Abstract
Background
In 2017, the international European Men-who-have-sex-with-men Internet Survey (EMIS-2017) collected data from 50 countries, including Canada for the first time.
Objective
To provide an overview of the Canadian EMIS-2017 data to describe the sexually transmitted and other bloodborne infection (STBBI) related needs of gay, bisexual and other men who have sex with men (gbMSM).
Methods
The EMIS-2017 questionnaire was an updated version of EMIS-2010. It included self-reported sociodemographic data, experience of discrimination, mental health and substance use, knowledge of preexposure prophylaxis (PrEP) for HIV, sexual practices and history of STBBI testing and diagnosis. Analysis was largely descriptive.
Results
Of the 6,059 respondents from Canada, 5,165 participants met the inclusion criteria for this analysis. The majority of participants were born in Canada (79.3%); and over half of the respondents (56.7%) were under the age of 39. In terms of discrimination related to their attraction to other men, participants reported high levels of intimidation (31.9%), verbal abuse (22.1%) and physical violence (1.5%) in the previous year. Regarding mental health, 23.9% had a moderate to severe depression/anxiety score. Almost two-thirds (64.1%) indicated substance use and one-fifth (21.5%) reported chemsex (or the use of stimulant drugs to make sex more intense or last longer). Only 8.4% of participants reported use of PrEP for HIV; however, 51.7% reported being likely to use PrEP if it was available and affordable. Sexual practices, such as condom use, varied by PrEP use with 91.3% of men using PrEP reporting condomless anal intercourse (CAI) compared with 71.5% of men not on PrEP. In terms of STBBI testing, 1.5% reported being diagnosed with hepatitis C and 9.0% reported an HIV diagnosis. Of those with an HIV diagnosis, most were on treatment (99.1%) and had an undetectable viral load (96.7%).
Conclusion
gbMSM in Canada experienced stigma, discrimination and mental health problems; substance use was high as were high-risk sexual practices, such as CAI, among some groups of men. There was a gap between the proportion of men who were interested in PrEP and those who actually used it; and comprehensive STBBI testing was low.
These findings can inform public health action and provide a baseline to examine the impact of current and new interventions.
Keywords: HIV, sexually transmitted infections, sexual risk practices, gay bisexual and other men who have sex with men, gbMSM, preexposure prophylaxis, postexposure prophylaxis
Introduction
In 2017, the second iteration of the European Men-who-have-sex-with-men Internet Survey (EMIS-2017) was launched (1). This survey collected data from gay, bisexual and other men who have sex with men (gbMSM) living in 50 countries, with the aim of generating data useful for planning HIV and sexually transmitted infection (STI) prevention and care programs, and monitoring of progress in these areas (1). Canada participated in this survey for the first time.
In Canada, gbMSM continue to be particularly affected by sexually transmitted and bloodborne infections (STBBIs). In 2016, it was estimated that gbMSM make up more than half (52.5%) of the population living with HIV infection in Canada (2). Rates of syphilis and gonorrhea have increased over the past several years, with the increase among men largely in the gbMSM population in Canada (3–5) and internationally (6,7). Hepatitis C is also on the rise among gbMSM who are HIV-positive (8).
The reasons for this are multifactorial. Among HIV-negative men, new preventive interventions like preexposure prophylaxis (PrEP) in combination with reduced use of condoms may, in part, contribute to the rise in STIs other than HIV (3,4). Among HIV-positive men, serosorting and knowledge of an undetectable viral load may lead to minimizing the risk of HIV transmission, which can lead to a concurrent decreased use of condoms, thus increasing the risk of other STBBIs (3,4). Other factors that could be influencing rates of STBBIs include changing community norms and the use of illicit drugs to enhance sexual experiences (i.e. party and play/chemsex) (9). Structural factors, such as stigma related to sexual orientation and to HIV infection, a lack of provider knowledge and training in gbMSM sexual health risks and needs, and issues related to cost and access to PrEP and HIV treatment may also be contributing to the STBBI burden among gbMSM (10).
Gathering national-level information on risk and prevention behaviours, health service needs and health outcomes is crucial for understanding the current trends and for guiding the planning and evaluation of public health interventions to prevent STBBIs among gbMSM. The objective of this report is to provide an overview of the EMIS-2017 data from Canada.
Methods
EMIS-2017 was undertaken by Sigma Research at the London School of Hygiene and Tropical Medicine in association with the Robert Koch Institute in Berlin. The survey was funded by the European Union Health Programme 2014–2020 for Europe. The survey ran from October 2017 to January 2018, inclusively, across 50 countries. In Canada, the Public Health Agency of Canada (PHAC) funded the promotion of the survey to Canadian gbMSM. Community-involved researchers (NJL, MB, DJB, TAH and BA), along with two PHAC representatives, provided feedback on the questionnaire and recruitment methods and a review and interpretation of the results.
While EMIS uses the term “men who have sex with men (MSM)”, the authors use the term “gbMSM“ to describe the same population as the latter is commonly used in Canada. A more detailed description of the methods can be found elsewhere (11).
Questionnaire
The EMIS-2017 survey was based on the questionnaire successfully used in EMIS-2010. Updates were based on a review of evidence of the epidemiology of HIV infection and STIs; the STBBI-related risk and precautionary behaviours of gbMSM; a policy and practice mapping exercise; a scoping exercise of available gbMSM questionnaires published since EMIS-2010; and three rounds of consultations with partner countries, including Canada.
The final version of the questionnaire included questions on:
Sociodemographic characteristics of EMIS participants
Experiences of discrimination, mental health and substance use
Knowledge and use of postexposure prophylaxis (PEP) and PrEP
Sexual practices – information on chemsex was captured by asking about the use of stimulant drugs (including ecstasy/MDMA, cocaine, amphetamine, crystal methamphetamine, mephedrone and ketamine to make sex feel more intense or last longer)
STBBI testing and diagnosis
The survey was available in 33 languages simultaneously, including 22 of the 23 official languages of the European Union; Canadian researchers provided edits to both the French and English version and the questionnaire was piloted among a small group of Canadian gbMSM. The EMIS-2017 questionnaire can be found online (12).
Recruitment
Sigma staff commissioned advertising from 10 multi-country “dating” platforms including PlanetRomeo, Grindr, Hornet, Qruiser, RECON, Scruff, Gaydar, Manhunt/Jack’d, GROWLr and Bluesystem. Within Canada, advertisements and banners on social media, gay news websites and sexual networking apps were posted. Electronic and offline promotional materials were provided to community-based organizations across Canada, such as the Health Initiative for Men, for distribution to their networks.
All online promotions of EMIS, paid or unpaid, were allocated a specific URL to direct potential participants to the EMIS landing page. Here they could make their language selection and proceed to the survey; this page also captured data on the recruitment source. Unfortunately, the Grindr Source codes were erroneously labelled in Canada; during data cleaning, these were rectified as much as possible using the timeline for participation invitations sent out by Grindr.
Consent and inclusion criteria
Before proceeding to the survey, participants in Canada had to confirm that they had read and understood the nature and purpose of the study, wanted to participate and were aged 16 years or older. Inclusion criteria included:
Living in one of 50 countries participating in the study
Identifying as a man, including cisgender men (i.e. individuals assigned male at birth who identify as men) and transgender men (i.e. individuals assigned female at birth who identify as men)
Being sexually attracted to men and/or ever having had sex with men
For the purposes of this analysis, participants needed to provide the first part of their postal code so they could be assigned to a province or territory. Three discrepancy flags were created with regard to age, steady male partners and non-steady partners. Participants with inconsistent data were excluded from this analysis.
Analysis
Descriptive analyses (frequencies and proportions) were conducted. Participants’ characteristics were described by province and territory. Due to sample sizes less than 10, men who resided in Yukon were combined with those living in British Columbia, those from Northwest Territories with Alberta and those from Nunavut with Ontario. Similarly, participants from Manitoba and Saskatchewan were combined as were those from the four Atlantic Provinces.
A combined measure of anxiety and depression was calculated using a validated brief screening scale for anxiety and depression, the Patient Health Questionnaire-4 (13). The CAGE 4-item questionnaire was used as an indicator of alcohol dependency (14).
To monitor the uptake and effect of new HIV prevention strategies, the following indicators were derived:
Anal intercourse with casual partners
Condom use with casual partners
Any condomless anal intercourse (CAI) with casual partners in the last 12 months by HIV-positive men on HIV treatment and with an undetectable viral load
Any CAI with casual partners in the last 12 months by HIV-negative men on PrEP
Any CAI with casual partners in the last 12 months by HIV-positive men not on HIV treatment or with a detectable viral load
Any CAI with casual partners in the last 12 months by HIV-negative or untested men not on PrEP (15). Casual partners were defined in the questionnaire as non-steady partners: “men you have had sex with once only, and men you have sex with more than once but who you don’t think of as a steady partner
“Full STI screening” was a composite variable indicating testing for HIV infection, a blood test, an anal swab and a urethral swab (or a vaginal swab or a urine test) in non-HIV-diagnosed respondents in the previous 12 months. Only non-HIV-diagnosed respondents were included in this indicator to ensure that it was not influenced by counts from HIV-diagnosed men who typically have regular routine STI checks as part of their clinical follow-up. This variable was developed for cross-country comparison of STI testing and treatment services coverage in the Dublin Declaration Monitoring (16). Although pharyngeal swabs are recommended in Canada (17), EMIS-2017 did not collect this information.
Numbers and proportions were suppressed when the numerator was less than five and the denominator was less than 100.
Results
A total of 6,059 Canadian gbMSM participated in EMIS-2017. Of these, 894 (14.8%) were removed because they had discrepant data or did not provide a forward sortation area (i.e. first three characters of their postal code) and so could not be categorized by province/territory. The remaining 5,165 participants from Canada were included in this analysis.
Characteristics of EMIS participants
All provinces and territories were represented, with 23.1% from British Columbia and Yukon, 13.7% from Alberta and the Northwest Territories, 6.6% from Saskatchewan and Manitoba, 33.0% from Ontario and Nunavut, 15.3% from Quebec and 8.3% from the Atlantic Provinces. Nationally, the majority of participants completed the survey in English (91.0%), with 7.4% completing it in French and the 1.6% completing it in one of 19 other languages.
Over 50% of participants were under the age of 39 (56.7%) (Table 1). The median age of the population was 36 years of age. The majority of the participants identified as gay (76.0%), and the remaining participants identified as bisexual (17.5%), straight (0.9%) or with another term or no term (5.7%). Of the participants, 2.4% identified as transgender men. In terms of ethnicity, 3.8% identified as Indigenous, 3.8% as Latin American, 3.1% identified as Asian, 2.8% as East or Southeast Asian, 1.9% as South Asian, 1.7% as Black and 1.4% as Arab/West Asian. One-fifth (20.7%) of the participants were born outside of Canada.
Table 1. Sociodemographic characteristics of Canadian participants in the EMIS-2017 (N=5,165).
| Characteristics | British Columbia + Yukon (n=1,191)a |
Alberta + Northwest Territories (n=710)a |
Saskatchewan + Manitoba (n=339)a |
Ontario + Nunavut (n=1,707)a |
Quebec (n=789)a |
Atlantic Provinces (n=429)a |
Total (N=5,165)a |
|||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | n | % | n | % | n | % | n | % | |
| Age category | ||||||||||||||
| 16–24 | 160 | 13.4 | 148 | 20.8 | 63 | 18.6 | 281 | 16.5 | 165 | 20.9 | 89 | 20.7 | 906 | 17.5 |
| 25–39 | 492 | 41.3 | 295 | 41.5 | 137 | 40.4 | 607 | 35.6 | 334 | 42.3 | 161 | 37.5 | 2,026 | 39.2 |
| 40–54 | 326 | 27.4 | 166 | 23.4 | 83 | 24.5 | 526 | 30.8 | 179 | 22.7 | 96 | 22.4 | 1,376 | 26.6 |
| 55–69 | 193 | 16.2 | 90 | 12.7 | 53 | 15.6 | 250 | 14.6 | 102 | 12.9 | 77 | 17.9 | 765 | 14.8 |
| 70+ | 20 | 1.7 | 11 | 1.5 | 3 | 0.88 | 43 | 2.5 | 9 | 1.1 | 6 | 1.4 | 92 | 1.8 |
| Sexual identity | ||||||||||||||
| Gay or homosexual | 975 | 82.0 | 503 | 70.8 | 223 | 65.8 | 1,294 | 75.8 | 627 | 79.5 | 302 | 70.4 | 3,924 | 76.0 |
| Bisexual | 138 | 11.6 | 156 | 22.0 | 98 | 28.9 | 297 | 17.4 | 116 | 14.7 | 96 | 22.4 | 901 | 17.5 |
| Straight or heterosexual | 4 | 0.3 | 12 | 1.7 | 6 | 1.8 | 17 | 1.0 | 4 | 0.5 | 2 | 0.5 | 45 | 0.9 |
| Other | 72 | 6.1 | 39 | 5.5 | 12 | 3.5 | 99 | 5.8 | 42 | 5.3 | 29 | 6.8 | 293 | 5.7 |
| Gender identity | ||||||||||||||
| Cisgender man | 1,158 | 97.2 | 690 | 97.2 | 331 | 97.6 | 1,675 | 98.1 | 772 | 97.8 | 413 | 96.3 | 5,039 | 97.6 |
| Transgender man | 33 | 2.8 | 20 | 2.8 | 8 | 2.4 | 32 | 1.9 | 17 | 2.2 | 16 | 3.7 | 126 | 2.4 |
| Proportion of friends, family who know about attraction to men | ||||||||||||||
| All, almost all | 652 | 55.1 | 291 | 41.7 | 139 | 41.5 | 819 | 48.6 | 432 | 55.0 | 203 | 47.4 | 2,536 | 49.6 |
| More than half | 227 | 19.2 | 125 | 17.9 | 52 | 15.5 | 318 | 18.9 | 124 | 15.8 | 60 | 14.0 | 906 | 17.7 |
| Less than half | 136 | 11.5 | 80 | 11.5 | 44 | 13.1 | 182 | 10.8 | 74 | 9.4 | 54 | 12.6 | 570 | 11.1 |
| Few | 131 | 11.1 | 135 | 19.3 | 71 | 21.2 | 255 | 15.1 | 100 | 12.7 | 79 | 18.5 | 771 | 15.1 |
| None | 38 | 3.2 | 67 | 9.6 | 29 | 8.7 | 110 | 6.5 | 55 | 7.0 | 32 | 7.5 | 331 | 6.5 |
| Born in Canada | ||||||||||||||
| No | 307 | 25.8 | 99 | 14.0 | 38 | 11.2 | 396 | 23.2 | 190 | 24.1 | 40 | 9.3 | 1,070 | 20.7 |
| Yes | 881 | 74.2 | 610 | 86.0 | 301 | 88.8 | 1,309 | 76.8 | 598 | 75.9 | 388 | 90.7 | 4,087 | 79.3 |
| Ethnicity | ||||||||||||||
| White | 795 | 74.2 | 507 | 80.9 | 237 | 78.0 | 1,151 | 76.5 | 524 | 78.9 | 306 | 87.7 | 3,520 | 77.9 |
| Indigenous | 46 | 4.3 | 34 | 5.4 | 24 | 7.9 | 35 | 2.3 | 20 | 3.0 | 11 | 3.2 | 170 | 3.8 |
| Latin American | 39 | 3.6 | 16 | 2.6 | 10 | 3.3 | 53 | 3.5 | 41 | 6.2 | 1 | 0.3 | 160 | 3.5 |
| Asian | 47 | 4.4 | 17 | 2.7 | 8 | 2.6 | 53 | 3.5 | 12 | 1.8 | 3 | 0.9 | 140 | 3.1 |
| East/Southeast Asian | 57 | 5.3 | 16 | 2.6 | 5 | 1.6 | 36 | 2.4 | 8 | 1.2 | 4 | 1.1 | 126 | 2.8 |
| South Asian | 22 | 2.1 | 10 | 1.6 | 4 | 1.3 | 45 | 3.0 | 5 | 0.8 | 2 | 0.6 | 88 | 1.9 |
| Blackb | 10 | 0.9 | 6 | 1.0 | 5 | 1.6 | 43 | 2.9 | 7 | 1.1 | 6 | 1.7 | 77 | 1.7 |
| Arab/West Asian | 13 | 1.2 | 5 | 0.8 | 2 | 0.7 | 22 | 1.5 | 19 | 2.9 | 4 | 1.1 | 65 | 1.4 |
| Other | 42 | 3.9 | 16 | 2.6 | 9 | 3.0 | 67 | 4.5 | 28 | 4.2 | 12 | 3.4 | 174 | 3.8 |
| Years of education past 16 years of age | ||||||||||||||
| None | 113 | 9.5 | 70 | 9.9 | 37 | 10.9 | 174 | 10.2 | 50 | 6.3 | 39 | 9.1 | 483 | 9.4 |
| 1–3 | 156 | 13.1 | 124 | 17.5 | 49 | 14.5 | 168 | 9.8 | 66 | 8.4 | 65 | 15.2 | 628 | 12.2 |
| 4–6 | 322 | 27.0 | 210 | 29.6 | 116 | 34.2 | 479 | 28.1 | 193 | 24.5 | 136 | 31.7 | 1,456 | 28.2 |
| 7+ | 600 | 50.4 | 306 | 43.1 | 137 | 40.4 | 886 | 51.9 | 480 | 60.8 | 189 | 44.1 | 2,598 | 50.3 |
| Occupation | ||||||||||||||
| Employed full-time | 664 | 55.8 | 394 | 55.5 | 206 | 60.8 | 944 | 55.5 | 422 | 53.6 | 228 | 53.1 | 2,858 | 55.4 |
| Employed part-time | 80 | 6.7 | 59 | 8.3 | 17 | 5.0 | 109 | 6.4 | 58 | 7.4 | 41 | 9.6 | 364 | 7.1 |
| Self-employed | 110 | 9.3 | 53 | 7.5 | 26 | 7.7 | 154 | 9.0 | 66 | 8.4 | 29 | 6.8 | 438 | 8.5 |
| Unemployed | 70 | 5.9 | 45 | 6.3 | 22 | 6.5 | 101 | 5.9 | 31 | 3.9 | 21 | 4.9 | 290 | 5.6 |
| Student | 125 | 10.5 | 88 | 12.4 | 40 | 11.8 | 214 | 12.6 | 155 | 19.7 | 60 | 14.0 | 682 | 13.2 |
| Retired | 84 | 7.1 | 41 | 5.8 | 18 | 5.3 | 105 | 6.2 | 41 | 5.2 | 34 | 7.9 | 323 | 6.3 |
| Other | 56 | 4.7 | 30 | 4.2 | 10 | 2.9 | 75 | 4.4 | 14 | 1.8 | 16 | 3.7 | 201 | 3.9 |
| Comfort level with current income | ||||||||||||||
| Living really comfortably | 190 | 16.0 | 108 | 15.2 | 50 | 14.7 | 250 | 14.7 | 144 | 18.3 | 64 | 14.9 | 806 | 15.6 |
| Living comfortably | 374 | 31.4 | 207 | 29.2 | 116 | 34.2 | 572 | 33.6 | 281 | 35.7 | 118 | 27.5 | 1,668 | 32.3 |
| Neither comfortable nor struggling | 387 | 32.5 | 244 | 34.4 | 106 | 31.3 | 530 | 31.1 | 234 | 29.7 | 145 | 33.8 | 1,646 | 31.9 |
| Struggling | 170 | 14.3 | 102 | 14.4 | 42 | 12.4 | 235 | 13.8 | 105 | 13.3 | 76 | 17.7 | 730 | 14.2 |
| Really struggling | 69 | 5.8 | 49 | 6.9 | 25 | 7.4 | 115 | 6.8 | 23 | 2.9 | 26 | 6.1 | 307 | 6.0 |
a The total counts for each characteristic do not always add up to the provincial totals because only participants with non-missing values were included. Missing values make up less than 3% of the totals
b Black includes people with African and Caribbean ethnicities
Over three-quarters (78.5%) of the participants reported having four or more years of education past the age of 16. Almost three-quarters (71.0%) reported that they were employed (including full-time, part-time and self-employed) whereas 13.2% identified as students, and the remaining 15.8% reported being unemployed, retired (including medically), on long-term sick leave or other. Almost half (47.9%) of the participants reported being comfortable in their financial situation, 31.9% reported being neither comfortable nor struggling, and one-fifth (20.2%) reported being uncomfortable.
Experiences of discrimination, mental health and substance use
In the year previous to the survey, 31.9% of participants reported experiencing intimidation, 22.1% reported experiencing verbal abuse and 1.5% reported experiencing physical violence related to knowledge or presumption of attraction to men (Table 2).
Table 2. Experiences of discrimination related to knowledge or presumption of attraction to men, mental health and substance use of Canadian participants in the EMIS-2017 (N=5,165).
| Characteristics | British Columbia + Yukon (n=1,191)a |
Alberta + Northwest Territories (n=710)a |
Saskatchewan + Manitoba (n=339)a |
Ontario + Nunavut (n=1,707)a |
Quebec (n=789)a |
Atlantic Provinces (n=429)a |
Total (N=5,165)a |
|||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | n | % | n | % | n | % | n | % | |
| Homophobic intimidation and assault started at or intimidatedb | ||||||||||||||
| Within last six months | 172 | 14.5 | 94 | 13.3 | 43 | 12.7 | 233 | 13.7 | 67 | 8.5 | 38 | 8.9 | 647 | 12.6 |
| Six months to a year ago | 249 | 20.9 | 145 | 20.5 | 69 | 20.4 | 306 | 18.0 | 135 | 17.2 | 89 | 20.7 | 993 | 19.3 |
| 1–5 years ago | 190 | 16.0 | 96 | 13.5 | 36 | 10.6 | 240 | 14.1 | 115 | 14.6 | 60 | 14.0 | 737 | 14.3 |
| 5+ years ago | 257 | 21.6 | 104 | 14.7 | 49 | 14.5 | 351 | 20.6 | 184 | 23.4 | 80 | 18.6 | 1,025 | 19.9 |
| Never | 321 | 27.0 | 270 | 38.1 | 142 | 41.9 | 570 | 33.5 | 286 | 36.3 | 162 | 37.8 | 1,751 | 34.0 |
| Verbal insultsb | ||||||||||||||
| Within last six months | 77 | 6.5 | 57 | 8.1 | 19 | 5.6 | 98 | 5.8 | 35 | 4.5 | 18 | 4.2 | 304 | 5.9 |
| Six months to a year ago | 223 | 18.8 | 113 | 16.0 | 62 | 18.3 | 289 | 17.0 | 83 | 10.6 | 64 | 15.0 | 834 | 16.2 |
| 1–5 years ago | 265 | 22.3 | 117 | 16.5 | 60 | 17.7 | 332 | 19.5 | 149 | 19.0 | 73 | 17.1 | 996 | 19.4 |
| 5+ years ago | 323 | 27.2 | 137 | 19.4 | 70 | 20.6 | 460 | 27.1 | 219 | 27.9 | 122 | 28.5 | 1,331 | 25.9 |
| Never | 301 | 25.3 | 283 | 40.0 | 128 | 37.8 | 520 | 30.6 | 299 | 38.1 | 151 | 35.3 | 1,682 | 32.7 |
| Punched, hit, kicked or beatenb | ||||||||||||||
| Within last six months | 4 | 0.3 | 8 | 1.1 | 1 | 0.3 | 4 | 0.2 | 1 | 0.1 | 4 | 0.9 | 22 | 0.4 |
| Six months to a year ago | 17 | 1.4 | 10 | 1.4 | 5 | 1.5 | 11 | 0.6 | 7 | 0.9 | 6 | 1.4 | 56 | 1.1 |
| 1–5 years ago | 40 | 3.4 | 40 | 5.6 | 13 | 3.8 | 50 | 2.9 | 23 | 2.9 | 13 | 3.0 | 179 | 3.5 |
| 5+ years ago | 216 | 18.2 | 83 | 11.7 | 34 | 10.0 | 292 | 17.2 | 125 | 15.9 | 71 | 16.6 | 821 | 15.9 |
| Never | 913 | 76.7 | 568 | 80.1 | 286 | 84.4 | 1,342 | 79.0 | 630 | 80.2 | 334 | 78.0 | 4,073 | 79.1 |
| Anxiety and Depression Scalec | ||||||||||||||
| Normal | 472 | 40.0 | 276 | 39.1 | 137 | 40.7 | 731 | 43.4 | 321 | 41.3 | 188 | 44.7 | 2,125 | 41.6 |
| Mild | 393 | 33.3 | 249 | 35.3 | 116 | 34.4 | 546 | 32.4 | 308 | 39.6 | 149 | 35.4 | 1,761 | 34.5 |
| Moderate | 176 | 14.9 | 92 | 13.0 | 41 | 12.2 | 245 | 14.5 | 87 | 11.2 | 44 | 10.5 | 685 | 13.4 |
| Severe | 139 | 11.8 | 88 | 12.5 | 43 | 12.8 | 164 | 9.7 | 61 | 7.9 | 40 | 9.5 | 535 | 10.5 |
| Suicidal ideation in previous two weeks | ||||||||||||||
| Not at all | 885 | 74.4 | 510 | 71.8 | 237 | 70.1 | 1,268 | 74.7 | 592 | 75.2 | 311 | 72.5 | 3,803 | 73.8 |
| Some days | 200 | 16.8 | 129 | 18.2 | 70 | 20.7 | 305 | 18.0 | 148 | 18.8 | 87 | 20.3 | 939 | 18.2 |
| More than half the days | 51 | 4.3 | 33 | 4.6 | 10 | 3.0 | 63 | 3.7 | 20 | 2.5 | 16 | 3.7 | 193 | 3.7 |
| Nearly every day | 54 | 4.5 | 38 | 5.4 | 21 | 6.2 | 62 | 3.7 | 27 | 3.4 | 15 | 3.5 | 217 | 4.2 |
| Alcohol dependencyd | ||||||||||||||
| Not alcohol dependent | 936 | 79.1 | 553 | 78.4 | 262 | 77.7 | 1,345 | 79.7 | 629 | 80.5 | 363 | 85.6 | 4,088 | 79.9 |
| Alcohol dependent | 248 | 20.9 | 152 | 21.6 | 75 | 22.3 | 343 | 20.3 | 152 | 19.5 | 61 | 14.4 | 1,031 | 20.1 |
| Ever taken recreational or illicit drugs | ||||||||||||||
| No | 367 | 31.1 | 254 | 35.9 | 151 | 44.7 | 597 | 35.3 | 294 | 37.4 | 176 | 41.6 | 1,839 | 35.9 |
| Yes | 812 | 68.9 | 454 | 64.1 | 187 | 55.3 | 1,092 | 64.7 | 492 | 62.6 | 247 | 58.4 | 3,284 | 64.1 |
| Illicit drugs used in previous yeare | ||||||||||||||
| Cannabis | 609 | 51.7 | 326 | 46.0 | 131 | 38.8 | 797 | 47.2 | 333 | 42.5 | 192 | 45.4 | 2,388 | 46.6 |
| Cocaine | 192 | 16.3 | 98 | 13.9 | 39 | 11.5 | 222 | 13.2 | 123 | 15.6 | 40 | 9.5 | 714 | 14 |
| Ecstasy pills | 152 | 12.9 | 53 | 7.5 | 15 | 4.4 | 147 | 8.7 | 77 | 9.5 | 16 | 3.8 | 458 | 8.9 |
| Ecstasy in the form of a crystal or powder | 146 | 12.4 | 65 | 9.2 | 19 | 5.6 | 132 | 7.8 | 59 | 7.5 | 23 | 5.5 | 444 | 8.7 |
| GHB or GBL | 136 | 11.5 | 46 | 6.5 | 9 | 2.7 | 119 | 7.1 | 58 | 7.4 | 8 | 1.9 | 373 | 7.3 |
| Crystal methamphetamine | 80 | 6.8 | 43 | 6.1 | 16 | 4.7 | 129 | 7.6 | 29 | 3.7 | 13 | 3.1 | 310 | 6.1 |
| Ever injected any drugsf | ||||||||||||||
| No, never | 1,139 | 96.0 | 679 | 95.8 | 328 | 96.8 | 1,640 | 96.6 | 770 | 98.1 | 413 | 96.3 | 4,969 | 96.5 |
| Yes | 48 | 4.0 | 30 | 4.2 | 11 | 3.2 | 58 | 3.4 | 15 | 1.9 | 16 | 3.7 | 178 | 3.5 |
Abbreviations: GBL, gamma-Butyrolactone; GHB, Gamma-hydroxybutyrate
a The total counts for each characteristic do not always add up to the provincial totals because only participants with non-missing values were included. Missing values make up less than 3% of the totals
b Because someone knew or presumed the participant was attracted to men
c PHQ-4 measurement (13)
d CAGE 4-item Indicator (14)
e The denominators for the proportions of participants who used each substance are based on the number of participants who responded to the individual substance use questions. Total counts for each substance ranged from 5,113 to 5,121. The proportions for substances used do not add up to 100% as they were not mutually exclusive; participants could report the use of more than one substance
f Other than anabolic steroids or prescribed medicine
Almost one-quarter (23.9%) of participants were classified as moderate to severe on a combined measure of anxiety and depression, and 26.1% of participants reported some suicidal ideation ranging from on occasion to nearly every day in the previous two weeks.
With regard to substance use, 64.1% indicated ever using any illicit substance. The most frequently reported drugs used included cannabis (46.6%), which was not yet legal at the time of the survey, cocaine (14.0%) and ecstasy pills (8.9%) (Table 2). Substances used in the previous year by less than 5% of participants overall were as follows: amphetamine (4.4%), ketamine (4.0%), LSD (3.9%), synthetic cannabinoids (2.1%), crack cocaine (1.5%), heroin (0.9%), mephedrone (0.4%) and synthetic stimulants other than mephedrone (0.5%). Only 3.5% of participants reported ever injecting drugs.
Knowledge and use of PEP and PrEP
Most participants had heard of PrEP (86.4%); a slightly smaller proportion had heard of PEP (74.3%), and 8.4% of all the participants, regardless of HIV status, had taken or were currently taking PrEP (Table 3). Of HIV-negative or untested men, 51.7% reported being likely to use PrEP if it was available and affordable.
Table 3. Awareness and use of PEP and PrEP, and healthcare provider knowledge of sexual attraction to men of Canadian participants in the EMIS-2017 (N=5,165).
| Characteristics | British Columbia + Yukon (n=1,191)a |
Alberta + Northwest Territories (n=710)a |
Saskatchewan + Manitoba (n=339)a |
Ontario + Nunavut (n=1,707)a |
Quebec (n=789)a |
Atlantic Provinces (n=429)a |
Total (N=5,165)a |
|||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | n | % | n | % | n | % | n | % | |
| Heard of PEP | ||||||||||||||
| No | 157 | 13.4 | 175 | 24.8 | 76 | 22.6 | 265 | 15.7 | 167 | 21.3 | 117 | 27.8 | 957 | 18.7 |
| Yes | 958 | 81.5 | 465 | 65.9 | 222 | 66.1 | 1,323 | 78.6 | 560 | 71.5 | 268 | 63.7 | 3,796 | 74.3 |
| Not sure | 61 | 5.2 | 66 | 9.3 | 38 | 11.3 | 96 | 5.7 | 56 | 7.2 | 36 | 8.6 | 353 | 6.9 |
| Ever taken PEPb | ||||||||||||||
| No, have not tried to get it | 923 | 89.4 | 634 | 95.5 | 304 | 94.4 | 1,395 | 91.8 | 629 | 87.1 | 386 | 95.5 | 4,271 | 91.6 |
| No, tried, but could not get it | 20 | 1.9 | 12 | 1.8 | 8 | 2.5 | 29 | 1.9 | 14 | 1.9 | 9 | 2.2 | 92 | 2.0 |
| No, had the opportunity but decided not to | 14 | 1.4 | 5 | 0.8 | 4 | 1.2 | 19 | 1.3 | 13 | 1.8 | 1 | 0.2 | 56 | 1.2 |
| Yes, one or more courses | 76 | 7.4 | 13 | 2.0 | 6 | 1.9 | 77 | 5.1 | 66 | 9.1 | 8 | 2.0 | 246 | 5.3 |
| Confidence in ability to access PEPb | ||||||||||||||
| Very confident | 322 | 31.2 | 145 | 21.9 | 71 | 22.0 | 470 | 30.9 | 262 | 36.2 | 69 | 17.0 | 1,339 | 28.7 |
| Quite confident | 268 | 25.9 | 149 | 22.5 | 66 | 20.5 | 344 | 22.6 | 231 | 31.9 | 70 | 17.2 | 1,128 | 24.1 |
| A little confident | 173 | 16.7 | 126 | 19.0 | 64 | 19.9 | 287 | 18.8 | 98 | 13.5 | 93 | 22.9 | 841 | 18.0 |
| Not at all confident | 118 | 11.4 | 107 | 16.1 | 56 | 17.4 | 192 | 12.6 | 49 | 6.8 | 79 | 19.5 | 601 | 12.9 |
| I don’t know | 152 | 14.7 | 136 | 20.5 | 65 | 20.2 | 230 | 15.1 | 84 | 11.6 | 95 | 23.4 | 762 | 16.3 |
| Heard of PrEP | ||||||||||||||
| No | 88 | 7.5 | 96 | 13.7 | 53 | 15.8 | 146 | 8.7 | 93 | 11.9 | 79 | 18.8 | 555 | 10.9 |
| Yes | 1,063 | 90.7 | 576 | 82.1 | 265 | 79.1 | 1,506 | 89.3 | 669 | 85.7 | 326 | 77.6 | 4,405 | 86.4 |
| Not sure | 21 | 1.8 | 30 | 4.3 | 17 | 5.1 | 34 | 2.0 | 19 | 2.4 | 15 | 3.6 | 136 | 2.7 |
| Ever taken PrEP | ||||||||||||||
| No | 1,099 | 92.4 | 674 | 95.5 | 325 | 95.9 | 1,532 | 90.3 | 664 | 84.7 | 415 | 97.6 | 4,701 | 91.6 |
| Yes | 90 | 7.6 | 32 | 4.6 | 14 | 4.1 | 165 | 9.7 | 120 | 15.3 | 10 | 2.4 | 431 | 8.4 |
| Likelihood of using PrEP if available and affordablec | ||||||||||||||
| Very unlikely | 117 | 11.3 | 46 | 6.9 | 30 | 9.3 | 143 | 9.4 | 88 | 12.2 | 36 | 8.9 | 460 | 9.9 |
| Quite unlikely | 111 | 10.7 | 50 | 7.6 | 39 | 12.1 | 134 | 8.8 | 99 | 13.7 | 32 | 7.9 | 465 | 10.0 |
| Not sure | 277 | 26.8 | 185 | 27.9 | 79 | 24.5 | 440 | 29.0 | 200 | 27.7 | 143 | 35.5 | 1,324 | 28.4 |
| Quite likely | 185 | 17.9 | 156 | 23.6 | 74 | 23.0 | 319 | 21.0 | 145 | 20.1 | 88 | 21.8 | 967 | 20.7 |
| Very likely | 343 | 33.2 | 225 | 34.0 | 100 | 31.1 | 483 | 31.8 | 190 | 26.3 | 104 | 25.8 | 1,445 | 31.0 |
Abbreviations: PEP, postexposure prophylaxis; PrEP, preexposure prophylaxis
a The total counts for each characteristic do not always add up to the provincial totals because only participants with non-missing values were included. Missing values make up less than 3% of the totals
b Among all HIV-negative or untested men (N=4,665)
c Among all HIV-negative or untested men (N=4,676)
Sexual practices
Over half of participants (62.1%) always or almost always had sober sex in the previous 12 months (Table 4). One-fifth (21.5%) of the participants reported participation in chemsex, and 5.8% participated in chemsex in the past six months.
Table 4. Sexual practices of Canadian participants in the EMIS-2017 (N=5,165).
| Characteristics | British Columbia + Yukon (n=1,191)a |
Alberta + Northwest Territories (n=710)a |
Saskatchewan + Manitoba (n=339)a |
Ontario + Nunavut (n=1,707)a |
Quebec (n=789)a |
Atlantic Provinces (n=429)a |
Total (N=5,165)a |
|||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | n | % | n | % | n | % | n | % | |
| Nonsober sex (last 12 months)b | ||||||||||||||
| None of it | 362 | 33.1 | 252 | 41.0 | 125 | 41.7 | 533 | 35.0 | 253 | 35.8 | 160 | 44.3 | 1,685 | 36.6 |
| Almost none of it | 278 | 25.4 | 174 | 28.3 | 81 | 27.0 | 380 | 25.0 | 171 | 24.2 | 87 | 24.1 | 1,171 | 25.5 |
| Less than half | 141 | 12.9 | 71 | 11.6 | 26 | 8.7 | 209 | 13.7 | 92 | 13.0 | 42 | 11.6 | 581 | 12.6 |
| About half | 115 | 10.5 | 42 | 6.8 | 21 | 7.0 | 122 | 8.0 | 67 | 9.5 | 24 | 6.6 | 391 | 8.5 |
| More than half | 74 | 6.8 | 27 | 4.4 | 9 | 3.0 | 111 | 7.3 | 49 | 6.9 | 16 | 4.4 | 286 | 6.2 |
| Almost all of it | 97 | 8.9 | 31 | 5.0 | 31 | 10.3 | 121 | 8.0 | 58 | 8.2 | 23 | 6.4 | 361 | 7.8 |
| All of it | 28 | 2.6 | 17 | 2.8 | 7 | 2.3 | 46 | 3.0 | 17 | 2.4 | 9 | 2.5 | 124 | 2.7 |
| Recency of chemsexc | ||||||||||||||
| Within six months | 95 | 8.1 | 26 | 3.7 | 11 | 3.3 | 105 | 6.2 | 47 | 6.0 | 14 | 3.3 | 298 | 5.8 |
| Six months to a year | 76 | 6.5 | 56 | 7.9 | 14 | 4.1 | 127 | 7.5 | 50 | 6.4 | 20 | 4.7 | 343 | 6.7 |
| 1–5 years ago | 50 | 4.2 | 37 | 5.2 | 10 | 3.0 | 62 | 3.7 | 31 | 3.9 | 12 | 2.8 | 202 | 3.9 |
| 5+ years ago | 77 | 6.5 | 31 | 4.4 | 8 | 2.4 | 84 | 5.0 | 40 | 5.1 | 20 | 4.7 | 260 | 5.1 |
| Never | 879 | 74.7 | 558 | 78.8 | 295 | 87.3 | 1,311 | 77.6 | 617 | 78.6 | 357 | 84.4 | 4,017 | 78.5 |
| Anal intercourse with casual partners (participants of any HIV status)d | ||||||||||||||
| No anal intercourse | 420 | 36 | 258 | 36.7 | 125 | 37.3 | 632 | 37.8 | 308 | 39.6 | 181 | 42.9 | 1,924 | 37.9 |
| Any anal intercourse | 748 | 64 | 444 | 63.3 | 210 | 62.7 | 1,038 | 62.2 | 470 | 60.4 | 241 | 57.1 | 3,151 | 62.1 |
| Consistent condom use with casual partners (participants of any HIV status)e | ||||||||||||||
| Non-consistent condom use | 561 | 75.0 | 327 | 73.6 | 160 | 76.2 | 765 | 73.8 | 320 | 68.2 | 185 | 76.8 | 2,318 | 73.6 |
| Consistent condom use | 187 | 25.0 | 117 | 26.4 | 50 | 23.8 | 272 | 26.2 | 149 | 31.8 | 56 | 23.2 | 831 | 26.4 |
| Any CAI by HIV-negative men, on PrEPf | ||||||||||||||
| No CAI | – | – | – | – | – | – | – | – | – | – | – | – | 30 | 8.7 |
| Any CAI | – | – | – | – | – | – | – | – | – | – | – | – | 314 | 91.3 |
| Any CAI among HIV-negative or HIV-unknown men not on PrEPg | ||||||||||||||
| No CAI | 180 | 26.5 | 114 | 27.4 | 50 | 25.1 | 265 | 29.5 | 134 | 36.1 | 54 | 23.4 | 797 | 28.5 |
| Any CAI | 498 | 73.5 | 302 | 72.6 | 149 | 74.9 | 632 | 70.5 | 237 | 63.9 | 177 | 76.6 | 1,995 | 71.5 |
| Any CAI by HIV-positive men, on treatment, undetectable viral loadh | ||||||||||||||
| No CAI | – | – | – | – | – | – | – | – | – | – | – | – | 22 | 7.3 |
| Any CAI | – | – | – | – | – | – | – | – | – | – | – | – | 278 | 92.7 |
| Any CAI among HIV-positive men not on treatment and detectable viral loadi | ||||||||||||||
| No CAI | – | – | – | – | – | – | – | – | – | – | – | – | 12 | 85.7 |
| Any CAI | – | – | – | – | – | – | – | – | – | – | – | – | 2 | 14.3 |
| Paid a man to have sex | ||||||||||||||
| Within 12 months | 57 | 4.9 | 33 | 4.8 | 24 | 7.4 | 108 | 6.6 | 51 | 6.8 | 14 | 3.5 | 287 | 5.8 |
| 1–5 years | 61 | 5.3 | 27 | 4.0 | 15 | 4.6 | 89 | 5.4 | 34 | 4.5 | 16 | 4.0 | 242 | 4.9 |
| 5+ years | 78 | 6.7 | 31 | 4.6 | 19 | 5.9 | 113 | 6.9 | 38 | 5.1 | 18 | 4.4 | 297 | 6.0 |
| Never | 961 | 83.1 | 590 | 86.6 | 266 | 82.1 | 1,333 | 81.1 | 626 | 83.6 | 357 | 88.1 | 4,133 | 83.3 |
| Paid by a man to have sex | ||||||||||||||
| Within 12 months | 40 | 3.5 | 30 | 4.4 | 7 | 2.2 | 67 | 4.1 | 36 | 4.8 | 20 | 4.9 | 200 | 4.0 |
| 1–5 years ago | 44 | 3.8 | 22 | 3.2 | 12 | 3.7 | 72 | 4.4 | 44 | 5.9 | 17 | 4.2 | 211 | 4.3 |
| 5+ years ago | 114 | 9.9 | 43 | 6.3 | 24 | 7.4 | 153 | 9.3 | 33 | 4.4 | 25 | 6.2 | 392 | 7.9 |
| Never | 959 | 82.9 | 586 | 86.0 | 281 | 86.7 | 1,353 | 82.2 | 637 | 84.9 | 344 | 84.7 | 4,160 | 83.8 |
Abbreviations: CAI,condomless anal intercourse; PrEP, preexposure prophylaxis; –, numbers were suppressed due to small cell sizes
a The total counts for each characteristic do not always add up to the provincial totals because only participants with non-missing values were included. Missing values make up less than 5% of the totals
b Among men who have had sex with a man in last 12 months (N=4,599)
c Used stimulant drugs to make sex more intense or last longer. Note: The stimulant drugs include ecstasy/MDMA, cocaine, amphetamine (speed), crystal methamphetamine (Tina, Pervitin), mephedrone and ketamine
d Among men of any HIV status who had one or more casual partners in the last 12 months (N=5,075)
e Among men of any HIV status who had anal intercourse with one or more casual partners in the last 12 months (N=3,149)
f Among HIV-negative men on PrEP who had anal intercourse with one or more casual partners in last 12 months (N=344)
g Among HIV-negative or untested men not on PrEP who had anal intercourse with one or more casual partners in last 12 months (N=2,792)
h Among HIV-positive men on treatment and undetectable viral load who had anal intercourse with one or more casual partners in last 12 months (N=300)
i Among HIV-positive men not on treatment and with a detectable viral load who had anal intercourse with one or more casual partners in last 12 months (N=21)
With regard to sexual practices, 62.1% of the participants reported any anal intercourse with casual partners; of these men, 73.6% were inconsistent in their condom use in the previous year (ranging from one to multiple condomless acts).
Of the HIV-negative men using PrEP who had anal intercourse with one or more casual partners in the past year (n=344), 91.3% participated in any CAI with casual partners in the past year. Of those who were HIV-negative or did not know their status, who had anal intercourse with one or more casual partners in the past year and were currently not using PrEP (n=2,792), 71.5% participated in any CAI with casual partners in the past year. Of the HIV-positive participants who had anal intercourse with one or more casual partners in the past year and who had an undetectable viral load (n=300), 92.7% participated in any CAI with casual partners in the past year. Of the men who were HIV-positive who had anal intercourse with one or more casual partners in the past year, were not taking antiretroviral therapy and had a detectable viral load (n=14), 14.3% had engaged in CAI with casual partners in the past year.
In the past year, 5.8% of participants bought sex and 4.0% sold sex with male partners.
STBBI testing and diagnosis
Although almost two-thirds of participants (62.5%) had tested for HIV in the previous year, only one-quarter (24.9%) reported full STI screening in the last 12 months (Table 5). This proportion was higher (37.7%) among participants who engaged in any CAI in the previous year.
Table 5. Sexually transmitted and bloodborne infection testing and diagnoses of Canadian participants in the EMIS-2017 (N=5,165).
| Characteristics | British Columbia + Yukon (n=1,191)a |
Alberta + Northwest Territories (n=710)a |
Saskatchewan + Manitoba (n=339)a |
Ontario + Nunavut (n=1,707)a |
Quebec (n=789)a |
Atlantic Provinces (n=429)a |
Total (N=5,165)a |
|||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| n | % | n | % | n | % | n | % | n | % | n | % | n | % | |
| Received full STI screen in last 12 monthsb | ||||||||||||||
| No | 698 | 66.7 | 480 | 71.6 | 246 | 76.4 | 1,270 | 82.5 | 473 | 64.9 | 377 | 92.0 | 3,544 | 75.1 |
| Yes | 348 | 33.3 | 190 | 28.4 | 76 | 23.6 | 269 | 17.5 | 256 | 35.1 | 33 | 8.0 | 1,172 | 24.9 |
| Healthcare provider’s knowledge of sex with menc | ||||||||||||||
| Definitely/Probably knew | 718 | 91.8 | 358 | 86.1 | 153 | 86.4 | 883 | 91.3 | 451 | 93.8 | 155 | 78.7 | 2,718 | 90.0 |
| Did not know or Don’t know if they knew | 64 | 8.2 | 58 | 13.9 | 24 | 13.6 | 84 | 8.7 | 30 | 6.2 | 42 | 21.3 | 302 | 10.0 |
| HIV testing historyd | ||||||||||||||
| Within six months | 213 | 20.6 | 94 | 14.2 | 39 | 12.1 | 224 | 14.7 | 131 | 18.1 | 26 | 6.4 | 727 | 15.5 |
| Six months to a year | 507 | 49.0 | 311 | 46.8 | 150 | 46.6 | 731 | 47.9 | 327 | 45.2 | 173 | 42.6 | 2,199 | 47.0 |
| 1–5 years | 151 | 14.6 | 91 | 13.7 | 36 | 11.2 | 219 | 14.4 | 103 | 14.2 | 67 | 16.5 | 667 | 14.3 |
| 5+ years | 45 | 4.4 | 26 | 3.9 | 22 | 6.8 | 83 | 5.4 | 28 | 3.9 | 25 | 6.2 | 229 | 4.9 |
| Never | 118 | 11.4 | 142 | 21.4 | 75 | 23.3 | 269 | 17.6 | 135 | 18.6 | 115 | 28.3 | 854 | 18.3 |
| Last syphilis diagnosis | ||||||||||||||
| Within 12 months | 50 | 4.2 | 21 | 3.0 | 8 | 2.4 | 53 | 3.2 | 25 | 3.2 | 5 | 1.2 | 162 | 3.2 |
| 1–5 years ago | 71 | 6.0 | 24 | 3.4 | 16 | 4.8 | 93 | 5.5 | 47 | 6.1 | 20 | 4.7 | 271 | 5.3 |
| 5+ years | 44 | 3.7 | 22 | 3.1 | 9 | 2.7 | 84 | 5.0 | 19 | 2.5 | 14 | 3.3 | 192 | 3.8 |
| Never | 1,015 | 86.0 | 635 | 90.5 | 301 | 90.1 | 1,447 | 86.3 | 684 | 88.3 | 387 | 90.8 | 4,469 | 87.7 |
| Last gonorrhea diagnosis | ||||||||||||||
| Within 12 months | 110 | 9.3 | 43 | 6.1 | 19 | 5.7 | 99 | 5.9 | 77 | 10.0 | 11 | 2.6 | 359 | 7.1 |
| 1–5 years ago | 147 | 12.5 | 60 | 8.5 | 22 | 6.6 | 135 | 8.0 | 72 | 9.3 | 17 | 4.0 | 453 | 8.9 |
| 5+ years ago | 131 | 11.1 | 60 | 8.5 | 22 | 6.6 | 180 | 10.7 | 65 | 8.4 | 32 | 7.5 | 490 | 9.6 |
| Never | 790 | 67.1 | 540 | 76.8 | 268 | 81.0 | 1,268 | 75.4 | 559 | 72.3 | 365 | 85.9 | 3,790 | 74.4 |
| Last chlamydia or LGV diagnosis | ||||||||||||||
| Within 12 months | 105 | 9.0 | 35 | 5.1 | 14 | 4.3 | 106 | 6.4 | 60 | 7.8 | 7 | 1.7 | 327 | 6.5 |
| 1–5 years ago | 109 | 9.3 | 57 | 8.2 | 26 | 7.9 | 140 | 8.4 | 67 | 8.7 | 18 | 4.3 | 417 | 8.2 |
| 5+ years ago | 94 | 8.0 | 43 | 6.2 | 24 | 7.3 | 127 | 7.6 | 42 | 5.4 | 21 | 5.0 | 351 | 6.9 |
| Never | 865 | 73.7 | 558 | 80.5 | 265 | 80.5 | 1,293 | 77.6 | 604 | 78.1 | 375 | 89.1 | 3,960 | 78.3 |
| Ever diagnosed with hepatitis C | ||||||||||||||
| No | 1,135 | 95.3 | 672 | 94.9 | 331 | 97.9 | 1,648 | 96.8 | 765 | 97.2 | 408 | 95.8 | 4,959 | 96.3 |
| Yes | 26 | 2.2 | 13 | 1.8 | 0 | 0.0 | 23 | 1.4 | 11 | 1.4 | 3 | 0.7 | 76 | 1.5 |
| I don’t know | 30 | 2.5 | 23 | 3.2 | 7 | 2.1 | 31 | 1.8 | 11 | 1.4 | 15 | 3.5 | 117 | 2.3 |
| Ever diagnosed with HIV | ||||||||||||||
| No | 1,034 | 87.4 | 664 | 94.1 | 322 | 95.0 | 1,526 | 89.8 | 724 | 92.0 | 406 | 95.5 | 4,676 | 91.0 |
| Yes | 149 | 12.6 | 42 | 5.9 | 17 | 5.0 | 174 | 10.2 | 63 | 8.0 | 19 | 4.5 | 464 | 9.0 |
| Currently taking ARTe | ||||||||||||||
| No | – | – | – | – | – | – | – | – | – | – | – | – | 4 | 0.9 |
| Yes | – | – | – | – | – | – | – | – | – | – | – | – | 436 | 99.1 |
| Detectable at last viral loadf | ||||||||||||||
| Undetectable | – | – | – | – | – | – | – | – | – | – | – | – | 440 | 96.7 |
| Detectable | – | – | – | – | – | – | – | – | – | – | – | – | 15 | 3.3 |
Abbreviations: ART, antiretroviral therapy; LGV, lymphogranuloma venereum; STI, sexually transmitted infection; –, numbers were suppressed due to small cell sizes
a The total counts for each characteristic do not always add up to the provincial totals because only participants with non-missing values were included. Missing values make up less than 3% of the totals
b Full STI screening in last 12 months: HIV infection, blood test, anal swab and urethral swab (or vaginal swab or urine test), excluding individuals with long-standing HIV infections of more than one year (N=4,716)
c Among men who had tested for STIs other than HIV in previous year (N=3,020)
d Among all HIV-negative or untested men (N=4,676)
e Among men who self-reported as HIV-diagnosed and responded to the question on ART (N=440)
f Among men who self-reported as HIV-diagnosed and responded to the question on viral load (N=455)
Most of the participants (90%) who had been tested for STIs other than HIV infection in the previous year stated that their healthcare provider knew they had sex with other men.
With regard to bloodborne infections, 1.5% of participants were ever diagnosed with hepatitis C and 9% reporting being diagnosed with HIV infection. Of those with an HIV diagnosis, 99.1% of the HIV-positive participants reported current use of antiretroviral therapies; of those, 96.7% reported an undetectable viral load. For other STBBIs, 3.2% of the participants had received a syphilis diagnosis within the previous year. The proportions of participants diagnosed in the previous year with gonorrhea and chlamydia (including lymphogranuloma venereum) were 7.1% and 6.5%, respectively.
Discussion
EMIS-2017 identified that Canadian participants experienced high levels of intimidation, as well as verbal abuse and physical violence related to their attraction to other men. Moderate to severe anxiety or depression were present in almost 25% of participants. Substance use was high and, for the first time, there are national data showing that over 20% of participants engaged in chemsex. There was a significant gap between the proportion of participants who reported using PrEP and the proportion who reported they would use PrEP if it was readily available: 8.4% versus 51.7%. Although virtually all HIV-diagnosed respondents were undergoing treatment and had undetectable viral loads, less than 25% stated that they had received full STI testing in the previous year.
Strengths and limitations
The strength of the Canadian EMIS-2017 survey was the use of a global, validated questionnaire that will facilitate cross-country comparisons, a large sample size and participation from all regions of Canada.
A number of limitations need to be considered when interpreting the findings. Since the EMIS-2017 was based on self-reported data and included sensitive topics such as sexual practices and substance use, some degree of underreporting of higher-risk behaviours may have occurred. However, any underreporting was likely limited given the self-administered nature of the survey. EMIS-2017 made use of non-probability sampling methods, including the use of social and sexual networking mobile applications for recruitment, and, as a result, it more likely represents sexually active nonmonogamous gbMSM. However, this is a main target population for both behavioural surveys and public health interventions.
Implications
Many of the findings are consistent with previous studies. For example, a Canadian survey of gbMSM found a higher risk of suicidal ideation and related behaviour among gbMSM than among heterosexual men (17). A review of the international literature found a higher prevalence of substance use among gbMSM than heterosexual men (18). The reported use of chemsex (21.5%) in the Canadian portion of the EMIS-2017 was higher than found by regional Canadian studies (6% and 18%) (19,20) and may reflect regional variation. Other studies have also found that mental health challenges and substance use are associated with gbMSM engaging in higher-risk sexual practices (21–23). The tendency of these issues to coincide has been conceptualized as a syndemic, defined as co-occurring epidemics that results in a higher disease burden in marginalized populations (24). Previous studies have indicated that in some cities between 10.5% and 12.5% of gbMSM are using PrEP (25), and that 50% to 60% of gbMSM are interested and willing to use PrEP (26,27), suggesting affordability and accessibility are barriers (28,29). A low proportion of participants reporting full STI testing have been found in other surveys of gbMSM in Canada (30) and internationally (31,32). The finding that almost all participants diagnosed with HIV infection were undergoing treatment and had undetectable viral loads is similar to recent regional surveys of gbMSM (33,34).
Next steps
The EMIS-2017 findings point to the need for implementation research to determine best practices to address the high levels of discrimination, poor mental health and substance use harms that gbMSM experience. The EMIS-2017 study also provides useful baseline data on PrEP. In light of changes to provincial formularies and recent guidelines on PrEP prescribing, we anticipate an uptake of this effective prevention technology. Further research would be useful in determining the role of PrEP on sexual risk practices and on the subsequent rates of infection with HIV and other STBBIs. As this survey likely captured a specific and important subgroup of gbMSM regarding STBBIs, triangulating these data with information generated from future surveys using alternative sampling methods would lead to a more comprehensive understanding of this population as a whole.
Conclusion
gbMSM in Canada experienced high levels of stigma, discrimination, mental health problems, and substance use. Furthermore, a low prevalence of condom use was found among them. The gap between the proportion of men who were interested in PrEP and those who actually used it is significant and comprehensive STBBI testing was low. These findings can inform public health action and provide a baseline to examine the impact of current and new interventions.
Acknowledgements
European Men-who-have-sex-with-men Internet Survey (EMIS-2017) was undertaken by Sigma Research at the London School of Hygiene and Tropical Medicine in association with the Robert Koch Institute in Berlin. The EMIS core team is made up of F Hickson, D Reid, AJ Schmidt and P Weatherburn at the London School of Hygiene and Tropical Medicine and U Marcus and SB Schink at the Robert Koch Institute. We especially thank AJ Schmidt for his continued and strong support of Canadian participation in EMIS-2017.
We thank all of the men who took part in EMIS-2017 and our nongovernmental organization (NGO) partners, particularly the Health Initiative for Men, Rézo, the Gay Men’s Sexual Health Alliance of Ontario and Canadian AIDS Treatment Information Exchange (CATIE), who recruited participants through activities on Facebook and/or other social media and by placing EMIS banners on their websites. We thank all our partners for being part of something huge! We also would like to thank C Archibald for his advice prior to and throughout data collection and for his review of the manuscript.
Conflict of interest: None.
Funding: As part of European Surveys and Trainings to Improve MSM Community Health project, EMIS-2017 was carried out under the service contract 2015 71 01 with the Consumers, Health, Agriculture and Food Executive Agency (Chafea), acting under powers delegated by the Commission of the European Union. Other financial contributions came from the Public Health Agency of Canada (PHAC) for recruitment in Canada. NJL is supported by a Scholar Award from the Michael Smith Foundation for Health Research (#16863). TAH is supported by an Endgame Leader Chair Award from the Ontario HIV Treatment Network. Promotion of the survey and recruitment of Canadian participants in EMIS-2017 was funded by the PHAC.
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