First it was gay men. Then it was drug users.
Now the face of Canada’s HIV crisis is immigrants and refugees from regions where the virus is endemic.
An alarming rise in infection rates among immigrants from Africa and the Caribbean has caught public health authorities off guard and brought warnings that governments have failed to protect some of the country’s most marginal communities.
Last year, Health Canada for the first time released epidemiological data showing that among those infected with the human immunodeficiency virus, those from HIV-endemic regions in Africa and the Caribbean now form the fourth-largest group. In Ontario, they are the second-largest HIV group, fewer than gay men but more numerous than injection-drug users.
Researchers and community groups say they have pressed Ottawa for years to collect epidemiological data on this group, and to tailor prevention and treatment programs to their needs.
“The way Health Canada collects the . . . data has not helped capture shifts in the disease,” said Esther Tharao of Women’s Health in Women’s Hands, a Toronto community health centre.
“Ottawa has an HIV strategy for aboriginal communities, for IV drug users and gay men. But there is no information on how to deliver services to people from HIV-endemic regions.
Ottawa has not developed federal guidelines.”
According to the Canada Communicable Disease Report, an estimated 3,700 to 5,700 people (7 to 10 per cent) of the 56,000 people in Canada living with HIV or AIDS at the end of 2002 were heterosexuals from African and Caribbean countries. Fifty-eight per cent were gay men, and 20 per cent were injection-drug users.
Ottawa began testing all immigrants and refugees for HIV only in 2002.
Community health-care workers say cultural taboos, fear of discrimination and deportation and the shame associated with HIV may make people from regions where it is endemic reluctant to seek medical attention or be tested.
As newcomers, they are often more isolated, and come from sexual cultures where practices such as female genital mutilation and vaginal cleansing may render mainstream prevention programs ineffective, Ms. Tharao said.
Dr. Chris Archibald, with the Centre for Infectious Disease Prevention and Control, said Ottawa is aware of the slow but steady increase of infection among people from HIV-endemic regions. “We have to work with provincial and territorial counterparts to find out why and to provide services for those people,” he said.
Health Canada has supported a number of funding projects for such groups, he added, and has doubled the overall annual funding for HIV/AIDS to $84.4-million over the next five years. Ottawa also funds programs in HIV-endemic countries in Africa and the Caribbean to help stem the spread of a disease that does not respect international borders.
Dr. Archibald points out that one of the challenges of tracking the virus among those from HIV-endemic regions is the lack of reliable data. Ontario and Quebec do not include ethnicity on HIV test reports.
Robert Remis, a University of Toronto researcher, says that has not stopped him from developing surveillance reports in Ontario based on statistical modelling. A study he conducted estimates that 12 per cent of Ontario’s 22,100 HIV/AIDS cases at the end of 2002 were people from Africa and the Caribbean.
“It’s striking that it has taken so long to bring attention to this issue,” Prof. Remis said. “We had a hard time convincing Health Canada to even mention this group in their annual surveillance report. We had to persuade them the HIV-endemic group is a distinct group with its own epidemiology.”
His research also found that in up to half of cases, transmission occurs after arrival in Canada, challenging the stereotype that immigrants are bringing the virus here.
He does credit Health Canada for its recent $200,000 grant to the African Caribbean Council on HIV in Ontario to develop prevention guidelines, training and a research agenda.
Through the efforts of Stephen Lewis, the UN’s special envoy on AIDS in Africa, and musician Bono, Canadians have been made aware of the terrible toll of HIV/AIDS in Africa and the Caribbean. But few realize how the pandemic is affecting people who have come to Canada from those parts of the world.
In Brooks, Alta., where a large number of African immigrants work in a meat-packing plant, health officials are confronting rising rates of HIV infection. Many of those who test positive for the virus are so concerned about maintaining their anonymity that they do not want to go in person to the nearest HIV clinic, in Medicine Hat.
Counsellor Bettie Christie ends up sending them bus tickets in the mail so they can seek treatment at a clinic in Calgary, 185 km. away.
“It’s frustrating. They fear they may lose their jobs or be deported. Their support systems are already so limited, they fear disclosing their HIV status could lead to more isolation,” Ms. Christie said. She added that one-third of her 22 clients at the HIV/AIDS Network of South Eastern Alberta are African immigrants.
Of Alberta’s approximately 1,000 cases of HIV, 9 per cent are people who moved there from endemic regions in Africa and the Caribbean.
Since Canada began screening both immigrants and refugees for HIV infection in 2002, refugees and those sponsored by family members who test positive are allowed into the country.
But immigrants and those seeking work or study permits are refused entry if they are deemed to place an excessive demand on the health-care system, defined as needing more than $15,016 worth of publicly funded health care over five years.
While many feared the screening would lead to discrimination, early data suggest that in 2002 only 75 would-be immigrants were barred from Canada because of HIV.
In the Palliser health region, where Brooks is located, officials worry the virus will spread without effective prevention programs. Yet they also fear that the safe-sex campaign they plan to unveil will cause a backlash by linking HIV with immigrants in the public mind in a town besieged by racial tensions.
“HIV/AIDS has been circulating in our communities already, and among newcomers it is there too, though the numbers are small . . . but in a small community, it is enough to unleash panic,” said Paul Schnee, Palliser’s medical officer of health.
About one-fifth of the population of Brooks is comprised of recent African immigrants and refugees, drawn to the town of 12,500 to work for Lakeside Packers, a $150-million plant owned by American conglomerate Tyson Foods.
Ms. Christie would like more funding to hire translators and develop programs tailored to the cultural needs of newcomers. “A large percentage of the African population isn’t yet willing to trust us,” she said.
In larger cities such as Toronto, there are organizations devoted to the health needs of HIV-positive people from endemic regions, such as the Black Coalition for AIDS Prevention.
But an immigrant from the Caribbean who contracted HIV after arriving in Toronto complains there are not enough programs directed at women and families. “A lot of the HIV focus in Canada is still on gay white men,” she said.
Ontario is ahead of Ottawa in that it has already developed a strategy to deal with people from endemic regions and has an HIV-Endemic Task Force.
Ms. Tharao noted that mainstream organizations do not understand the sexual habits or attitudes of people from traditional cultures. For example, some African and Caribbean cultures are homophobic, so men hide their gay relationships.
Some women have undergone genital mutilation, making the use of female condoms impossible. Others engage in cleansing with herbs that can cause vaginal lacerations, making transmission of HIV more likely.
Dr. Archibald noted that until a few years ago, there was a sensitivity around presenting epidemiological data on HIV among people from endemic regions. “The general mood has changed so the communities themselves recognize that such data is needed so they can advocate for their cause,” he said.