Men Who Have Sex With Men (MSM) and rising HIV infection rates in Toronto


The Issue
The Plan

An Action Plan
prepared by:

The AIDS Committee of Toronto

Released June 18, 2001

Introduction
Twenty years after the first reported cases in North America of what would come to be known as “AIDS”, Toronto’s HIV infection rates are on the rise among Toronto’s men who sex with men (MSM) community.

Across North America, researchers saw infection rates drop to their lowest in the mid-nineties. Data presented in 20001, however, identified a consistently upward trend among MSM in Toronto in the years since, prompting the AIDS Committee of Toronto (ACT) to respond with the formation of an Emergency Task Force and Community Advisory Panel comprised of community partners in HIV/AIDS prevention and education in Toronto, including:
  • Black Coalition for AIDS Prevention (Black-CAP),
  • Alliance for South Asian AIDS Prevention (ASAAP),
  • Asian Community AIDS Services (ACAS) and
  • Centre for Spanish Speaking Peoples (CSSP).


The goal of the Emergency Task Force and its community advisors was to develop a prevention campaign focused on the group with the highest infection rate: MSM.

The term MSM is used by epidemiologists in assessing risk for HIV infection and comprises gay and bisexually-identified men, as well as men who engage in same-sex sexual activity and self-identify as heterosexual.

Historically, MSM have been the group most affected by HIV/AIDS in Canada. As has been the case since the mid-1980s, the great majority of new infections are in Toronto, which has been the core of the MSM epidemic in Ontario.


Understanding the numbers
Surveillance data, by nature, provides only an indicator of the rate of infection. It does not provide clear incidence information (the number of newly infected people each year) or prevalence data (numbers representing the total number of those living with HIV). This is because the numbers generated represent only those individuals who seek testing, not the population as a whole.

National numbers
  • Across Canada, 2,104 positive HIV tests were reported to Centre for Infectious Disease Prevention and Control (CIDPC) in 2000 across all groups.
  • The national number reported has slowly declined each year from 2,983 positive reports in 1995 to 2,772, 2,537, 2,330 and 2,240 in 1996, 1997, 1998 and 1999 respectively2

Toronto numbers
Using data from the Ontario Ministry of Health and Long Term Care (MOHLTC) HIV Laboratory and other studies, Robert Remis, MD, MPH, FRCPC, of the University of Toronto Department of Public Health Sciences, working under a mandate from the AIDS Bureau of the MOHLTC, has modeled prevalence of HIV among MSM in Toronto (see table 1).3
The modeled data reflects a steady increase in the prevalence of HIV infections since the mid-nineties. Last year, the prevalence of HIV infections was 7 per cent higher than 1999 and 34 per cent higher than 1996 (see Table 1 and Chart 1)

Table 1: Modeled estimates of HIV infection among MSM in Ontario

2000
All exposure categories – Ontario
MSM Ontario
MSM Toronto
Annual increase in HIV prevalence MSM, Toronto
Cumulative HIV incidence
28,500
18,200
12,300
Cumulative mortality
7,100
4,900
3,200
Prevalence
21,400
13,300
9,100
7 %
Diagnosed
13,700
9,000
6,800
Proportion diagnosed
64%
68%
75%
On therapy
8,200
6,200
4,700
HIV incidence (number)
1,800
900
700
HIV incidence (proportion)
1.0%
1.5%
1999
Cumulative HIV incidence
26,700
17,300
11,600
Cumulative mortality
6,800
4,700
3,100
Prevalence
19,900
12,600
8,500
8%
Diagnosed
12,800
8,500
6,500
Proportion diagnosed
64%
67%
76%
HIV incidence (number)
1,800
900
700
HIV incidence (proportion)
1.0%
1.5%
Notes:
  • Cumulative HIV incidence is the total number of infections since the epidemic began
  • Cumulative mortality is the number of AIDS deaths since the epidemic began
  • Prevalence is the number of persons living with HIV
  • Diagnosed is the number of persons living with HIV who have been diagnosed
  • Proportion diagnosed is the percentage of persons living with HIV who have tested positive for the virus
  • HIV incidence (number) is the total number of new infections this year
  • HIV incidence (proportion) is the percentage of the MSM community in Toronto diagnosed HIV-positive that year



Chart 1


The number of HIV-infected MSM in Toronto between 1977 and 2000 can be viewed in three phases. The first phase is the period from 1977 to 1987, when the infection rate was rapid, with high incidence but low mortality. The second period (1988 to 1995) saw the incidence level off with education and prevention strategies, and increasing mortality. The third phase (1996 to 2000) saw prevalence increase streadily due to a number of factors: mortality decreased with the introduction of new therapies (more people are living longer with HIV) and more are becoming infected.

Prior to 1995, 81 per cent of positive HIV tests in Canada among men were from MSM. This proportion levelled off at 49 per cent by 1999. In 2000, however, the proportion of positive HIV tests attributed to MSM in Canada had increased to 60 per cent.4


HIV diagnoses among MSM: In Ontario, MSM accounted for 56 per cent of all newly diagnosed HIV infections in 1995. This dropped to an historic low of 47 per cent by 1999. However, in 2000, MSM accounted for 55 per cent of all newly diagnosed HIV infections in Ontario; marking the first noted increase in the proportion of MSM HIV infections since testing began in the 1985. 4

Age trends: Recent Toronto MSM infections tend to occur largely in two age groups. Overall, 76 per cent of new HIV infections among Toronto MSM occurred among men between 25 and 44 years old. Twenty-four per cent of Toronto MSM infections occurred among men aged 30 to 34 years.4


What’s driving the upward trend?
Studies in the United States5, Europe6, and Australia7 have recently reported that high-risk sexual behaviour (i.e. anal intercourse without a condom) and sexually transmitted infection (STI) incidence have increased among MSM in those parts of the world. A U.S. study found widespread unprotected receptive and insertive anal intercourse among MSM, some of whom were HIV-positive. A Dutch study found similar high-risk behaviours, as well as an increased incidence of gonorrhea.8

Possible Explanations
What are the reasons behind increased risk-taking? Unfortunately, there is a lack of HIV behavioural research for MSM in Ontario. However, anecdotal information, qualitative data from the Polaris Seroconversion Study9, and research from other jurisdictions suggest that increased HIV risk-taking among Toronto MSM is attributable to the following factors:

Treatment optimism due to Highly Active Antiretroviral Therapy (HAART) in 1996: The introduction of HAART has reduced AIDS mortality rates and may have contributed to the feeling that HIV/AIDS is not a life-threatening disease. Subsequently, men may be less worried about acquiring HIV.


Safer Sex “Burnout”: Among MSM, the adoption of safer sex practices was dramatic in the early-to-mid 1980s. Since that time, qualitative evidence from several scientific studies has suggested that some at-risk people may have become less vigilant about avoiding HIV infection. This may be due, ironically, to the proliferation of hopeful information about the HIV/AIDS epidemic (treatments, living with HIV, long-term survival, etc.).

The Desire for Intimacy Between Sexual Partners: Sex with a latex condom is seen as a barrier that reduces intimacy between sexual partners, in terms of physical pleasure and emotional bond.

Issues Facing Men over 40: Current qualitative research conducted by ACT with men over age 40 indicated that some of these men are less likely to insist on condom use out of fear of rejection from (often younger) sexual partners. Some men have also indicated that their quality of life today, including the pleasure and intimacy they get through unprotected and/or spontaneous sex, is more important than the risk of acquiring HIV. These feelings are heightened for men who came out later in life, and/or for men who perceive their future to hold a decline in social and economic supports. The current social climate which places greater value on youth, coupled with a perception in the decline of the seriousness of HIV infection, provide further validation for this perspective.

Making Assumptions About HIV-Status: Some men have indicated that they make assumptions about the HIV-status of their sexual partners when condom use is not discussed before anal sex. In other words, they assume the ‘partner’ will take responsibility therefore they do not need to. For example, an HIV-negative man may assume that if his sexual partner does not discuss condom use, this means that his sexual partner is also HIV-negative. Similarly, an HIV-positive man may assume that his sexual partner must also be HIV-positive because condom use is not discussed.


False Assurances Regarding HIV Risk-Taking: The Polaris Study of repeat HIV testers indicates that an HIV-negative test result may contribute to some testers’ false sense of security regarding the risks that they took.10 Their HIV-negative test result may reinforce their risk-taking behaviour.

New behavioural information
The Polaris Study has been trying to understand why the incidence of infections has been rising in Ontario. To date, its researchers have identified some key predictors of recent infection among MSM in Ontario. The study is an Ontario-wide longitudinal open study comparing those who have recently tested HIV-positive with two HIV-negative controls. Participants are recruited through Ontario's HIV diagnostic laboratory, physicians, support organizations and advertisements.

The study modeled a number of potential risk variables, including participants’ sociodemographics, lifestyle, psychological and social variables, the number of sexual partners, the characteristics of sexual partners, where they met, specific sexual activities, condom use and STIs.

The research has reinforced knowledge about factors relating to infection and has identified some new and interesting key predictors for HIV infections among MSM in Ontario.

Unprotected receptive anal sex with partners HIV status positive or unknown
Persons having had an episode of unprotected receptive anal sex with an HIV-positive or status unknown partner were 4.4 times more likely to become infected. This still remains the behaviour responsible for most of the infections among MSM in Ontario.

Imperfect condom use
While researchers had expected that unprotected receptive anal sex would be associated with a higher risk of becoming infected, they were somewhat surprised at the high levels reporting imperfect condom use and how strongly it was linked with becoming infected. The data showed that delayed condom application and premature removal, as well as the rate of condom breakage and slippage are worthy of attention.
  • 56 per cent of those who became positive and 19 per cent of those who remained HIV-negative reported at least one episode of imperfect condom use while engaging in receptive anal sex during the time period.
  • Those who experienced “imperfect” condom use during receptive anal sex with an HIV-positive or status unknown partner were 4.8 times more likely to be infected.

Learning of partner’s affair
Also a statistically significant predictor of becoming HIV infected was having learned of a partner’s affair. Those who became infected were 6.4 times more likely to have learned of an affair, indicating that the partner may have been the source of the infection and/or to have precipitated the cause of the high-risk behaviour that led to the infection.


A CALL TO ACTION
Behavioural data such as this does not support the myths that gay men are irresponsible or indifferent in the face of AIDS. What it does is provide a roadmap for education and public awareness purposes. Reasons that men in the MSM community have unsafe sex are complex: the awkwardness of condom use, desire for intimacy, loneliness, depression, alcohol and drug use, inexperience with gay sex, false beliefs about HIV transmission, a lack of self confidence, poverty, having experienced childhood sexual abuse, relationship violence, grief, growing older in a youthful culture, being black or brown in a culture that is predominantly white, stereotypes … and the list goes on. Unsafe sex is related to a range of social, psychological, and emotional experiences and issues that impact on a gay man’s sexual life.

Our challenge is to meet the needs of MSM in Toronto and beyond. Men who have sex with men are our brothers and sons but also our fathers and husbands. We must reach out to them with the message that HIV is not backing down, so condom use and regular testing is a must. We must break through the complexity of social and demographic barriers that challenge us. And finally, we must encourage the funding required over the long-term to succeed in our goals.

New approaches to reaching out
The community-based AIDS movement has a long history of providing targeted HIV prevention initiatives to gay and bisexual men and other men having sex with men (MSM). In the early years of the HIV epidemic, ACT’s HIV prevention materials (posters and brochures) had high visibility within gay community establishments such as bars and bath houses. HIV prevention and safer sex posters and brochures were distributed through information bulletin boards located in commercial venues.

In addition, staff and volunteers from local AIDS service organizations (ASOs) provide direct outreach to men through condom distribution in bars, bath houses, and public parks where men meet for sex.

However, the last twenty years of HIV prevention and health promotion work have coincided with an economic “mainstreaming” of gay culture. Businesses now routinely market commodities to gay consumers. As such aggressive and increasingly ubiquitous advertising campaigns compete for the attention of gay and bisexual men, other messages get squeezed out. Over the past five years, the visibility of HIV prevention materials has diminished considerably within gay community venues and within the gay media. While ASOs still provide direct outreach in bars, bath houses, and public parks, and maintains information boards in gay commercial venues, our HIV prevention materials cannot compete with ads from commercial advertisers who saturate the gay press and commercial venues.
The challenge, then, is clear. We have to devise new ways to get the HIV prevention message out and compete effectively with commercial marketing for the attention of gay and bisexual men, and other MSM.

Compounding the challenge is the need to create messages that will be effective with diverse ethno-racial communities. For example, messages delivered in English to gay identified, white, urban men might not translate well or meaningfully in other languages and cultures. They also might not be appropriate in reaching MSMs who identify as heterosexual or bisexual. The campaign must be mindful of how it might impact on the female partners of MSM.

Strategy Overview
To address the significant increase in new HIV infections among MSM in Toronto, which is home to the largest concentration of MSM in Ontario and Canada. ACT is embarking upon a high profile, multi-faceted, multi-lingual social marketing campaign containing HIV prevention messages that challenge current assumptions, compete effectively with commercial marketing, re-engage the attention of the community and reach MSM from diverse ethno-racial communities who are not gay identified.
In the absence of more complete data about the socio-demographic and ethno-cultural characteristics of newly HIV-infected MSM in Toronto, our response to the rise in HIV infection among MSM must be as broad as possible. Because we cannot know, for example, whether these new infections are occurring among gay or bisexually identified men, or among heterosexual MSM, we must fashion messages to reach all such men in various venues. Furthermore, to compete with the campaigns of commercial advertisers, we must continue to develop new ways to engage Toronto’s savvy, urban, and marketing-laden gay community, to win its attention and to communicate our messages. HIV prevention and health education/social marketing work must achieve the same sophistication and broad market saturation as corporate advertising ventures.

Despite Toronto’s large MSM population, limited financial resources have prevented ACT and other community-based AIDS service organizations in Toronto from carrying out large-scale HIV prevention campaigns. By contrast many large U.S. urban centres, like New York and San Francisco, make dramatic use of powerful, broad, and market-saturating HIV prevention social marketing campaigns.

Historically, we have relied in large part on postering and brochure campaigns, disseminated through its information boards located in gay community venues. Often located away from areas of prime visibility, the information boards deliver poor market saturation of HIV prevention messages.

Men interviewed in focus groups conducted by ACT in the past have indicated the need for HIV prevention messages to be disseminated through more “mainstream” advertising vehicles: via billboards, transit shelters, subway ads, televised public service announcements, and print media. Some of these materials would need to be developed in languages other than English.

To address the current situation and to be mindful of longer-term HIV education needs, and to address MSM from diverse ethno-cultural backgrounds that reside in Toronto, we have prepared a comprehensive HIV prevention education campaign. This undertaking aims to publicize HIV prevention and health education messages via street media (subway posters and bus shelters), television ads, and a variety of print vehicles (including ads in both the gay and non-gay media).



Goal
Our goal is simple: to reduce the rate of new HIV infections among Toronto MSM via a comprehensive social marketing campaign.

Objectives
Our educational program will:
• raise awareness of the increase in HIV infections among Toronto MSM
• encourage the adoption and/or re-adoption of risk reduction/safer sex practices
• provide support for MSM that would like to practice safer sex
• make safer sex practices a priority health consideration
• reach a larger percentage of MSM than current educational campaigns have allowed

Methods
To achieve our goal and objectives, ACT has assembled an Emergency Task Force comprised of highly skilled professionals who are leaders in the field of advertising, marketing and communications. This Task Force is responsible for guiding the development and delivery of this campaign. They have selected the marketing/design firms to develop and manage a comprehensive HIV prevention and health education campaign.

The Emergency Task Force also draws on the expertise of a Community Advisory Panel that is comprised of representatives from our partner agencies as well as other community representatives such as social researchers and clinicians. The Panel helps the Task Force with a variety of tasks including: selecting media that will best reach MSM from a variety of ethno-cultural backgrounds; establishing priorities; providing input regarding the creative; assembling focus groups for testing creative; and using its expertise to advise the Task Force on the key causes of the rise in the HIV rate among MSMs in Toronto.
The centrepiece of the campaign is three high-impact social marketing messages:
1. HIV infection rates are once again on the rise in Toronto among MSM
2. Toronto has the largest population of MSM (approximately 60,000) and has among the highest infection rates in the country
3. Condoms are the most effective means of preventing HIV transmission
All campaign materials have been designed to include a recognizable common feature that will unify the messages, make the point memorable, and thereby increase the educational force of the campaign which is being launched on June 18, the first day of Pride week in Toronto. Pride is a celebration of gay, lesbian, bisexual, transsexual and transgendered communities. Pride’s many events are a magnet for huge numbers of Torontonians and visitors and will provide our campaign with a superb outreach opportunity.

Design and Development
The campaign’s creative principles adhere to certain important guidelines. All messages display a direct, friendly, and upbeat format. Language is simple, bold, and informative. All details are written in a clear, simple, and culturally appropriate way.

Mass Media Marketing
Our goal is to saturate the city core, especially high-traffic downtown venues frequented by gay and bisexual men. Media include:
  • Subway and transit shelter posters
  • Xtra! Newspaper, NOW Magazine and Fab Magazine Advertising
  • Advertisements in Ethnocultural Media
  • Web Banner Advertising and Community Marketing
  • Mini-Poster Boards, Postcards, Bathhouse Poster and Display Unit
  • ACT Building Banner, Street Banners, Campaign Poster, Brochure, and ACT Website
  • Venue-Based Initiatives and Special events, such as PRIDE activities

In the fall of 2001, ACT will release a television commercial and Public Service Announcement to continue to the message through the winter months.

Evaluation
The success of the campaign will be tracked through a survey program that will be conducted throughout the course of the campaign. Respondents will be questioned on message retention and behavioural changes.

Acknowledgements
Funding for this program was provided by the AIDS Bureau, Ontario Ministry of
Health and Long-Term Care, the AIDS Community Action Program, Health Canada, and Toronto Public Health.

The views expressed herein do not necessarily represent the official policy of Health Canada, the Ontario Ministry of Health and Long-Term Care or Toronto Public Health..

References
1 HIV and AIDS in Canada Surveillance Report to December 31, 1999, Health Canada

2 Remis R. The HIV Epidemic Among Men Who Have Sex With Other Men: The Situation in Ontario in
the Year 2000, Robert S. Remis MD, December 2000, Department of Public Health Sciences,
University of Toronto

3 Remis R. Estimates of HIV infection among MSM in Ontario, Department of Public Health Sciences,
University of Toronto. June 2001

4 Remis R, et al. The HIV Epidemic Among Men Who Have Sex With Other men: The Situation in Ontario
in the Year 2000. December 2000, Department of Public Health Sciences,
University of Toronto

5 Lehman, JS, et al. Are At Risk Populations Less Concerned About HIV Infection in the HAART
Era? 7th Conference on Retroviruses and Opportunistic Infections, San Francisco, California,
USA, January, 2000.

6 Ostrow DG, et al. Attitudes Toward Highly Active Antiretroviral Therapy Predict Sexual Risk-
taking Among HIV Infected and Uninfected Gay Men in the Multicenter AIDS Cohort Study
(MACS). 13th International Conference on AIDS, Durban Southa Africa, July, 2000.

7 Dukers N, et al. Recent increase in sexual risk behaviour and sexually transmitted diseases in a
cohort of homosexual men: the price of highly active antiretroviral therapy? 13th International
Conference on AIDS, Durban Southa Africa, July, 2000.

8 Rise in Gonorrhoea in London UK. London Gonoccocal Working Group. Lancet 2000; 355:623.

9 Calzavara L., et al. Risk Factors for Recent HIV Infection Among Men Who Have Sex With
Men (MSM): Results from the Polaris HIV Seroconversion Study. Tenth Annual Canadian
Conference on HIV/AIDS Research, May, 2001.

10 Calzavara, et al.The Role of HIV Test Counselling in Reducing HIV Incidence; Are We Doing Enough?
The 9th Annual Canadian Conference on HIV/AIDS Research, Montreal, Canada, April 27-30, 2000)
Abstract published in the Canadian Journal of Infectious Diseases Vol 11, Supplement B March/April
2000.