Surveillance program for human immunodeficiency virus (HIV) infection in Québec: 2020 report

In Quebec, infection with the human immunodeficiency virus (HIV) has been the subject of epidemiological data collection for the purposes of continuous surveillance of the state of health of the population since April 2002.

This report describes the main characteristics of people living with HIV (PLHIV) who were newly diagnosed in 2020, as well as the changes in the number of cases reported between 2019 and 2020.

On March 11, 2020, the World Health Organization declared the COVID-19 pandemic. The response to this pandemic and the mobilization of resources has affected the entire health system, from infection surveillance to access to health services. This context strongly influences the analysis and interpretation of program data for the year 2020.

Highlights

• The name of tests HIV detection tests performed in Quebec, which had generally increased year over year since the start of the program, decreased by 18.4% in 2020.
• The name of total cas (new and old diagnoses), which was down 2.8% to 3.9% year-over-year since 2017, decreased 21.3%, from 655 cases in 2019 to 515 in 2020.
• The slight downward trend in new diagnoses recorded in the program continues, despite fluctuations from year to year. The significant decrease in cases in 2020 must therefore be interpreted with prudence.
• Cases reported in 2020 include:

• 212 people newly diagnosed in 2020 (new diagnoses);
• 301 people who had had a positive diagnosis before 2020 and had not been registered in the program, or might not be registered at the time of the previous positive tests (the old diagnoses);
• 2 cases which might not be classified in one or the other of these categories.

• Ethnocultural background: among these cases, there are 237 people of Canadian origin, 275 people of ethnocultural origins other than Canadian and 3 others who did not specify their ethnocultural origin.
• median age of new diagnoses was 36 years for men and 45 years for women. The opposite was generally observed in previous years: women were younger than men at the time of the positive screening.
• Geographic distribution : the 515 cases for the year 2020 were reported in seventeen of the eighteen regions of Quebec, mainly in Montreal (59.6%). The Terres-Cries-de-la-Baie-James region recorded none in 2020.
• Gender Breakdown : the cases are predominantly male. There are 378 cases in men and 137 in women.
• Demographic portrait : certain population groups, mainly men who have sex with men (MSM), are disproportionately affected by HIV infection. Of those newly diagnosed in 2020:

• 54.2% (n=115) of cases are recorded among MSM (57.1% if we add MSM who inject drugs, n=6). This population group accounts for 70.1% of new diagnoses among males (73.8% if we include the six MSM who inject drugs).
• 20.8% (n=44) of cases are in people from countries where HIV is endemic. This population group accounts for 60.4% of new diagnoses in females and 9.1% of new diagnoses in males.
• 15.6% (n = 33) of new diagnoses are reported in people who have heterosexual partners at risk or for heterosexual people with no other risk (31.2% of female cases and 11.0% of cases of male gender).
• 5.7% (n=12) of new diagnoses come from people who inject drugs (8.5% if you add the six MSM who inject drugs).
• A new diagnosis of perinatal infection has been reported in a young immigrant infected at birth and in his country of origin.

The frequency of screening seems suboptimal:

• 60.8% of people newly diagnosed in 2020 had never had an HIV test before;
• More than half (57.8%) of cases reporting a previous HIV test had a negative test that was more than a year old.
• 39.8% of people newly diagnosed in 2020 received a late diagnosis (CD4 count below 350 per ml), including 25.0% at an advanced stage of the infection (CD4 count below 200 per ml and/or or at the AIDS stage).
• The average rate of new diagnoses was 2.5 cases per 100,000 people in Quebec in 2020:

• The Montreal region stands out with a rate that is clearly higher than the provincial average, namely 5.6 per 100,000;
• The rate among men is 3.8 per 100,000. It is three times higher than that among women, which is estimated at 1.1 per 100,000;
• Among men, the highest rate is observed in the 30-34 age group, at 10.1 per 100,000.
• In women, it is reported in the 55-59 age group, or 3.5 per 100,000.

Interpretation and limitation of data

• The decrease in cases in 2020 is directly associated with the decrease in the number of HIV tests for the same period.
• The HIV testing service offer has been affected by the COVID-19 pandemic, among other things by limiting face-to-face appointments, reducing hours of service and the availability of nursing resources. This situation fluctuated according to the waves of the pandemic, the region and the needs of the health network. In addition, the health measures in place, which were intended to reduce contact between people, may have reduced the demand for screening.
• The number of new diagnoses is still high for an infection that can be prevented in a targeted and effective way, considering the impact on the lives of people living with the virus.
• HIV transmission is high among MSM: this population group records the highest number of cases annually since the start of the HIV surveillance program.
• Program data include cases detected and registered; they exclude diagnosed PLHIV who are not registered, and those who are not tested and who do not know their HIV status. It is therefore not possible to specify the prevalence or incidence of HIV in Quebec with these data.
• New diagnoses do not just represent incident cases; it is a set made up of recent infections (incidence) and late-diagnosed old infections.

In conclusion

Despite its limitations, the program provides a portrait of HIV infection in Quebec in 2020.

• Transmission of the virus is still active in Quebec.
• A relatively large proportion of people living with HIV are diagnosed late and do not receive appropriate treatment.
• MSM remain the most affected population group.
• People from countries where HIV is endemic follow, and they rank first among women.
• Relatively low numbers of cases continue to be seen among people who have unprotected heterosexual relationships, and among those who inject drugs with non-sterile equipment.
• The Covid-19 pandemic has influenced the analysis and interpretation of program data for the year 2020.
• The available data do not point to an increase in new infections and there is little change in the characteristics of new diagnoses.