Canada’s progress towards ending the HIV epidemic, 2022

Highlights

• In 2022, an estimated 1,848 new HIV infections occurred in Canada, a 15% increase from the estimate for 2020 (1,610 new infections).
  • The number of new infections was highest among people aged 30-59 years
  • The proportion of new infections among gay, bisexual and other men who have sex with men continued to decrease, whereas the proportion of new infections among people who inject drugs slightly increased.
• An estimated 65,270 people were living with HIV in Canada at the end of 2022. Among those living with HIV, an estimated 89% were diagnosed. Of those diagnosed, 85% were estimated to be on treatment and an estimated 95% of people on treatment had a suppressed viral load.
  • Variation in the 95-95-95 targets between provinces / regions demonstrates the need for focus and improvement in the different stages of the HIV care continuum.
  • Among the estimated people living with HIV, 74.1% were males, and 25.3% were females.
  • Among males living with HIV, progress towards the 95-95-95 targets was similar to the overall population (90%-86%-96%). However, among females, the proportion of those who were diagnosed, on treatment and virally suppressed were lower than the overall population (86%-84%-92%).
• HIV/AIDS-related mortality was included in the report for the first time. In 2022, there were 126 deaths with HIV/AIDS listed as the underlying cause, 309 deaths with HIV/AIDS listed as underlying cause or one of the 19 antecedent causes of death, and an estimated 855 total deaths among people living with HIV in Canada.
• As a part of the Pan-Canadian STBBI Framework for Action, Canada has set a strategic goal of reducing stigma and discrimination which may create vulnerabilities to sexually transmitted and blood borne infections. Additional information related to HIV prevention and stigma have been included in the report for the first time.
• Despite current efforts, Canada has not seen a decrease in new HIV infections in recent years and further work is needed to meet the global 95-95-95 targets. These estimates will be used to measure Canada's progress in meeting the priorities set out in the Government of Canada five-year STBBI action plan, with the goal of accelerating prevention, diagnosis and treatment to reduce the health impacts of STBBI by 2030.

Acknowledgements

The Public Health Agency of Canada acknowledges the Provincial / Territorial public health authorities, other government departments, research and community organizations for their contribution to the national estimates of HIV incidence, prevalence and 95-95-95 targets.

The Public Health Agency of Canada acknowledges the efforts by First Nations partners in the prevention of HIV infections, the care of people living with HIV, and their contribution in estimating HIV indicators for First Nations communities in Saskatchewan.

The Public Health Agency of Canada acknowledges the efforts by other communities and advocates representing civil society and other key populations affected by HIV in Canada.

The Public Health Agency of Canada recognizes and appreciates the invaluable contributions of people living with HIV. Their willingness to participate in data collection, share personal experiences, and provide critical insights significantly enhances our understanding of the epidemic. Their involvement not only enriches the data we collect but also ensures that our strategies and interventions are more effectively tailored to meet the needs of those most affected. Their courage and commitment are vital in our collective effort to advance research, improve public health responses, and ultimately work towards ending the HIV epidemic.

Table of Contents

• Highlights
• Acknowledgements
• Introduction
  • Understanding Canada's progress is important
• Monitoring progress in Canada
  • Data Sources
  • Data limitations
• HIV Incidence – Estimated number of new HIV infections in Canada
  • Geographical Breakdown
• HIV Prevalence – Estimated number of people living with HIV in Canada
  • Geographical Breakdown
  • Mortality among PLHIV
• Canada's progress toward meeting the 95-95-95 HIV targets
  • 95-95-95 estimates by sex
  • 95-95-95 estimates by geography
• HIV Prevention and Stigma
  • Vertical Transmission of HIV in Canada
  • HIV-PrEP & HIV-PEP
  • HIV-Related Stigma
• Discussion / Conclusion
• Appendix 1. Additional detail related to Canada's modelling method
• Appendix 2. Key population definitions
• Appendix 3. National HIV incidence and prevalence tables
• Appendix 4. Canada's progress towards global HIV elimination targets, 2022

Introduction

Sexually transmitted and blood borne infections (STBBI) remain a significant health concern in Canada even though they are largely preventable, treatable and in many cases, curable. STBBI impose significant physical, emotional, social and economic costs on individuals, communities, and society. The Pan-Canadian STBBI Framework for Action ^{Footnote 1} provides an overarching and comprehensive approach to reduce the impact of STBBI in Canada. Canada has endorsed the Joint United Nations Programme on HIV/AIDS (UNAIDs) and the World Health Organization (WHO) strategies that aim to end HIV/AIDS as a public health concern by 2030 ^{Footnote 1 Footnote 2}.The global strategies include the following targets for 2025: 95% of all people living with HIV (PLHIV) know their status, 95% of those diagnosed receive antiretroviral treatment (ART), and 95% of those on treatment achieve viral suppression ^{Footnote 3}. When these three targets are achieved, at least 86% (95% x 95% x 95%) of all people living with HIV (PLHIV) will be virally suppressed ^{Footnote 4}. This will limit both the severe health consequences of chronic infection with HIV as well as community transmission. Modelling suggests that achieving these targets by 2025 will enable the world to eliminate the AIDS epidemic by 2030 ^{Footnote 5}. These documents also include targets related to reducing new infections, deaths, improving access to prevention and harm reduction services, and reducing stigma. The global targets mark the pathway to elimination of the HIV epidemic. Documenting progress is important in the achievement of these goals and an essential component of the Government of Canada STBBI five-year action plan ^{Footnote 6}.

This report provides an update for 2022 on Canada's progress towards the global elimination targets, incidence and prevalence. Available information on HIV prevention and HIV-related stigma will also be highlighted as they affect key populations and can profoundly impact each stage of the HIV care cascade.

Why monitoring Canada's progress is important

The Government of Canada is committed to measuring the impact of programs and policies as we implement the Government of Canada five-year action plan on STBBI, through monitoring and reporting on STBBI trends and results ^{Footnote 6}.These estimates support all partners and stakeholders to have a better understanding of the impact of HIV/AIDS on key populations and where action is needed to reduce the public health impact of HIV and AIDS.

Understanding HIV incidence (the number of new infections occurring during a specific period of time) is fundamental for understanding temporal changes in transmission patterns and is useful for public health decision makers to monitor, strengthen and evaluate the impact of multi-sectoral public health actions. Estimating HIV prevalence (the number of PLHIV - both diagnosed and undiagnosed) is critical for guiding the planning and investment for treatment, care and ongoing support for people living with and affected by HIV. It is also the first step in the HIV care continuum.

The HIV care continuum is a public health model that outlines the steps or stages that people with HIV go through from initial HIV diagnosis to achieving and maintaining viral suppression ^{Footnote 7}. The HIV care continuum is useful both on an individual level to assess care outcomes, as well as at the population-level to analyze the proportion of people with HIV who are engaged in each successive step ^{Footnote 7}. Typical steps in the care continuum are diagnosis of HIV infection, linkage to HIV care, received or retained in care, and achieving viral suppression.

By establishing the HIV care continuum, one can then use this as a framework for assessing and reporting on progress against the global 95-95-95 targets. The sequential nature of the stages in the continuum, and the associated metrics at each stage (e.g. 95-95-95 targets) allow organizations (e.g. public health, research, community) —on national and regional levels—to identify gaps in care and determine the types of interventions that might help increase the number of people who achieve and maintain viral suppression ^{Footnote 8}.

How we are monitoring progress in Canada

Since 2018, The Public Health Agency of Canada (PHAC or the Agency) has been collaborating with an expert working group to determine the measures used to assess Canada's progress within the HIV care continuum. Based on a review of measures used internationally, the PHAC expert group recommended evaluating the 95-95-95 targets using a four-stage continuum: Stage 1 – the estimated number of PLHIV; Stage 2 – the number of PLHIV who have been diagnosed; Stage 3 – the number of PLHIV who have been diagnosed and who are on antiretroviral treatment (ART); and Stage 4 – the number of PLHIV on ART who are virally suppressed (Figure 1).

Text description

This diagram shows the four-stage continuum that Canada uses to measure the HIV continuum of care:

• Stage 1 – the estimated number of all people living with HIV (PLHIV);
• Stage 2 – the number of all PLHIV who have been diagnosed;
• Stage 3 – the number of PLHIV who have been diagnosed and who are on ART; and
• Stage 4 – the number of PLHIV on ART who are virally suppressed.

Variables and Measures

Standard definitions for each of the HIV care continuum measures were developed and used where possible (Table 1). These definitions, which were agreed to by the expert working group supporting the monitoring of Canada's progress, are aligned with the definitions used by the European Centres for Disease Control (ECDC), the United States Centers for Disease Control and Prevention (USCDC), the Kirby Institute (Australia), and Public Health England (United Kingdom). In some instances, definitions were adapted by jurisdictions to account and adjust for differences in the definitions of "on treatment" and "suppressed viral load".

Data Sources

Input for modelling and HIV care continuum

HIV estimates related to incidence, prevalence and the first 95 target were developed using HIV surveillance data reported by provinces and territories (PTs), estimated deaths among PLHIV, and back-calculation statistical modelling methods. Additional detail on the back-calculation modelling is provided in Appendix 1.

Data sources to estimate deaths among all PLHIV include vital statistics data from Statistics Canada or provincial/ territorial vital statistics registries, linked HIV diagnostic and mortality information, national reports of HIV/AIDS deaths, cohort data related PLHIV who are in care, and Canadian research studies.

The development of estimates for the second and third 95 targets required additional information from the provinces and territories, including the following where available:

• HIV surveillance data
• Centralized HIV care program data, including linked treatment and laboratory viral load data
• Provincial antiretroviral drug prescription data linked to HIV laboratory data
• Unlinked data from drug prescription databases, laboratories, and HIV clinics
• Cohorts of diagnosed people engaged in HIV care

Measures were refined through an iterative process with provinces and territories, particularly where adjustments were necessary to account for uncertainty due to incomplete or lack of representative data. The collaborative estimates process is finalized when each jurisdiction validates and approves their own data. The data are then combined to produce national estimates for Canada.

HIV prevention, stigma and mortality

Indicators for the measurement of programs for the primary prevention of HIV are less well-defined than for the HIV care continuum. Therefore, this report draws on currently available data related to HIV prevention (e.g. vertical transmission, pre-exposure prophylaxis (HIV-PrEP) and post-exposure prophylaxis (HIV-PEP)) as a starting point for monitoring progress towards global HIV prevention measures.

Data related to vertical transmission of HIV in Canada comes from the Canadian Perinatal HIV Surveillance Program (CPHSP), which collects national data on infants born to women or other pregnant PLHIV through a sentinel-based, active surveillance system ^{Footnote 10}. CPHSP collects data on two groups of children: infants born to HIV positive women in Canada and HIV positive children receiving care at any participating site (whether born in Canada or abroad). These sites represent approximately 95% of the HIV exposed infants born in Canada ^{Footnote 10 Footnote 11}.

Annual estimates of people using HIV-PrEP and HIV-PEP for 8 provinces were generated from IQVIA's geographical prescription monitor dataset. Data for the three territories and Alberta are not currently available and therefore have not been presented. Data for British Columbia were provided by the BC Centre for Excellence in HIV/AIDS.

Canadian data on HIV-related stigma is limited, however some national data is available among key population groups most affected by HIV. Data on HIV-related stigma among key populations (Indigenous Peoples, gay, bisexual and other men who have sex with men (GBMSM) and people with recent (past 6 months) history of injection drug use) are collected through the Public Health Agency of Canada's integrated bio-behavioural surveillance system ^{Footnote 12 Footnote 13}.

In addition to the available national data, some provincial data on HIV-related stigma are available. In Ontario, the OHTN Cohort Study ^{Footnote 14} is a longitudinal study of PLHIV receiving HIV care at 15 clinics across the province. A standardized tool was used to study four types of stigmas: disclosure, concerns about public attitude, self-image, and personalized. Additionally, in British Columbia the STOP HIV/AIDS Program Evaluation (SHAPE) study used the 10-item Berger HIV Stigma Scale to examine the association between the year of an individual's HIV diagnosis and HIV-related stigma scores ^{Footnote 15}.

To examine national trends in HIV-related mortality we compared the number of deaths with the underlying cause of death listed as HIV/AIDS (ICD-9 codes 279.5 or 279.6; 042-044; ICD-10 codes B20-B24), to the number of deaths with HIV/AIDS listed as either the underlying cause or one of the 19 antecedent causes of death. These data are both from the national vital statistics registry ^{Footnote 16}, and were compared to the estimated number of deaths among PLHIV provided by provinces and territories from various sources.

Data limitations

Provincial / territorial data sources for the second and third 95 targets vary between jurisdictions. These differences occur due to the diverse methods used for HIV surveillance (e.g. laboratory-based versus case-based) and the ability to link data sources. Some jurisdictions can link datasets related to HIV diagnoses, deaths, treatment, and viral load, which allows those jurisdictions to describe progress through the HIV care continuum at the population level. Other jurisdictions estimate each of the HIV care continuum measures using unlinked data sources (e.g. separate diagnosis, death, treatment, and viral load data) along with an analysis of, and an adjustment for, the inherent limitations for each data source. As a result, caution should be taken when making comparisons between jurisdictions.

For the 2022 HIV estimates, data related to the number of people on treatment and with viral suppression data were not provided by four jurisdictions. To account for this, the total number of PLHIV was adjusted by removing data from these four jurisdictions in the national calculation of the 2^nd and 3^rd 95 targets.

In some instances, provinces / territories have been grouped into regions (e.g. Atlantic and Territories), or data have been suppressed due to small counts and to reduce the risk of identifying an individual. Estimates by sex were based on binary sex categories assigned at birth (male or female). Information on trans, non-binary and other gender identities is limited.

Data related to HIV-PrEP and HIV-PEP have several limitations.

• Only prescriptions that were acquired from a community pharmacy are included (dispensations from hospital pharmacies, those provided at no cost, and those purchased online are not included).
• The dispensation data cover approximately 60% of all retail pharmacies in Canada. Patient counts from participating pharmacists are projected to the whole population of each province by IQVIA using their proprietary algorithm.
• An algorithm was used to assign a treatment indication to each person prescribed medication for HIV-PrEP or HIV-PEP. Any misclassifications could have produced an over- or under-estimate of the number of people taking this medication.
• Not all dispensed medications are consumed, which could contribute to over-counting of people taking this medication.

HIV Incidence – Estimated number of new HIV infections in Canada

An estimated 1,848 new infections occurred in Canada in 2022 (plausible range: 1,050-2,740 (Figure 2). This estimate is a 15% increase from the 2020 estimate (1,610 infections). The incidence rate in 2022 was an estimated 4.7 per 100,000 people for the overall Canadian population (plausible range: 2.7 and 7.0 per 100,000 people). This is a slight increase from the 2020 estimate, which was 4.2 per 100,000 people (plausible range: 3.0 – 5.5 per 100,000 people). In 2022, among females the estimated incidence rate was 3.3 per 100,000 people, and among males the rate was 6.1 per 100,000 people.

Text description

This graph shows the estimated number of new HIV infections in Canada by year. The vertical axis shows the point estimate of new HIV infections per year, along with the associated low and high range estimates, and the horizontal axis shows the calendar years.

Year	Estimated number of new HIV infections	Plausible Range
		Upper Bound	Lower Bound
1975	1	9	0
1976	5	38	0
1977	38	108	0
1978	121	236	9
1979	294	649	50
1980	847	1,575	290
1981	2,146	3,460	967
1982	3,848	5,689	2,156
1983	4,934	7,402	2,607
1984	4,904	7,146	2,628
1985	4,209	6,097	2,295
1986	3,430	4,964	2,019
1987	2,835	4,215	1,704
1988	2,440	3,532	1,437
1989	2,170	3,030	1,372
1990	1,996	2,818	1,298
1991	1,910	2,720	1,250
1992	1,888	2,745	1,129
1993	1,891	2,781	1,064
1994	1,907	2,843	1,036
1995	1,919	2,818	1,060
1996	1,943	2,757	1,115
1997	1,964	2,671	1,148
1998	2,004	2,580	1,283
1999	2,068	2,587	1,490
2000	2,171	2,683	1,633
2001	2,295	2,840	1,673
2002	2,396	3,054	1,716
2003	2,440	3,075	1,719
2004	2,426	3,033	1,728
2005	2,372	2,948	1,679
2006	2,298	2,858	1,649
2007	2,218	2,754	1,640
2008	2,119	2,696	1,575
2009	1,995	2,576	1,448
2010	1,854	2,400	1,374
2011	1,747	2,256	1,299
2012	1,678	2,117	1,256
2013	1,649	2,055	1,262
2014	1,660	2,083	1,281
2015	1,692	2,088	1,294
2016	1,721	2,130	1,296
2017	1,712	2,155	1,318
2018	1,657	2,093	1,264
2019	1,598	2,064	1,194
2020	1,610	2,080	1,150
2021	1,721	2,327	1,100
2022	1,848	2,740	1,050

The annual number of new HIV infections was also estimated by age group (0-29 years, 30-59 years, and 60 years and over). The incidence curve for people aged 30-59 years closely follows overall incidence trend with increases in the mid-1980s and early 2000s (Figure 3). Estimated new infections among those aged 0-29 years increased in the beginning of the epidemic, reached a peak in the mid-1980s, and stabilized after the 1990s. Estimated incidence among people aged 60 years and over has remained relatively low, reaching the highest annual number in the mid-1980s, stabilizing in the late 1980s, and increasing slightly in the past 10 years.

Text description

This graph shows the estimated number of new HIV infections in Canada per year by age group. The ranges of uncertainty were omitted. The vertical axis shows the point estimate of new HIV infections, and the horizontal axis shows the calendar year. The categories are: people of all ages, people aged 0-29 years, people aged 30-59 years and people aged 60+ years.

Year	Estimated number of new HIV infections
	People of all ages	People aged 0-29 years	People aged 30-59 years	People aged 60+ years
1975	1	1	0	0
1976	5	4	1	0
1977	38	26	12	0
1978	121	67	53	1
1979	294	103	186	5
1980	847	198	626	23
1981	2,146	503	1569	74
1982	3,848	931	2769	148
1983	4,934	1209	3531	194
1984	4,904	1263	3464	177
1985	4,209	1210	2871	127
1986	3,430	1125	2217	88
1987	2,835	1035	1731	69
1988	2,440	940	1437	64
1989	2,170	844	1270	57
1990	1,996	760	1189	46
1991	1,910	692	1180	38
1992	1,888	636	1219	33
1993	1,891	587	1276	28
1994	1,907	543	1338	26
1995	1,919	502	1392	25
1996	1,943	471	1445	27
1997	1,964	445	1486	33
1998	2,004	434	1529	41
1999	2,068	439	1579	50
2000	2,171	465	1649	57
2001	2,295	496	1741	58
2002	2,396	518	1821	57
2003	2,440	530	1851	59
2004	2,426	536	1826	63
2005	2,372	540	1768	64
2006	2,298	543	1694	62
2007	2,218	542	1620	56
2008	2,119	531	1535	53
2009	1,995	512	1427	56
2010	1,854	484	1307	63
2011	1,747	461	1215	71
2012	1,678	450	1147	81
2013	1,649	448	1101	100
2014	1,660	456	1077	127
2015	1,692	463	1085	144
2016	1,721	464	1111	146
2017	1,712	458	1112	142
2018	1,657	442	1076	139
2019	1,598	421	1038	140
2020	1,610	409	1056	145
2021	1,721	413	1152	156
2022	1,848	426	1256	166

HIV incidence was also estimated within key population groups most affected by HIV in Canada. This includes GBMSM, people who inject drugs (PWID), GBMSM-PWID, and heterosexual people. Definitions for the key populations and type of exposure to HIV are included in Appendix 2.

Among new HIV infections in 2022, an estimated 709 were among GBMSM. This represents 38.4% of all new HIV infections in 2022 (Figure 4, Appendix 3), despite GBMSM representing 3.5% of males aged 15 years and older in Canada^{Footnote 17}. The GBMSM population continues to be over-represented in new HIV infections in Canada and the absolute number of new infections has increased since 2020. However, the proportion of new infections among this population has decreased compared to 2020 (42.0%). In 2022, the estimated HIV incidence rate among sexually active GBMSM who report having anal sex with a man in the past 6 – 12 months was 187 per 100,000 people.

In 2022, an estimated 453 new infections occurred among PWID, which represents 24.5% of new HIV infections in Canada. The incidence rate among people who have injected drugs within the past 12 months was 494 per 100,000 people in 2022 (plausible range: 272 to 741 per 100,000 people^{Footnote a}). This is an increase compared to 2020 (22.2% of new infections and rate of 388 per 100,000 people). Calculating an incidence rate among heterosexual people was not possible since a population size estimate (denominator) is not available.

Text description

These two pie charts show the estimated percentage of new HIV infections by key population in 2020 and 2022.

Key Population	2020 Percentage	2022 Percentage
Gay, bisexual and other men who have sex with men (GBMSM)	42.0%	38.4%
People who inject drugs (PWID)	22.2%	24.5%
Heterosexual people	32.7%	33.4%
GBMSM-PWID	3.0%	3.7%

Geographical Breakdown

The provinces with the highest estimated number of new infections in 2022 were Quebec (522), Ontario (475), and Saskatchewan (283). There is heterogeneity among provinces / territories regarding representation of new infections by key population (Table 2). The incidence rate of HIV varies across jurisdiction with the highest being Saskatchewan (24 per 100,000 people), Manitoba (19 per 100,000 people) and Quebec (6 per 100,000 people).

HIV Prevalence – Estimated number of people living with HIV in Canada

An estimated 65,270 people were living with HIV at the end of 2022 (plausible range: 57,000-73,500) (Figure 5). This represents a 5.1% increase from the 2020 estimate (62,110 people). Of the estimated 65,270 PLHIV, 50.8% were GBMSM, 13.1% were PWID and 32.3% were heterosexual people. Males represented 74% of PLHIV, whereas females represented 25% (Appendix 3).

In 2022, the estimated HIV prevalence in Canada was 0.17% (plausible range: 0.1% and 0.2%). HIV prevalence among men was 0.25% and 0.08% among women. Estimated prevalence among GBMSM was 5.0% (plausible range: 4.3% - 5.6%), 2.2% (plausible range: 1.9% - 2.5%) among PWID and 0.9% among people who were incarcerated in federal prisons (data from Correctional Service of Canada).

Text description

This graph shows the estimated number of people living with HIV in Canada by year. The vertical axis shows point estimate of the number of people living with HIV, along with the associated low and high range estimates, and the horizontal axis shows the calendar years.

Year	Estimated number of people living with HIV	Plausible Range
		Lower bound	Upper bound
1977	44	1	97
1978	166	63	276
1979	455	215	768
1980	1276	754	1990
1981	3360	2280	4484
1982	7099	5092	9163
1983	11880	9002	14479
1984	16588	12864	20579
1985	20531	16281	25038
1986	23528	18496	29251
1987	25710	20569	32304
1988	27345	21800	34220
1989	28472	22736	35857
1990	29268	23676	36639
1991	29686	24339	36567
1992	29969	24589	36071
1993	29986	24389	35803
1994	29865	23901	35703
1995	29620	23840	35436
1996	29946	24036	35885
1997	30832	25185	37308
1998	31975	25941	38865
1999	33225	27013	40251
2000	34503	28019	41571
2001	36019	29117	43029
2002	37644	30867	44948
2003	39261	32231	46720
2004	41054	33804	48245
2005	42666	35586	49961
2006	44297	37266	51615
2007	45892	38669	53135
2008	47350	40408	54389
2009	48621	41528	55459
2010	49847	43156	57170
2011	51041	44369	58376
2012	52184	45520	59150
2013	53363	46683	60458
2014	54626	47608	62722
2015	55866	48265	64698
2016	57134	49354	65677
2017	58381	50910	66723
2018	59592	52237	67693
2019	60913	53354	69257
2020	62110	54700	70500
2021	63450	55738	72000
2022	65270	57000	73500

Geographical Breakdown

The provinces with the highest estimated number of PLHIV at the end of 2022 were Ontario (23,172), Quebec (19,101) and British Columbia (9,364). This is expected given these are the three most populous provinces in Canada. The proportion of PLHIV by key population varies across jurisdictions (Table 3).

Mortality among PLHIV

According to Statistics Canada, deaths in Canada are registered in two parts: first, the medical certificate of cause of death is completed by a certifier (usually a physician or a nurse); second, a death registration form is completed by the provincial or territorial registrar. Every province and territory have a different death registration form, however a standard medical certificate of cause of death recommended internationally by the World Health Organization is used across all jurisdictions. The medical certificate of cause of death form contains the immediate cause of death, the antecedent causes of death including the underlying cause, as well as other significant conditions contributing to the death. The underlying cause of death is defined by the WHO as the disease or injury that initiated the chain of events leading directly to death or the circumstances of the accident or violence that produced the fatal injury^{Footnote 18}.

In most official statistics and research, only the underlying cause of death is considered, despite less than 20% of deaths having only a single reported cause ^{Footnote 16}. Multiple cause death data provide information on other diseases listed on the death certificate, on associations among diseases/comorbidities, and on injuries reported when deaths result from an external cause. Although multiple cause death data improve accuracy of reporting on mortality related to HIV/AIDS, it is not a complete picture of all PLHIV who have died either because of HIV/AIDS or other causes, due to under-reporting or reporting delay. For the purposes of these estimates, other sources of data are used to more closely approximate all-cause mortality among all PLHIV. The Public Health Agency of Canada works with each jurisdiction to estimate all-cause mortality among PLHIV. This is a necessary step in estimating the number of people currently living with HIV in Canada.

Figure 6 shows a comparison of three different measures of mortality related to HIV in Canada. First, it shows the number of deaths where HIV/AIDS was listed as the underlying cause of death, as reported by Statistics Canada. Second, it shows the number of deaths where HIV/AIDS was listed either as the underlying cause or as one of the 19 antecedent causes of death, also based on data from Statistics Canada. Finally, the figure shows an estimated number of all-cause mortality among PLHIV, adjusting for under-reporting and reporting delays.

In 2022, the number of deaths where HIV/AIDS was listed as either the underlying cause or one of the 19 antecedent causes of death (n= 309), is higher than the number of deaths where HIV/AIDS was the listed as only the underlying cause (n=126). Expectedly, the estimated total number of deaths among PLHIV in Canada, which accounts for under-reporting and reporting delay, was highest at 855.

In the late 1980s and early 1990s, many PLHIV died from their HIV infection (i.e. HIV was the underlying cause of death), therefore the vital statistics data on underlying cause of death closely approximated the estimated all-cause mortality among PLHIV, with deaths with the underlying cause listed as HIV/AIDS making up 85-90% of the estimated all-cause mortality. However, after the introduction ART for HIV in the mid 1990s, deaths with HIV/AIDS listed as the underlying cause decreased significantly. Between the late 1990s and early 2000s, deaths with the underlying cause listed as HIV/AIDS made up approximately 60% of the estimated all-cause mortality among PLHIV. In recent years, this decreased to approximately 15%, highlighting the effectiveness of treatment and the importance of comorbidities as competing risks as PLHIV age ^{Footnote 19}.

Fig 6 Footnote *

Statistics Canada has documented up to 20 causes of death since 2000.

Return to footnote * referrer

Text description

This graph shows annual number of deaths with HIV/AIDS as the underlying cause, the number of deaths with the underlying cause or 19 other antecedent causes as HIV/AIDS, and the estimated all-cause mortality among people living with HIV. The vertical axis shows the number of deaths and the horizontal axis shows the calendar years. Please note data from Statistics Canada on the 19 other antecedent causes of death is only available starting in 2000.

Year	Underlying cause - HIV/AIDS	Underlying or 19 other causes - HIV/AIDS	Estimated all-cause mortality among PLHIV
1987	511	No data	567
1988	642	No data	722
1989	820	No data	960
1990	944	No data	1117
1991	1119	No data	1406
1992	1301	No data	1429
1993	1493	No data	1679
1994	1565	No data	1823
1995	1679	No data	1945
1996	1210	No data	1470
1997	576	No data	912
1998	436	No data	692
1999	393	No data	653
2000	460	546	755
2001	405	472	632
2002	386	459	630
2003	402	480	684
2004	393	472	692
2005	437	521	732
2006	406	495	685
2007	396	487	704
2008	379	481	735
2009	321	450	713
2010	305	404	677
2011	272	393	647
2012	258	356	635
2013	217	408	612
2014	192	359	560
2015	179	316	613
2016	172	353	663
2017	137	295	637
2018	141	284	689
2019	102	289	671
2020	129	306	821
2021	133	304	843
2022	126	309	855

Canada's progress toward meeting the 95-95-95 HIV targets

In Canada at the end of 2022, an estimated 65,270 people were living with HIV (plausible range: 57,000 – 73,500). Among those living with HIV, an estimated 89% (plausible range: 83%-95%) were diagnosed. Of those diagnosed, 85% were estimated to be on treatment (plausible range 81% - 89%) and an estimated 95% of people on treatment had a suppressed viral load (plausible range: 93% - 97%) (Figure 7 and Table 4).

Fig 7 Footnote *

Treatment and viral suppression data were not available from four jurisdictions. To account for these missing data, these four jurisdictions were removed from the denominator in the calculation of the national 2nd and 3rd 95 targets.

Return to footnote * referrer

Text description

This vertical bar graph shows the estimated number of persons in Canada at the end of 2022 who were living with HIV, diagnosed, on treatment, and virally supressed. The horizontal axis shows the four components that were estimated (people living with HIV, diagnosed with HIV, on treatment, and suppressed viral load). The vertical axis shows the estimated number of persons, with the low and high ranges associated with each component.

This graph also shows the point estimate and plausible range associated with each of the three 95-95-95 targets. The first target is the percentage of persons living with HIV who are diagnosed; the second target is the percentage of persons diagnosed who are on treatment; and the third target is the percentage of persons on treatment who had suppressed viral load.

Estimated number of persons

Estimated number of persons	Lower bound	Point estimate	Upper bound
Living with HIV	57,000	65,270	73,500
Diagnosed with HIV	54,170	58,220	62,010
On treatment	42,980	45,330	47,220
Suppressed viral load	42,160	43,240	43,970

95-95-95 Measures

95-95-95 Measures	Lower bound	Point estimate	Upper bound
Percentage of persons living with HIV who were diagnosed	83%	89%	95%
Percentage of persons diagnosed who were on treatment	81%	85%	89%
Percentage of persons on treatment who had suppressed viral load	93%	95%	97%

Canada's progress towards achieving the 95-95-95 targets, has stalled since 2020. Using current methods and updated data to revise the 2020 estimates, it was estimated that in 2020, 89% (plausible range: 83%-95%) of PLHIV knew their status, 87% (plausible range: 83%-91%) of those diagnosed were on antiretroviral treatment, and 95% (plausible range: 93%-97%) of those on treatment had a suppressed viral load.

The 95–95–95 targets and the HIV care continuum are two ways of looking at the same data. When we report on the progress towards the 95-95-95 targets, the denominator for each of the 95 targets is different (described in Table 1). The first 95 numerical value is the denominator for the second 95, and the second 95 numerical value is the denominator for the third 95. If we look at the data differently, across the HIV care continuum, the denominator for each step remains the same - all PLHIV. In this approach, when all three 95-95-95 targets are achieved, 90% of all PLHIV will be on ART (95% x 95%), and 86% of all PLHIV will be virally suppressed (86% x 95%) ^{Footnote 4}.

Using the care continuum measurement approach, 72% of PLHIV in Canada in 2022 were estimated to have a suppressed viral load; these people would be expected to derive personal health benefits and would not pass on infection sexually, decreasing further HIV transmission, as long as they are virally suppressed (Figure 8).

Fig 8 Footnote *

Treatment and viral suppression data were not available from four jurisdictions. To account for these missing data, these four jurisdictions were removed from the denominator.

Return to footnote * referrer

Text description

This vertical bar graph shows Canada's overall HIV care continuum estimates, and gaps to meet global elimination targets, 2022. The continuum of care shows the proportion of persons living with HIV (n = 65,270) who are diagnosed, on treatment and virally suppressed.

Care continuum measure	Global elimination target	2022 Canada estimates	Gap to achieve target
Percentage of persons living with HIV who were diagnosed	95%	89%	6%
Percentage of persons living with HIV who were on treatment	90%	76%	14%
Percentage of persons living with HIV who were virally suppressed	86%	72%	14%

By using data to better understand who has been missed throughout the care continuum, community and public health programs can be adjusted to improve their reach to PLHIV, then increase the number of people who achieve and maintain viral suppression.

Text description

This pie chart shows the estimated percentage of people not engaged or represented in the HIV care continuum, 9 jurisdictions in Canada, 2022.

People not engaged or represented in the care continuum	Percentage
People who were undiagnosed	47.1%
People who were diagnosed but not on treatment	40.2%
People were on treatment, but did not have a suppressed viral load	12.7%

Identifying gaps along the HIV care continuum can help make necessary course-corrections to improve prevention and care programs where needed most in Canada. In the nine jurisdictions in Canada where data were available, 16,413 people were not engaged in HIV care continuum (Figure 9). The most significant gaps were among those who were diagnosed but not on treatment (7,729; 47.1%), followed by those who were undiagnosed (6,590; 40.2%), suggesting a need for interventions targeting linkage and retention in care as well as testing, respectively. An estimated 2,092 (12.7%) of people were on treatment, but did not have a suppressed viral load. Individuals missed along the HIV care continuum present an important opportunity to assure better individual health outcomes and to reduce community transmission of HIV.

95-95-95 estimates by sex

In a continued effort to measure progress towards global HIV targets for epidemiologically relevant groups in Canada, the Agency estimates the number of PLHIV by sex, defined as sex assigned at birth, and reports on Canada's progress towards the 95-95-95 targets by sex and by province or region. In Canada at the end of 2022, among the estimated 65,270 PLHIV, 48,370 were males (74.1%), and 16,540 were females (25.3%). Among males living with HIV, an estimated 90% were diagnosed. Among those diagnosed 86% were estimated to be on treatment, and an estimated 96% of those on treatment had a suppressed viral load (Figure 10 and Table 5). Compared to males living with HIV in Canada, females appear to have had lower awareness of infection, as well as treatment and viral suppression levels. Among females living with HIV, an estimated 86% were diagnosed. Of those diagnosed, 84% were estimated to be on treatment, and an estimated 92% of those on treatment had a suppressed viral load (Figure 9 and Table 5).

Fig 10 Footnote *

Treatment and viral suppression data were not available from four jurisdictions. To account for these missing data, these four jurisdictions were removed from the denominator in the calculation of the national 2nd and 3rd 95 targets.

Return to footnote * referrer

Text description

This vertical bar graph shows the estimated number of persons in Canada at the end of 2022 who were living with HIV, diagnosed, on treatment, and virally supressed by sex. The horizontal axis shows the four components that were estimated (people living with HIV, diagnosed with HIV, on treatment, and suppressed viral load). The vertical axis shows the estimated number of persons associated with each component.

This graph also shows the point estimate associated with each of the three 95-95-95 targets by sex. The first target is the percentage of persons living with HIV who are diagnosed, the second target is the percentage of persons diagnosed who are on treatment, and the third target is the percentage of persons on treatment who are virally suppressed.

95-95-95 Measure	Males	Females
Estimated number of persons living with HIV	48,370	16,540
Percentage of persons living with HIV who were diagnosed	90%	86%
Percentage of persons diagnosed who were on treatment	86%	84%
Percentage of persons on treatment who were virally suppressed	96%	92%

It is estimated that 11,414 males and 4,970 females in the 9 jurisdictions in Canada were not engaged or represented in the continuum of care. For both males and females, the most significant gaps were among those who were diagnosed, but not on treatment (50% for males, and 41% for females), followed by those who were undiagnosed (39% for males and 36% for females).

95-95-95 estimates by geography

Routinely assessing not only country-level, but also regional progress towards HIV targets is critical to determining progress. Progress towards the 95-95-95 global targets, across provinces and territories in Canada is presented below. Some jurisdictions have been grouped together because delivery of HIV treatment and care is conducted jointly between two provinces, or because the data are too small to be presented separately.

Two jurisdictions have met the first 95 target, with ≥95% of PLHIV in their region being diagnosed. Most of the other jurisdictions still have progress to make to meet the first 95 target (Figure 11). The proportion of people diagnosed with HIV who were on treatment ranged from 73% to 99%, with one jurisdiction meeting the second 95 target. Five of the jurisdictions met the 3rd 95 target for viral suppression (Figure 11).

Text description

This horizontal bar graph shows each province or region's point estimate associated with each of the three 95-95-95 targets at the end of 2022. The first target is the percentage of persons living with HIV who were diagnosed, the second target is the percentage of persons diagnosed who were on treatment and the third target is the percentage of persons on treatment who had a suppressed viral load. The graph also shows a vertical line which represents the UNAIDS 2025 targets of 95% and demonstrate each province or region's progress toward this target.

Province or Region	% of persons living with HIV who were diagnosed	% of persons diagnosed who were on treatment	% of persons on treatment who had a suppressed viral load
British Columbia (BC)	94%	94%	96%
Alberta (AB)	92%	No data	Not data
Saskatchewan (SK)	76%	73%	84%
Manitoba (MB)	81%	83%	78%
Ontario (ON)	90%	86%	98%
Quebec (QC)	89%	82%	96%
New Brunswick & Prince Edward Island (NB & PE)	88%	99%	97%
Nova Scotia (NS)	87%	88%	92%
Newfoundland (NL)	95%	88%	98%
Territories	92%	No data	No data
Canada	89%	85%	95%

95-95-95 estimates among key populations

HIV disproportionately affects certain populations and communities, and progress towards the 95-95-95 targets vary across key populations. Table 6 shows the most recent 95-95-95 estimates among key populations. Updated data for 2022 were provided for people incarcerated in federal correctional facilities, and people living in First Nations communities in Saskatchewan. Data for all other key populations are from previously published reports.

HIV Prevention and Stigma

HIV prevention is an essential component of the global health strategy to eliminate the HIV epidemic ^{Footnote 3}. Combination HIV prevention strategies include structural, biomedical, and behavioural interventions to prevent HIV transmission ^{Footnote 28}. In this report, prevention measures focus on data related to HIV vertical transmission, HIV-PrEP and HIV-PEP.

Although innovations in HIV prevention, testing and treatment have generally led to better individual and population health outcomes among Canadians ^{Footnote 1}, stigma and discrimination experienced by PLHIV continue to be pervasive issues that undermine HIV elimination efforts. HIV-related stigma and discrimination can include experiences of avoidance, social rejection, verbal and physical abuse, denial of health or social services, and loss of employment and education, among many others ^{Footnote 29}. These experiences can have adverse impacts at each stage of the HIV care cascade, as they can impede an individual's access to HIV services, adherence to treatment and retention in care ^{Footnote 29}.

Vertical Transmission of HIV in Canada

In 2022, 239 infants were perinatally exposed to HIV and there were six new perinatal HIV infections in children born in Canada. The proportion of women and other pregnant PLHIV who received antiretroviral therapy (ART) during pregnancy in 2022 was 96%. In 2022, of the six infants experiencing perinatal HIV transmission, three were born to mothers who received some or partial ART. Two of the infants were born to mothers who did not receive any ART, and one was born to a mother where use of ART could not be confirmed. Additional data are included in the annual HIV surveillance report ^{Footnote 31}.

HIV-PrEP & HIV-PEP

HIV-PrEP

HIV-PrEP involves antiretroviral medication that is taken either on-demand or continuously before HIV exposure ^{Footnote 32}. The use of HIV-PrEP in Canada is increasing each year. The annual prevalence of HIV-PrEP use was 43 per 100,000 people in 2018 and increased to 89 per 100,000 people in 2022. Annual estimated HIV-PrEP use prevalence varies across the country (Table 7).

In 2022:

• 98% of HIV-PrEP was used by males and 2% by females.
• HIV-PrEP use was highest in those aged 30 – 39 years.
• 54% of HIV-PrEP prescriptions were paid for by private insurance, 43% by public insurance, 1% out of pocket and 1% by combined private and public insurance.
• 47% of HIV-PrEP prescriptions were provided by primary care physicians, 16% by physician specialists and 37% by other practitioners (e.g. physician specialty unknown, nurse practitioners).

HIV-PEP

HIV-PEP involves the use of antiretroviral medications taken for 28 days immediately following a potential high-risk HIV exposure ^{Footnote 32}. The annual prevalence of HIV-PEP use was 29 per 100,000 people in 2018 and increased to 41 per 100,000 people in 2022 (Table 8).

In 2022:

• 62% of HIV-PEP was used by males, and 38% by females.
• HIV-PEP use was highest in those aged 30 – 39 and 20-29 years (88 and 86 per 100,000 people respectively)
• 44% of HIV-PEP prescriptions were paid for by private insurance, 41% by public insurance, and 15% were paid for out of pocket.
• 54% of HIV-PEP prescriptions were provided by primary care physicians, 19% by physician specialists and 27% by other practitioners (e.g. physician specialty unknown, nurse practitioners).

HIV-Related Stigma

Data from the tracks biobehavioural surveys among key populations showed that:

• Among participants from the Tracks survey of PWID (Phase 4, 2017-2019) who were aware of their HIV-positive status, 45.3% reported they avoided HIV services in the past 12 months because of stigma and discrimination ^{Footnote 12}. Tracks survey implemented by First Nations in Saskatchewan and Alberta (2018-2020) asked the same question, however results were not published due to a small number of responses.
• Among Canadian participants from the European Men-who-have-sex-with-men Internet Survey (EMIS-2017) ^{Footnote 13}: 1.5% had experienced physical abuse, including being punched, kicked, beaten or hit; 22.1% had experienced verbal abuse, including insults; and 31.9% had experienced intimidation, including being stared at or intimidated - because someone knew or presumed they were attracted to men.

Data from the OHTN Cohort Study ^{Footnote 14} showed that:

• 91.5% of participants indicated that they had experienced any type of stigma.
  • Disclosure concerns were most commonly reported at 83.9%, followed by concerns about public attitude (65.9%), self-image (43.5%) and personalized stigma (36.8%).
  • Of these participants who experienced any type of stigma, 11% also reported having experienced discrimination within the healthcare system.
• Among priority populations receiving HIV treatment, stigma experiences were highest in the African, Caribbean and Black (ACB) population (96.5%), followed by women (95.6%) and GBMSM (90.5%).

The STOP HIV/AIDS Program Evaluation (SHAPE) examined the association between the year of an individual's HIV diagnosis and HIV-related stigma scores. Researchers found that there was no difference in experiences of HIV-related stigma among those with recent diagnoses, compared to those diagnosed early in the AIDS epidemic ^{Footnote 15}.

Discussion / Conclusion

The national HIV estimates report for 2022 provides updated insight into the trends of HIV in Canada. In 2022, an estimated 1,848 new infections occurred in Canada and HIV incidence has been increasing since 2014. At the end of 2022, an estimated 65,270 people were living with HIV in Canada. HIV treatment has reduced HIV-related mortality, and new infections are occurring at a rate greater than the number of deaths, resulting in an increase in the overall number of PLHIV in Canada. This trend will likely continue to increase and result in an increased demand for HIV-related care and treatment.

Among the 65, 270 PLHIV in Canada, an estimated 89% were diagnosed, 85% of those diagnosed were on treatment, and 95% of those on treatment were virally suppressed. Canada's path towards elimination of HIV as a public health concern by 2030 has stalled. While Canada continues to succeed with respect to people having a suppressed viral load once on treatment (3^rd 95), it falls short on the diagnostic (1^st 95) and treatment (2^nd 95) targets for 2025. These data highlight the need for a stronger and more inclusive response to effective HIV services to reduce the ongoing transmission of HIV infection.

Canada's stalled progress on meeting the 95-95-95 HIV targets may be the result of several interrelated and complex factors. This includes the COVID-19 pandemic and the subsequent reduction in access to HIV prevention, testing and treatment services^{Footnote 33}. Intersecting health challenges such as socio-economic complexities, geographical location, health status, misinformation about HIV and HIV-related stigma can result in barriers to accessing HIV care and adherence to treatment. Although innovations in HIV prevention, testing and treatment have led to better individual and population health outcomes among Canadians, stigma and discrimination experienced by PLHIV continue to be pervasive issues that threaten to undermine HIV elimination efforts. As a part of the Pan-Canadian STBBI Framework for Action, Canada has set a strategic goal of reducing stigma and discrimination that create vulnerabilities to STBBI ^{Footnote 1}. A multi-disciplinary and collaborative approach where HIV programs are integrated and linked to care is required for HIV prevention and treatment services to be available for all Canadians that need it. Identifying and removing barriers so that Canadians have equitable access will require systematic change within the healthcare system. This will require the collaboration of many key partners, including PLHIV, key populations, governments, communities, academia, researchers, and health-care providers ^{Footnote 1}.

Despite current efforts, Canada has not seen a decrease in new HIV infections in recent years and further work is needed to meet the global 95-95-95 targets. The Agency will continue to work closely with provinces and territories to improve the ability to measure and assess progress towards ending the HIV epidemic ^{Footnote 6}. These estimates will be used to measure Canada's progress in meeting the priorities set out in the Government of Canada five-year STBBI action plan, with the goal of accelerating prevention, diagnosis and treatment to reduce the health impacts of STBBI by 2030.

Appendix 1. Additional detail related to Canada's modelling method

Reference: Yan, Ping; Zhang, Fan; and Wand, Handan (2011). Using HIV Diagnostic Data to Estimate HIV Incidence: Method and Simulation. Statistical Communications in Infectious Diseases: Vol. 3: Iss. 1, Article 6.

The statistical modelling method that was used to estimate the number of new HIV infections in Canada is based on a back-calculation method that combines HIV and AIDS diagnostic data (from national routine HIV/AIDS surveillance) with data on the proportions of recent infections among newly diagnosed individuals (from specialized recent infection laboratory testing algorithms). The model estimates the time trend in the number of past HIV infections, up until the present time (2022 in this case) since surveillance data can only record the date of diagnosis and not the date of infection (which is some time before diagnosis). From this trend in past HIV infections, the model then projects forward to calculate the expected number of HIV diagnoses (using a mathematical formulation of the time between HIV infection and diagnosis based on the recent-infection algorithm data and model assumptions). The back-calculation method used for incidence estimation in Canada is similar to methods used in the European Union, the USA, and Australia. Once the time trend in past HIV infections has been estimated, cumulative HIV incidence is calculated by adding up the incidence estimates for all years up to and including the most recent year (2022 in this case). Prevalence for the most recent year is then calculated as the cumulative incidence minus estimated total mortality among HIV infected people. For this, total mortality needs to be estimated (using data from Statistics Canada, provincial/territorial vital statistics, national reports of AIDS deaths, and Canadian research studies) since vital statistics data only record mortality among people who died of HIV-related causes. Note that there are additional details not discussed here, such as accounting for HIV cases who had been previously diagnosed, who were likely infected in another province/territory or country, or who migrated out of the province / territory.

Appendix 2. Key population definitions

Key populations used for the national estimates of HIV incidence and prevalence

In previous reports, the heterosexual category was separated into an "endemic" group (people born in a so-called HIV-endemic country, mainly sub-Saharan Africa, and the Caribbean) and a "nonendemic" group (born elsewhere). 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.

Appendix 3. National HIV incidence and prevalence tables

HIV incidence: Estimated number of new HIV infections and associated plausible ranges in Canada in 2022 and 2020, by key population, and sex.

HIV prevalence: Estimated number of PLHIV and associated ranges in Canada at the end of 2022 and 2020, by key population, and sex.

Appendix 4. Canada's progress towards global HIV elimination targets, 2022

Canada's progress towards HIV elimination targets outlined in the 2022-2030 Global Health Sector Strategy on STBBI