Montreal Gazette

Why HIV and syphilis cases are up sharply


Younger people don't remember the 1980s, when the human immunodefi­ciency virus was fatal, when those contractin­g it were feared and shunned — sometimes even by their own families.

Lifesaving antiretrov­iral therapy, introduced in the mid-1990s, commuted HIV from a death sentence to a manageable chronic illness. Set against the backdrop of a pandemic that has taken 40 million lives worldwide, that's good news.

But it has been tempered of late by not-so-good news that makes one wonder: Have people forgotten the need to be vigilant?

New HIV cases are up, for one: There were 1,833 new HIV diagnoses in 2022 in Canada, according to the Public Health Agency of Canada — an increase of nearly 25 per cent over 2021 and the biggest rise in more than a decade.

According to a Montreal public health report on HIV, syphilis and other sexually transmitte­d infections (STIS) from 2013 to 2022, new HIV diagnoses in the Montreal region rose to 310 in 2022 from 141 in 2021: This 120-percent jump is the biggest in nearly 10 years.

A slight decrease in new HIV diagnoses in 2020 and 2021 can be explained by reduced screening capabiliti­es during the COVID-19 pandemic. “But it's not normal that in 2022 we have a 120-per-cent increase in cases of HIV,” said Dr. Réjean Thomas, co-founder and director of Clinique médicale L'actuel, a Montreal clinic dedicated to the well-being and education of people affected by HIV and other STIS.

“It's not because the illness doesn't kill anymore and has become a chronic illness that we should stop doing prevention.”

Also noted in the Montreal report, released in November 2023, is a considerab­le increase in infectious syphilis — from 400 cases in 2013 to nearly 700 cases in 2022. Left untreated, syphilis, which is often silent in initial stages, can eventually damage organs including the heart, brain and eyes. It usually affects men, but a stunning increase among women was reported between 2013 and 2022: from nine cases to 68.

As well, 11 cases of congenital syphilis, a serious, potentiall­y fatal condition in which women with untreated syphilis give birth to affected babies, were reported between 2020 and 2022. Congenital syphilis occurs in women with poor access to prenatal care, the report states; vulnerabil­ity factors include homelessne­ss, precarious immigratio­n status and drug use.

“In our clinic, we always do HIV and syphilis testing,” said Thomas. “Syphilis is treated easily but often under-diagnosed — especially among women because the test is not done.”

Condom use, which protects against HIV and other STIS, has declined from the days when the spectre of AIDS made it widespread and when “the media did prevention education and there were awareness campaigns in schools,” he said. Today, “it is rare at the clinic that we see people who use condoms.”

The first World AIDS Day, Dec. 1, 1988, was held to raise awareness around HIV/AIDS and to remember lives lost: People wore red ribbons. “Then when HIV became a chronic illness, we stopped talking about prevention and people stopped using condoms and stopped wearing red ribbons on World AIDS Day,” said Thomas.

“Every day, there are campaigns about alcohol and tobacco. But no one is talking about sexually transmitte­d infections or HIV. It is difficult for me to understand: Even if HIV is not terminal, it is still a serious illness — one that always involves human drama.”

The increase in HIV diagnoses particular­ly affects two groups, the Montreal public health report states: Gay men, bisexual men and other men who have sexual relations with men comprise one group; the other is new arrivals from countries where HIV is strongly endemic, mostly in Africa and the Caribbean. Cases in the second group rose from 32 in 2021 to 158 in 2022.

“There is some good news in our report of this heterogene­ous group of people from diverse countries of origin,” said Dr. Julian Gitelman, lead physician with Montreal's public health department for sexually transmitte­d and blood-borne infections. “Most were diagnosed quickly after arriving and linked into care within three months and followed, which is amazing, because people living with HIV and taking medication­s will live a long life and are not able to transmit it.”

Today more than three-quarters of people with HIV worldwide are on lifesaving antiretrov­iral medication, which reduces the amount of the virus in their bodies to undetectab­le levels: Undetectab­le means untransmit­table. The regimen also prevents HIV from progressin­g to acquired immunodefi­ciency syndrome (AIDS).

To Thomas, HIV has been “trivialize­d” now that it is no longer fatal in those being treated. Yet people with HIV are often isolated, he said: They have more anxiety and suicidal ideation than the majority of the population and more comorbidit­ies, including diabetes, heart disease and certain types of cancer.

“There have been great advances in the treatment of HIV, but it remains a chronic medical condition with no cure and no vaccine — and very strong stigmatiza­tion around it still exists.”

Thomas said he attributes the increase in HIV cases in part to social media. Many who used to meet in Montreal's Village, where “there was a community spirit,” now connect on social media. “I'm not sure Grindr is better,” he said of the online dating app catering to the gay, bisexual and transgende­r community.

“It is mind-blowing to me how people trust people they don't know. They tell me, `I met someone on Grindr and slept with him.' I think a lot of it is linked to self-esteem. If we have low self-esteem, we think it's frowned upon to ask someone to use a condom.”

And a new and worsening problem in the gay community, said Thomas, is the use of the stimulant crystal meth. The drug, which is addictive, heightens sexual pleasure and reduces inhibition­s, making users more likely to engage in behaviours associated with an increased chance of acquiring HIV.

Montreal arts and culture journalist Richard Burnett is a veteran AIDS activist. “What I find shocking is that men aged 30 to 39 are the category with the highest rates of HIV,” he said. “Young adults didn't live through the AIDS pandemic and see all their friends die. I kind of feel that, the older you are, the more you should know better.

“The other thing I think is contributi­ng to increased rates of syphilis and gonorrhea is that gay men have been able to take PREP,” said Burnett, using the acronym for pre-exposure prophylaxi­s. PREP, approved in 2012 in the United States and in 2016 in Canada, is recommende­d for anyone at risk for HIV infection: This includes men who have sex with men, straight people who have unprotecte­d sex and people who inject drugs.

“You need a prescripti­on and can get it only after you have tested negative for HIV — and it allows you to not wear a condom,” he said. “If you have condomless sex, PREP will prevent the risk of HIV by 99 per cent. For those who are tired of wearing condoms while having sex, this is an alternativ­e — but not if the person you are having sex with has syphilis or gonorrhea.” PREP does not protect against these STIS.

“Negotiatin­g sex is intimidati­ng for some, but I think it is really important that people have the courage to negotiate sex with a potential partner,” Burnett said.

The death toll from AIDS was mounting in 1989 when Montreal hosted the fifth internatio­nal Global AIDS Conference and protesters from local activist groups and the New York City-based organizati­on ACT UP — the AIDS Coalition to Unleash Power — disrupted the opening ceremony. Their action was considered by many a watershed for HIV activism and research — a signal that scientists could no longer ignore patients' voices.

Among those storming the stage that June day was 27-yearold Montrealer David Shannon, a journalist and political activist who had become a leader, if a reluctant one, in Montreal's gay-rights movement at a crucial time in its history.

“In Montreal the crucible years of queer activism were 1989 to 1994 and, during that time, David was one of the important central figures in the trenches. We all owe him a lot,” said Burnett.

Recalled Chris Shannon, one of David's four brothers: “When AIDS was a scourge for people who were marginaliz­ed and pushed aside by their families, government and health care, David was one of the primary spokespeop­le in the country. I look at him as being almost a historical figure now.”

David died in 2018 of liver cancer in Toronto. Casey House, where he died, had been founded in 1988 as an AIDS hospice by journalist and social activist June Callwood and other volunteers. As HIV evolved, its role expanded: In 2016 Casey House establishe­d a 14-bed hospital and today an outpatient clinic offers a wide range of services to hundreds of clients living with HIV or at risk for HIV.

The inaugural edition of a fundraiser to support the compassion­ate and judgment-free health care Casey House provides was inspired by David and dreamed up by his eldest brother, Craig Shannon, and Kristin Shannon, Craig 's wife. David's Disco (davidsdisc­, to take place Friday in Toronto, is billed as a night of dancing and drag.

The goal, said Kristin, is “to honour a man we should have honoured more when he was alive and to acknowledg­e a problem that has, sadly, not gone away.”

David became known in Montreal's LGBTQ community for the Homo Show, the radio program he hosted on CKUT, Mcgill University's campus community radio station, and his column for the Montreal Mirror newsweekly, Out in the City. He co-founded AIDS Community Care Montreal and the Montreal chapter of ACT UP.

In his column, “David took on politician­s and doctors who were marginaliz­ing people and he became very much their voice,” said Chris Shannon, the head of school at Lower Canada College.

The column, recalled Montrealer Earl Pinchuk, who met David in 1990 through ACT UP, “gave people a sense of community.

“David was eloquent and smart and I looked up to him as a leader. I was in awe of him.”

“One message David kept trying to drive home was the need to protect oneself,” said Burnett. “In those days HIV was still a death sentence and he and I knew a lot of people who had HIV/AIDS and we saw a lot of them die over the years.”

In the west at the height of the HIV/AIDS global epidemic, gay men were the most affected: By 1995, 10 per cent of the 1.6 million men aged 25 to 44 in the U.S. who identified as gay had died.

“I think David would be heartbroke­n today to see the numbers rising when they should not be,” said Burnett. “He would be angry that people are still dying from HIV/AIDS and he would be horrified. It is completely unnecessar­y.”

To Gitelman of Montreal public health, “gay men are still taking HIV seriously.”

For one, PREP use is up, he said. About half of eligible gay men are taking PREP and “there has been a big increase in the past few years. To me that shows an interest in their sexual health.

“Of course we can still do better,” he said. “One message I have is that, if you are gay or bisexual, you should talk to your doctor.”

Another message is that “condoms are really effective tools at preventing not just HIV but all sexually transmitte­d infections.”

Montreal's public health department funds community organizati­ons to distribute condoms and counsel users around topics including safer sex strategies, PREP and where and how frequently to get tested, Gitelman said.

“If you are sexually active, you should be tested regularly,” he said. “When you have a new sexual partner, you should get tested.”

Worldwide, more than 600,000 people still die every year from Hiv-related causes — generally because they don't know they have HIV or because they start treatment too late, according to the World Health Organizati­on. In 2022 alone, 1.3 million people were newly infected with HIV. It's not yesterday's story.

Said Burnett: “I hope this memorial for David is an opportunit­y to remind people that we still need to be vigilant.”

Condoms are really effective tools at preventing not just HIV but all sexually transmitte­d infections.

 ?? PIERRE OBENDRAUF /MONTREAL GAZETTE ?? Dr. Réjean Thomas, co-founder and director of Clinique médicale L'actuel, says HIV has been “trivialize­d” now that it is no longer fatal in those receiving treatment. It is “not normal that in 2022 we have a 120-per-cent increase in cases of HIV.”
PIERRE OBENDRAUF /MONTREAL GAZETTE Dr. Réjean Thomas, co-founder and director of Clinique médicale L'actuel, says HIV has been “trivialize­d” now that it is no longer fatal in those receiving treatment. It is “not normal that in 2022 we have a 120-per-cent increase in cases of HIV.”
 ?? CHRIS SHANNON ?? Late gay activist David Shannon, seen here with a portrait he had done for his 50th birthday.
CHRIS SHANNON Late gay activist David Shannon, seen here with a portrait he had done for his 50th birthday.

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