Fewer people worldwide are getting HIV — so why are rates going up in Canada?

Fewer people are being diagnosed with and dying of HIV/AIDS around the world. But progress is uneven, and only a few countries are on track to meet global targets set by the United Nations to end HIV as a public health threat by 2030, suggests a new study from The Lancet HIV medical journal.

Between 2010 and 2021, new HIV infections decreased globally by almost 22 per cent, a decline largely driven by the progress in sub-Saharan Africa. But in Canada, the opposite is happening. In 2023, there were 2,434 new diagnoses of HIV here: a 35 per cent increase compared to the year before. The number of new cases had been on the decline between 2016 and 2020. Despite the increase in infections, fewer people are dying of HIV in Canada.

Globally, HIV-related deaths have also declined between 2010 and 2021 by almost 40 per cent, say the authors of the Lancet report, noting that’s thanks to antiretroviral treatment — usually a combination of drugs that stop the virus from reproducing. Most people who take the medications daily for a few months have so little virus in their blood it doesn’t show up in tests and can’t be transmitted to others.

“The biggest takeaway is, progress is possible, but it will require sustained focus,” said Austin Carter, a research scientist at the Institute for Health Metrics and Evaluation at the University of Washington and one of the authors of the study.

The most dramatic improvements in both diagnoses and deaths were in sub-Saharan Africa. But the region still leads the world in mortality rates. “Some patients get tested too late, and HIV testing is not free countrywide,” said Dr. Gertrude Komoyo, who works with Doctors Without Borders to care for patients with advanced HIV in Bangui, Central African Republic.

‘The problem is that we forgot’

Canada is not the only country experiencing increasing HIV infections. It’s a pattern other wealthy countries are also seeing, say researchers. 

“The story in high-income countries is that it’s challenging to eliminate HIV,” said Carter.

He says the numbers reflect a growth in high-risk populations — including men who have sex with men and those who inject drugs — as well as a declining interest in HIV care. 

Almost 40 per cent of the new diagnoses in Canada were after exposure to heterosexual contact; 36 per cent involved exposure to male-to-male sexual contact; 18 per cent involved injection drug use.

“The problem is that we forgot,” said Dr. Rejean Thomas, who saw the worst ravages of the AIDS crisis in the 1980s at his clinic in Montreal’s Gay Village.

At that time, he says, most of the patients with AIDS that he saw died within a year. Now, he’s following patients who are growing old with the virus.

“I say some days, I’m doing geriatrics,” Thomas said.

“In the ’80s, it was a new disease killing people. No treatment. Now we have treatment. It’s a chronic disease, but it’s more difficult to do education and prevention.” 

Better prevention, treatment

Prevention includes self-testing, and taking a daily pill — known as PrEP, or pre-exposure prophylaxis — which substantially lowers the risk of contracting HIV.

And there may be easier methods of prevention in the future. Doctors Without Borders is set to start rolling out an injectable HIV prevention drug in Southern Africa, which would replace the daily pill with a shot every two months. In Canada, the drug was approved this spring for some at-risk adolescents and adults. 

Another drug — lenacapavir — has also been shown to be effective in preventing HIV with an injection twice a year. That drug has not yet been approved for preventing the infection, though it is already used in Canada as an antiretroviral treatment. 

Injectable prevention drugs, like lenacapavir, could prove to be a game-changer for the HIV epidemic, but there are already concerns about access, says Dr. Antonio Flores, an HIV specialist with Doctors Without Borders. 

“We do expect this to be a game changer if it’s made widely available and reaches the people that will benefit from it,” he said, noting that in order to effectively eliminate HIV as a public health threat globally, long-acting injectable drugs need to be priced similarly to oral PrEP, “which currently is very cheap.”

Harm reduction, culturally sensitive solutions

In Canada, the situation is most dire in the Prairies, where Saskatchewan and Manitoba have much higher rates of new diagoses than other provinces, according to PHAC. 

In Regina, one of the Canadian cities seeing the highest rates of HIV diagnoses according to PHAC, community workers are focusing on meeting people where they are and giving them information about where and how to access care. 

Vidya Reddy, the education co-ordinator for AIDS Program South Saskatchewan, says he feels like he’s playing catch-up since the pandemic. PHAC numbers suggest more people were getting infected during the COVID-19 pandemic, but Reddy says testing didn’t keep up, because health resources were stretched thin. 

Reddy says that in Saskatchewan, unsafe injection drug use, like sharing syringes and needles, is the key factor related to the spread of HIV. He says it reinforces the need for harm-reduction programs, such as providing sterile injection equipment. 

“People are not having access to safe supplies and not enough people know whether they have HIV or not,” he said.

Another fear among those who work to prevent HIV, is that some people fall through the cracks — especially those who already have trouble accessing medical care. 

Margaret Kisikaw Piyesis, the CEO of the Canadian Aboriginal AIDS Network, says she knows many Indigenous people are reluctant to get tested in medical facilities because they fear they’ll face discrimination.

“There’s some barriers for them to access this type of care,” she said. “If you don’t have a place to live, why would you worry about being tested for HIV?”

Piyesis is calling for culturally sensitive solutions made by — and for — Indigenous people.

“Solutions that are really guided through our Indigenous knowing and our knowledge. Those have to come to life again,” she said, emphasizing that programs focusing on these solutions need more government funding.

Increasing funding for HIV prevention would be a bargain for the health-care system in the long-run, when compared to the cost of long-term treatments, according to Thomas. 

“This epidemic is not finished,” he said. “We hope the government continues to be aware that this epidemic is still important.”