily subSaharan Africa and the Caribbean) and those born in a non HIV-endemic country (those born in Canada or those born abroad but not from an HIV-endemic country). According to the Public Health Agency of Canada “This separation is no longer considered appropriate, for reasons of increasing data incompleteness. The Public Health Agency of Canada is working with communities and with provinces and territories to find ways to better reflect the HIV situation in these communities.”
How many new HIV infections (incidence) are acquired through heterosexual sex in Canada each year?
According to national HIV estimates, 761 new HIV infections in Canada were acquired through heterosexual sex in Canada in 2020. This represents 34.0% of all new HIV infections.
In 2016, the Public Health Agency of Canada separated heterosexual transmission into two categories – those born in an HIV-endemic country (primarily subSaharan Africa and the Caribbean) and those born in a non HIV-endemic country (those born in Canada or those born abroad but not from an HIV-endemic country). According to the Public Health Agency of Canada “This separation is no longer considered appropriate, for reasons of increasing data incompleteness. The Public Health Agency of Canada is working with communities and with provinces and territories to find ways to better reflect the HIV situation in these communities."
HIV among Indigenous people
How many Indigenous people are living with HIV in Canada (prevalence)?
According to national HIV estimates, 6,180 Indigenous people were living with HIV in Canada in 2020. This represents 10.0% of all people with HIV in Canada.
How many new infections (incidence) are there in Indigenous people in Canada each year?
According to national HIV estimates, 314 new HIV infections in Canada were in Indigenous people in 2020. This represents 14.0% of all new infections. In comparison, Indigenous people made up only 4.9% of the total Canadian population in 2018, making Indigenous people over-represented in new HIV infections in Canada.
How is Canada doing at reaching the global targets of 90-90-90 for Indigenous people who inject drugs?
According to a surveillance study conducted with Indigenous people who inject drugs (PWID) in Canada between 2017 and 2019:
- 78.2% of Indigenous PWID with HIV were aware of their status in 2017–2019
- 83.7% of Indigenous PWID diagnosed with HIV were on treatment in 2017–2019
- 64.4% of Indigenous PWID on HIV treatment reported an undetectable viral load in 2017–2019
HIV among females
How many females are living with HIV in Canada (prevalence)?
According to national HIV estimates, 14,545 females were living with HIV in Canada in 2020. This represents 23.4% of all people with HIV in Canada.
How many new infections (incidence) are there in females in Canada each year?
According to national HIV estimates, 566 new HIV infections in Canada were in females in 2020. This represents 25.2% of all new infections.
HIV diagnoses in Canada
How many people are newly diagnosed with HIV in Canada each year?
There were 2,122 HIV diagnoses in Canada in 2019. This represents a 4% increase over the past 5 years (since 2014).
Among new HIV diagnoses in 2019 where sex was known (2,188), 30.2% were in females and 69.8% were in males.
Among the HIV diagnoses in adults where the likely exposure is known (1,203 diagnoses), 39.7% were in gbMSM, 28.3% were from heterosexual sex and 21.5% were in PWID in 2019.
Among females, 38.4% of HIV diagnoses were in women who injected drugs and 48.0% were from heterosexual sex in 2019.
Among males, 56.2% were in gbMSM, 4.8% were among gbMSM who also injected drugs, 14.6% were in men who injected drugs and 20.0% were from heterosexual sex in 2019.
Just over a quarter (27.0%) of all HIV diagnoses in males were in male youth (aged 15 to 29) in 2019. Just under a quarter (23.4%) of all HIV diagnoses in females were in female youth (aged 15 to 29) in 2019
Where are HIV diagnoses rates the highest?
There are four provinces with HIV diagnoses rates above the national average of 5.6 per 100,000 people in 2019:
- Saskatchewan (16.9 for every 100,000 people)
- Manitoba (8.8)
- Quebec (7.4)
- Alberta (5.8)
The remaining regions have diagnoses rates below the national average:
- Ontario (4.7)
- Columbia (3.5)
- the Atlantic provinces (3.0)
- the territories (1.7)
How many people test positive during the immigration process to Canada each year?
- A total of 1,188 people tested positive during the immigration process to Canada (626 tested in Canada and 562 tested outside of Canada) in 2019.
How many babies are born to HIV-positive females in Canada each year?
There were 250 babies born to mothers with HIV in 2019. Only one of these infants was confirmed HIV positive. The mother did not receive HIV treatment during her pregnancy. In total, 98% of HIV-positive pregnant females received HIV treatment in 2019, which significantly reduces the risk of HIV transmission.
HIV prevalence—The number of people with HIV at a point in time. Prevalence tells us how many people have HIV.
HIV incidence—The number of new HIV infections in a defined period of time (usually one year). Incidence tells us how many people are getting HIV.
HIV diagnoses—The number of new HIV diagnoses in a defined period of time (usually one year). HIV diagnoses tell us how many people have been diagnosed within a certain time frame.
Where do these numbers come from?
Most of the data contained in this fact sheet come from HIV in Canada: 2019 Surveillance Highlights; Summary: Estimates of HIV incidence, prevalence and Canada’s Progress on Meeting the 90-90-90 HIV target, 2018; and population-specific surveillance data.
HIV diagnoses (routine HIV reporting)
Healthcare providers are required to report HIV diagnoses to their local public health authorities, including diagnoses resulting from anonymous tests. Each province and territory then compiles this information and provides it to the Public Health Agency of Canada. This information does not contain names or personal identifiers. Sometimes additional information is also collected and sent to the Public Health Agency of Canada, such as information about a person’s age, gender, ethnicity, exposure category (the way the person may have acquired HIV) and laboratory data such as the date of the HIV test.
National estimates of HIV prevalence and incidence
National HIV estimates are produced by the Public Health Agency of Canada using statistical modelling that takes into account some of the limitations of surveillance data (the number of HIV diagnoses reported to the Public Health Agency of Canada) and also accounts for the number of people with HIV who do not yet know they have it and the number of people with HIV who have died.
Several national surveillance studies monitor trends in key priority populations through periodic cross-sectional surveys conducted at selected sites in Canada. Because these systems only recruit voluntary participants and are conducted only in certain locations, the results do not represent all people who belong to each population in Canada.
I-Track is the national surveillance system of people who inject drugs conducted by the Public Health Agency of Canada. Through this surveillance system, anonymous information is collected directly from PWID, using a questionnaire and a biological specimen sample for HIV and hepatitis C testing. This cross-sectional survey was administered at selected sites (typically needle and syringe programs) across Canada from 2017 to 2019.
The European Men-who-have-sex-with-men Internet Survey (EMIS) is an international surveillance system of gbMSM. Through this surveillance system, information is collected anonymously directly from gbMSM using a cross-sectional survey. The survey was undertaken in 2017 across 50 countries including Canada. Recruitment was conducted through advertisements and banners on social media, gay news websites and sexual networking apps. In addition, promotion occurred through community-based organizations. Data used in this fact sheet pertain to Canadian respondents only.
Engage is a national surveillance system of gbMSM in three Canadian cities: Vancouver, Toronto and Montreal. Through this surveillance system, information is collected anonymously directly from gbMSM using a questionnaire and a biological specimen sample for HIV and hepatitis C testing. The Engage study used a form of chain referral sampling where additional participants were recruited by people who had already participated in the study. Data used in this fact sheet pertain to data from Montreal collected in 2017–2018.
Sex Now is a national surveillance system of gbMSM across Canada. Participants are recruited online and at in-person events across Canada. Through this surveillance system, information is collected anonymously directly from gbMSM using a questionnaire and biological specimen sample for testing. Data used in this fact sheet pertain to data collected in 2018.
Canadian Perinatal HIV Surveillance Program
The Canadian Perinatal HIV Surveillance Program collects information on infants born to females with HIV in Canada.
Oral pre-exposure prophylaxis (PrEP)
Oral pre-exposure prophylaxis, or PrEP, is a way for an HIV-negative person who is at risk of HIV infection to reduce their risk of becoming infected by taking antiretroviral drugs. The daily use of oral PrEP, under the brand name Truvada, is approved by Health Canada to reduce the risk of the sexual transmission of HIV in combination with safer sex practices for people at high risk of HIV infection. Use of oral PrEP involves regular medical appointments for monitoring and support. The use of Truvada as PrEP is a highly effective HIV prevention strategy when used consistently and correctly. Truvada is generally safe and well-tolerated, and is available by prescription from physicians in Canada.
What is oral PrEP?
Oral PrEP involves the use of antiretroviral drugs by an HIV-negative person to reduce their risk of becoming infected with HIV. Oral PrEP refers to the use of a pill called Truvada, starting before someone is exposed to HIV and continuing afterwards. Truvada is also used as a treatment for HIV-positive people and contains two antiretroviral drugs: tenofovir (also called TDF) and emtricitabine (also called FTC).
Oral PrEP is intended for people at high risk of HIV infection as part of a comprehensive prevention strategy.
How does oral PrEP work to help prevent HIV?
PrEP interferes with the pathways that HIV uses to cause a permanent infection. For HIV to cause infection the virus must gain entry into the body, infect certain immune cells, make copies of itself (replicate) within these immune cells, then spread throughout the body.
When oral PrEP is taken consistently and correctly, antiretroviral drugs get into the bloodstream and genital and rectal tissues. The drugs work to help prevent HIV from replicating within the body’s immune cells, which helps to prevent a permanent infection.
For PrEP to help stop HIV replication from happening, drug levels in the body must remain high. If pills are not taken consistently as prescribed there may not be enough medication in the body to reduce the risk of HIV infection.
How well does daily oral PrEP work?
There is evidence from randomized clinical controlled trials (RCTs) that daily oral PrEP is a highly effective strategy to reduce the risk of the sexual transmission of HIV if taken consistently and correctly as part of a comprehensive prevention package in gay men and other men who have sex with men (MSM) and in heterosexual men and women. In addition, limited evidence from one RCT found that daily oral PrEP (with tenofovir alone), when used consistently and correctly, is effective at reducing the risk of HIV transmission among people who inject drugs.
In all the clinical trials, PrEP was provided as part of a comprehensive prevention package that included regular testing and treatment for sexually transmitted infections (STIs), free condoms and ongoing behavioural counselling.
Adherence (taking medications exactly as prescribed) is crucial for oral PrEP to work. The evidence shows that higher adherence is associated with greater protection.
Before taking adherence into account, the overall risk reduction provided by a daily oral PrEP regimen in RCTs ranged from zero to 86%. All of these studies evaluated the sexual transmission risk except for one, which found a 49% overall risk reduction in people who inject drugs. The wide range of protection observed in these trials has been explained by varying levels of adherence to daily pill taking.
To demonstrate the importance of adherence, additional analyses in these trials looked at drug levels in the blood of people who were taking oral PrEP consistently compared to those who were not. These analyses found that daily oral PrEP reduced the risk of HIV transmission by between 85% and 92% among MSM and heterosexual men and women who took the drug consistently compared to those who did not. In people who inject drugs, daily oral PrEP with tenofovir alone reduced the risk of HIV transmission by 84% among people who used the drug consistently compared to those who did not.
The daily use of oral PrEP has also been evaluated in “open-label” studies, predominantly among MSM. In these types of studies, no placebo is used and all participants know they are taking PrEP and that it is effective at preventing HIV transmission. These studies support the finding that oral PrEP is highly effective at reducing HIV transmission when taken consistently and correctly. One open-label study found that the risk for HIV was reduced by 86% overall among MSM who were taking daily oral PrEP compared to those who were not. In open-label studies, adherence to daily pill taking was higher than in RCTs.
The daily use of Truvada as oral PrEP has been approved by Health Canada to reduce the risk of the sexual transmission of HIV in combination with safer sex practices in people at high risk for HIV infection. This approval did not include transmission through injection drug use. However, daily oral PrEP is recommended by the Centers for Disease Control and Prevention (CDC) in the United States and by the World Health Organization (WHO) to reduce the risk of HIV transmission in people at high risk through sexual activities and injection drug use.
Who should take PrEP?
PrEP should only be used by people who are HIV negative and at high risk for HIV infection. The Truvada product monograph recommends that the following factors may help to identify individuals at high risk:
A sexually active person who:
- has partner(s) known to be living with HIV, or
- engages in sexual activity within a high prevalence area or social network and one or more of the following:
- inconsistent or no condom use
- diagnosis of sexually transmitted infections
- exchange of sex for commodities (such as money, food, shelter, or drugs)
- use of illicit drugs or alcohol dependence
- partner(s) of unknown HIV status with any of the factors listed above
What else is involved with taking oral PrEP?
Oral PrEP is part of a comprehensive HIV prevention strategy that includes safer sex practices and routine medical appointments.
The first step is to make sure a person is HIV negative before starting PrEP. They will also need to be tested for hepatitis B and other STIs and have their kidney function checked.
A person using oral PrEP needs to take Truvada as prescribed by their healthcare provider. In addition to taking the medication as prescribed, they must also attend regular doctor’s appointments, approximately every three months. These regular visits are necessary in order to be tested for HIV and other STIs, monitored for drug side effects, and receive ongoing adherence and risk-reduction counselling.
Is PrEP intended to replace condoms and other HIV prevention strategies?
Oral PrEP is not intended to replace other HIV prevention strategies because it is not 100% effective, is substantially less effective if used inconsistently or incorrectly, and is not intended for everyone. PrEP can still be effective at reducing the risk of HIV infection when condoms are not used; however, guidelines recommend that PrEP be used in combination with safer sex practices and harm-reduction strategies to optimally reduce the risk of HIV infection.
PrEP only helps to prevent HIV and does not offer protection against STIs (such as herpes, chlamydia or syphilis) or blood-borne infections such as hepatitis C. Other prevention strategies (such as using condoms or new injection equipment) are needed to reduce the risk of all other infections that can be passed through sex or sharing of injection drug use equipment.
What are the advantages of PrEP?
The main advantage of oral PrEP is that it adds another highly effective HIV prevention option to the growing list of prevention strategies. For example, PrEP may provide another method to help protect people who are unable to negotiate condom use with their partner(s), people in serodiscordant relationships (where one partner is HIV negative and the other is HIV positive), people who inject drugs but are not able to obtain new injection equipment, or other people who do not use condoms or new injection equipment consistently for whatever reason.
Another advantage is that oral PrEP use can be started during periods of higher risk and stopped during periods of lower risk.
How can people at high risk of HIV infection access PrEP?
An HIV-negative person who wants to take PrEP needs to get a prescription for Truvada from a doctor who is willing to provide the necessary medical follow-up in a safe and informed way. Health Canada has approved the prescription of Truvada as PrEP for reducing the risk of sexually acquired HIV infection, in combination with safer sex practices.
Not all doctors are knowledgeable about PrEP and it may be difficult for clients to find a doctor who is willing to prescribe Truvada as PrEP for HIV prevention.
Although the use of Truvada as PrEP has not been approved by Health Canada to reduce the risk of injection-related HIV transmission, healthcare providers can still prescribe it for this purpose. This is possible because Truvada has already been approved for PrEP to reduce the sexual transmission of HIV and the treatment of HIV. When an approved drug is prescribed for an unapproved use, this is called an “off-label” prescription. These types of prescriptions are legal and – for some types of drugs – common.
Antiretroviral drugs are expensive and Truvada as PrEP costs approximately $1000 a month. Currently, only some private and public health insurance plans in Canada will cover the cost of the drugs. PrEP was approved for prevention in Canada in February 2016 and we expect that more insurance coverage will eventually become available. Advocacy may be needed to get PrEP covered by all provincial, territorial and federal drug programs to ensure that people who need PrEP can access it.
Post-exposure prophylaxis (PEP)
Post-exposure prophylaxis, or PEP, is a way for a person who may have recently been exposed to HIV to prevent HIV infection. It involves taking anti-HIV medications right after a potential exposure to HIV. Anyone who thinks they may have been exposed to HIV should contact their doctor immediately. PEP is not 100% effective.
What is PEP?
PEP consists of a combination of two to three anti-HIV drugs that an HIV-negative person who may have been exposed to HIV takes to reduce their risk of HIV infection. PEP should be taken as soon as possible, within 72 hours of being exposed to HIV. These prescription drugs need to be taken every day, exactly as directed, for four full weeks.
When is PEP used?
After exposure to HIV in the workplace (occupational exposure)
PEP is used when people are exposed in the workplace to body fluids that may contain HIV—for example, a healthcare worker who accidently suffers a needle-stick injury.
After exposure to HIV in other settings (non-occupational exposure)
PEP can also be used after a high-risk exposure that is not work-related, such as unprotected sex, a condom breaking during sex, needle sharing or sexual assault.
How much protection does PEP provide from HIV infection?
We don’t know. Several studies suggest that anti-HIV drugs can reduce the risk of HIV infection if taken within 72 hours of an exposure to HIV and if taken every day for four weeks. The sooner PEP is started after an exposure, the more likely it is to work.
We do know that PEP does not always prevent HIV infection. There are several reports of people becoming infected with HIV despite taking PEP medications.
Who should consider taking PEP?
An HIV-negative person who has had a possible high-risk exposure to HIV within the last 72 hours should consider taking PEP.
Not all types of exposure have the same chance of causing HIV infection—some are riskier than others. Before taking PEP, a person must first discuss their situation with a nurse, doctor or counsellor. If the chance of becoming infected with HIV is low, either because it is unlikely that the source person was HIV-positive or because the way they were exposed has a low risk of transmission, PEP may not be recommended.
PEP is intended to prevent HIV infection and should not to be used by a person who is HIV-positive. When a person starts PEP, an HIV test must be done to determine the person’s HIV status. If rapid testing (which gives results within a matter of minutes) is not available, the test result may not be ready for one to two weeks; nevertheless, PEP will be started immediately. If the test result is positive, the person will stop taking PEP and a doctor will need to decide whether HIV treatment is needed.
Is PEP an alternative to other prevention methods, such as condoms or clean needles?
No. PEP is for emergencies only. It should not replace other more effective prevention methods, such as condoms or clean needles.
A person should not use PEP regularly to prevent HIV infection.
- PEP is not like a “morning-after” pill that prevents pregnancy; it requires taking pills several times every day for an entire month.
- The medications are very expensive, can cause side effects—such as nausea, fatigue and diarrhea—and can be difficult to access.
- There is no guarantee that PEP will prevent HIV infection.
- PEP provides no protection against other sexually transmitted infections.
What are the safety concerns associated with PEP?
A false sense of safety
There is a concern that when people know that PEP is available to prevent HIV after an exposure, they may develop a false sense of safety and engage in more risky behaviours as a result. For example, they may be more likely to have sex without a condom, have sex with more partners or share needles to inject drugs. This is concerning because these behaviours could increase a person’s risk of becoming infected with HIV and other sexually transmitted infections.
A person could develop drug resistance if they become infected with HIV while taking PEP. If a person’s HIV becomes resistant to the PEP drugs, the same anti-HIV drugs may not work for treating their HIV.
Side effects and adherence
Anti-HIV drugs can cause side effects. The nature and severity of the side effects depend on the type and number of anti-HIV drugs prescribed and the person who is taking them. The side effects of PEP drugs may make it difficult for a person to adhere to their medication schedule. If the medications are not continued for an entire month or if some doses are missed, then the risk of infection and drug resistance will increase. Newer anti-HIV drugs cause fewer side effects and are better tolerated than many of the older anti-HIV drugs. A doctor can help choose the best medications for a person who has decided to take PEP.
What is involved in taking PEP?
First, a doctor will assess whether the risk of HIV transmission is high or low. If the risk is high and the person who may have been exposed to HIV decides to start taking PEP, they will be tested for HIV. If the HIV test is negative, or cannot provide immediate results, the exposed person will be given a prescription for PEP medications.
If the HIV status of the source person is unknown, the PEP user will be encouraged to ask the source person to get tested for HIV. If the source person is HIV-negative, then the use of PEP medications can be discontinued.
PEP medications need to be taken correctly—every day for one month—or the risk of infection will increase. A counsellor, doctor, nurse, pharmacist, friend and/or staff member at an AIDS Service Organization can help a person manage the side effects of the drugs and adhere to the pill-taking schedule.
A person taking PEP needs to be monitored for side effects and other complications. Blood tests may be performed to ensure that the anti-HIV medications are not causing harm to the body. If side effects and toxicity are a problem, a doctor may decide to change one or more of the anti-HIV drugs being used for PEP.
A person taking PEP should take extra precautions to avoid exposure to HIV while taking PEP. PEP is only intended to reduce the risk of infection associated with the initial exposure. If a person taking PEP continues to engage in high-risk behaviours, such as unprotected sex or sharing needles, PEP will be less likely to work and the risk of HIV infection will increase.
How can PEP be accessed?
Although there are clear guidelines across Canada for access to PEP for occupational exposures, the guidelines are less clear for non-occupational exposures. After a non-occupational exposure, it may be possible to access PEP in some emergency rooms and urgent care clinics in Canada; however, it is not always readily available. The decision to provide PEP lies with the healthcare provider and is often made on a case-by-case basis. Many healthcare providers are unaware of non-occupational PEP, are not trained to provide PEP, or may be unwilling to presribe it.
Anti-HIV drugs are expensive: a month-long course of PEP can cost more than $1,000. Although occupational PEP is normally covered by workplace insurance, coverage for non-occupational PEP varies across Canada. Non-occupational PEP medications are covered by some private and public health insurance plans; coverage varies depending on the province or territory and the nature of the exposure.
Condoms for the prevention of HIV transmission
Condoms are physical barriers that can reduce the risk of a sexual exposure to HIV because they are made of materials that do not allow HIV to pass through them. This makes condoms a highly effective strategy to reduce the risk of HIV transmission when used consistently and correctly. They are much less protective if used inconsistently and/or incorrectly. Condoms also provide protection from other sexually transmitted infections (STIs).
What types of condoms are available to prevent HIV transmission?
Two types of condoms are available to prevent the sexual transmission of HIV:
The external condom, also known as the male condom, is a sheath made from polyurethane, latex or polyisoprene, which covers the penis during sexual intercourse. There are many types and brands of external condoms available.
The internal condom, also known as the female condom, is a pouch made of polyurethane or nitrile. The internal condom was designed for vaginal sex but can also be used for anal sex. The pouch is open at one end and closed at the other, with a flexible ring at both ends. The ring at the closed end is inserted into the vagina or anus to hold the condom in place. The ring at the open end of the pouch remains outside of the vagina or anus.
How do condoms help prevent the sexual transmission of HIV?
Condoms help prevent transmission by reducing the risk of an exposure to HIV during sex.
Laboratory studies show that the materials used to make most condoms (such as latex, nitrile, polyurethane and polyisoprene) do not let HIV pass through them. Condoms act as a barrier to HIV infection by preventing the vagina, penis, rectum and mouth from being exposed to bodily fluids (such as semen, vaginal fluid and rectal fluid) that can contain HIV.
Some condoms are made from a thin membrane of sheep intestine, and are also known as lambskin condoms. These condoms can be used to help prevent pregnancy but since HIV can pass through them, they should not be used as an HIV prevention strategy.
How effective are condoms at preventing the sexual transmission of HIV?
Condoms are a highly effective strategy to help prevent the sexual transmission of HIV when used consistently and correctly. Condoms have been well studied in laboratory tests and it has been determined that condoms are impermeable to HIV, meaning that HIV cannot pass through them.
Condoms can fail to prevent an exposure to HIV if they break, slip or leak during sex. These types of mechanical condom failure are relatively rare, with studies estimating that external condoms fail between 0.4% and 6.5% of the time, and that internal condoms fail between 0.1% and 5.6% of the time.
In studies of condom breakage, slippage and leakage, it was not possible to know how many participants were actually using condoms correctly. However, research suggests that rates of condom failure decrease with more frequent condom use and more experiences of previous failure. This evidence all points to the conclusion that over time people learn to use condoms correctly and this reduces failure rates. However, failure is never reduced to zero, even for experienced condom users who use condoms consistently and correctly.
When condom effectiveness is tested in serodiscordant couples (where one partner is HIV positive and the other is HIV negative), condom effectiveness can range considerably. This is because condoms are not always used consistently and correctly in real life. Observational studies of condom effectiveness have looked at the rates of HIV transmission among couples who reported always using condoms compared to couples who said they never use condoms. Subsequent analyses (meta-analyses) of many studies in heterosexual couples have estimated that the effectiveness of consistent condom use ranges between 69% and 94%. A similar result (70% effectiveness) has been observed in studies of gay men and other men who have sex with men. No similar data exist for the effectiveness of internal condoms at reducing the risk of HIV transmission through vaginal or anal sex; however, because they are also made of material that does not let HIV pass through, and they have low rates of failure, they are likely to be of similar effectiveness.
The effectiveness of condoms is most likely higher than the above estimates, when used consistently and correctly, because there are three limitations to these observational studies:
- These studies did not ask people about whether they were using condoms correctly. We know that incorrect use can cause condoms to break, slip or leak, allowing HIV to enter the body.
- These studies relied on self-report of consistent condom use. Self-reports can be an unreliable way of measuring behaviours that may be considered socially undesirable such as sex without a condom. Couples may not have used a condom for every sex act, despite reporting consistent use.
- In observational studies, couples are not randomly assigned to use condoms or not. Without randomization, the two groups (those that used condoms consistently and those that did not) may be different in other ways that may contribute to a lower level of effectiveness. For example, people who said they used condoms consistently may have been having sex with a higher number of casual partners making their risk for HIV much higher.
What are the advantages and disadvantages of condoms?
Condoms have several advantages compared to other HIV prevention strategies. Some examples are:
- Condoms are a highly effective strategy to help prevent HIV transmission.
- Condoms reduce the risk of other STIs, such as gonorrhea, chlamydia, herpes and syphilis.
- Condoms are inexpensive and readily available.
- Condoms do not require medical intervention or follow-up.
- Condoms can reduce the risk of unintended pregnancy.
Condoms have several disadvantages and this can make it difficult for people to use them consistently and correctly. Some examples are:
- There are many ways in which condoms can be used incorrectly.
- Condom use can be difficult to negotiate with a sex partner.
- Condoms need to be available at the time of sex.
- Condoms can make it difficult for some people to maintain an erection.
- Condoms can be uncomfortable and can decrease sexual pleasure and intimacy.
- When condoms are used for HIV prevention they do not allow conception.
Genital herpes is a sexually transmitted infection caused by the herpes simplex virus type 1 (HSV-1) or type 2 (HSV-2). Once a person is infected with HSV, the virus stays in the body for life. Both HSV-1 and HSV-2 can be transmitted through sexual contact. Genital herpes is an HSV infection of the groin, pubic area, genital area, anus, rectum or buttocks.
All people who are sexually active may be at risk for genital herpes.
Many people with genital herpes have no symptoms or the symptoms are very mild so they go unnoticed or are mistaken for another skin condition. The most common symptoms of genital herpes are lesions, which appear as painful blisters in the genital area.
To test for genital herpes, samples are taken from the sites of suspected infection and tested for the presence of the virus. Blood tests can also be used to determine if HSV-1 or HSV-2 is present in the body.
Antiviral medications can reduce the severity and frequency of genital herpes outbreaks.
Genital herpes increases the risk of HIV transmission.
Correct and consistent condom use and antiviral medication can reduce the risk of genital herpes transmission.
What is genital herpes?
Genital herpes is a sexually transmitted infection (STI) caused by the herpes simplex virus type 1 (HSV-1) or type 2 (HSV-2). Genital herpes is generally defined as an HSV infection of the groin, pubic area, urethra (the tube that allows urine and semen to pass out of the body), vagina, vulva, cervix, clitoris, labia, penis, perineum (the area between the anus and the scrotum or vagina), anus, rectum or buttocks.
HSV-1 usually infects the mouth or lips but can also infect the genital area.
HSV-2 usually infects the genital area. A person can be co-infected with both HSV-1 and HSV-2. HSV infects the epithelial cells (top layers) of the skin and the mucous membranes (the “wet” linings of the body). The virus then travels to a nerve root called a ganglion at the base of the spine. HSV stays in the ganglion for the rest of a person’s life. Periodically, the virus travels back to the skin or mucous membranes, which may or may not cause symptoms (lesions) to occur.
How is genital herpes transmitted?
HSV is transmitted through direct skin-to-skin contact with an HSV lesion and it can also be spread through contact with a partner’s infected oral or genital area. When the virus is shed (released) from infected skin it can be present in genital or oral secretions. Transmission can occur when the infected partner has no visible lesions and, in many cases, is not aware of the infection. HSV can be spread through sexual contact.
HSV-1 is usually transmitted by kissing. (Oral HSV-1 is a very common infection with or without symptoms. When HSV-1 symptoms appear on the lips they are referred to as “cold sores.”) HSV-1 can also be spread from the mouth to the genitals or anus during oral sex. Although it is less likely, HSV-1 can also be transmitted via genital-to-genital contact and anal intercourse.
HSV-2 is most often transmitted by vaginal and anal intercourse. HSV-2 can spread from a person’s genitals to another person’s mouth during oral sex, although HSV-2 infections of the mouth are rare.
Condomless vaginal and anal intercourse and oral sex are considered high risk for HSV transmission. Although lower risk, fingering, hand jobs and sharing sex toys can transmit HSV.
Genital HSV-1 or HSV-2 can be passed to a fetus or newborn during pregnancy or childbirth. The risk of transmission is higher if the pregnant person is experiencing a first (primary) HSV outbreak.
Many people with genital herpes have no symptoms or the symptoms are very mild so they go unnoticed or are mistaken for another skin condition. As a result, most people with genital herpes are unaware that they have the infection. Transmission can occur when the infected partner has no symptoms. If noticeable symptoms do occur, they usually appear two to 12 days after infection (the incubation period). The first appearance of symptoms is known as the primary outbreak and subsequent outbreaks are known as recurrences. Genital herpes infections can involve a number of different symptoms:
- painful blisters in the genital area; these crust over and heal within one to two weeks. Genital herpes lesions can appear individually or in clusters.
- itchy, tingling, burning or painful skin in the infected area
- pain in the legs or buttocks
- swollen and tender lymph nodes in the groin area
- thin watery discharge from the vagina
- fever, headache or muscle ache
Hepatitis A is an infection caused by the hepatitis A virus, which is a virus of the Hepadnaviridae family. It can be sexually transmitted. The hepatitis A virus infects hepatocytes (a type of liver cell) and interferes with usual liver functions, causing inflammation of the liver (hepatitis).
How is hepatitis A transmitted?
Hepatitis A is found in the feces of an infected person. The virus is transmitted when the fecal matter of an infected person makes its way into the mouth of another person (fecal-oral contact) who has not been previously exposed to hepatitis A or who has not been vaccinated against hepatitis A. A person becomes immune to the virus after being infected.
Hepatitis A can also be transmitted if a person ingests food or water that has been contaminated with the feces of someone with hepatitis A.
Hepatitis A can be spread by sexual activities involving fecal-oral contact (such as rimming). The virus can also be transmitted by fingers (anal-finger contact), a penis if having anal intercourse, and sex toys if they have come into direct contact with infected feces during sex and then enter another person’s mouth. Handling a used condom after anal sex and then putting fingers in the mouth can also transmit hepatitis A.
Most adults infected with hepatitis A have some symptoms. Symptoms can appear two to six weeks after infection (the incubation period). Adults and older children may have an abrupt onset of the following symptoms: loss of appetite, nausea, abdominal pain, fatigue, fever, light-coloured stool, dark urine and jaundice (yellowing of the skin and/or eyes).
Children under the age of six may have no symptoms (asymptomatic) or display only mild symptoms.
Most adults will clear the infection on their own within two months. After the infection clears, a person has lifelong immunity from hepatitis A.
Hepatitis B is an infection caused by the hepatitis B virus (HBV), which is a virus of the Hepadnaviridae family. The virus enters the bloodstream. Hepatitis B mainly infects the liver but has been found in other tissues and organs, such as the kidneys or pancreas.
How is hepatitis B transmitted?
Hepatitis B is transmitted through contact with infected blood, semen and vaginal fluids. Transmission occurs when infected blood or other bodily fluids of an infected person comes into contact with the body’s “wet” linings (mucous membranes) or the torn or cut skin of another person.
In Canada, hepatitis B is most commonly transmitted via sexual contact. Hepatitis B can be transmitted during oral, anal or vaginal sexual activity if a person’s mucous membranes or torn or cut skin comes into contact with infected blood or bodily fluids.
Hepatitis B can also be transmitted via objects that carry the virus because hepatitis B can survive outside the body for up to seven days. Sharing sex toys can also transmit hepatitis B. It is possible to transmit hepatitis B through touch or fingering if a person’s mucous membranes or torn or cut skin is exposed to infected blood or bodily fluids on a partner’s hands.
Other than sexual activity, the most common form of hepatitis B transmission in Canada is from sharing both injection and non-injection (for example, straws or pipes) drug use equipment that carries the virus.
Hepatitis B can be transmitted between household members if objects such as toothbrushes, razors or nail files are shared. Occupational exposure among health professionals (doctors, dentists, nurses) via contaminated medical or dental equipment is another form of transmission. Although rare in Canada, the virus can also be transmitted by equipment that has not been sterilized properly (for example, medical or dental equipment, acupuncture tools, and tattoo, piercing or electrolysis equipment). This is one of the most common routes of transmission among people in countries where hepatitis B is common.
Hepatitis B can be passed from an infected pregnant person to a fetus in the uterus, but vertical transmission most commonly occurs during vaginal or cesarean delivery because the newborn is exposed to the parent’s infected blood.
Many people with hepatitis B have no symptoms. Symptoms can appear two to three months after infection (the incubation period).
If symptoms do appear when a person is first infected during the acute hepatitis B phase, they are often deceptive. Although the symptoms may appear to be harmless, they can actually be very harmful to a person’s health.
The main organ affected by hepatitis B is the liver. Symptoms may include: fatigue, loss of appetite, jaundice, nausea and/or vomiting, rash, dark urine, and joint and/or abdominal discomfort or pain.
Approximately 30% to 50% of adults and less than 10% of children develop symptoms during an acute hepatitis B infection.
- Public Health Agency of Canada. Summary: Estimates of HIV incidence, prevalence and Canada’s progress on meeting the 90-90-90 HIV targets, 2018. Ottawa: Public Health Agency of Canada, 2020.
- Public Health Agency of Canada. HIV in Canada – 2019 surveillance highlights. Ottawa: Public Health Agency of Canada, 2020. Available at: https://www.canada.ca/en/public-health/services/publications/diseases-conditions/hiv-2019-surveillance-highlights.html
- Haddad N, Weeks A, Robert A, Totten S. HIV in Canada – surveillance report, 2019, 2021. Canada Communicable Disease Report 2021;47(1):77-86. Available at https://www.canada.ca/en/public-health/services/reports-publications/canada-communicable-disease-report-ccdr/monthly-issue/2021-47/issue-1-january-2021/hiv-surveillance-report-2019.html
- Tarasuk J, Sullivan M, Bush D, et al. Findings among Indigenous participants of the Tracks survey of people who inject drugs in Canada, Phase 4, 2017-2019. Canada Communicable Disease Report 2021;47(1):37-46. Available at https://www.canada.ca/en/public-health/services/reports-publications/can...
- Tarasuk J, Zhang J, Lemyre A, et al. National findings from the Tracks survey of people who inject drugs in Canada, Phase 4, 2017–2019. Canada Communicable Disease Report 2020;46(5):138-48. Available at: https://doi.org/10.14745/ccdr.v46i05a07
- Brogan N, Paquette DM, Lachowsky NJet al. Canadian results from the European Men who-have-sex-with-men Internet survey (EMIS-2017). Canada Communicable Disease Report 2019;45(11):271-82. Available at: https://doi.org/10.14745/ccdr.v45i11a01
- Lambert G, Cox J, Messier-Peet M, et al. Engage Montréal: portrait of the sexual health of men who have sex with men in Greater Montréal, cycle 2017-2018, highlights. Montreal: Direction régionale de santé publique, CIUSSS du Centre-Sud-de-l’Île-de-Montréal; January 2019. Available at: https://www.engage-men.ca/wp-content/uploads/2019/04/Engage_Highlights_ENG_Mars-2019.pdf