Health Committee on April 11th, 2019

[The Vice-Chair, Conservative, Marilyn Gladu]

Good afternoon. Welcome to the 139th meeting of the health committee, where we're continuing our study of LGBTQ2 health in Canada.

Today we have some excellent witnesses. From the British Columbia Centre for Disease Control, we have Dr. Mark Gilbert. From the British Columbia Centre for Excellence in HIV/AIDS, we have Dr. David Moore by video conference. From the Canadian AIDS Society, we have Gary Lacasse, the Executive Director; and from the Gilbert Centre for Social and Support Services, we have Gerry Croteau.

Each of you will have 10 minutes for your opening statement, and we'll begin with Dr. Mark Gilbert.

[Dr. Mark Gilbert, Medical Director, Clinical Prevention Services, BC Centre for Disease Control]

Great. First off, I'd like to thank the Standing Committee on Health for the invitation to speak here today, and also for dedicating the resources of the committee to this study, which I think is pretty unprecedented in Canada. It's a real sign of progress in society, as well as in the federal government. It's a real honour to be here today.

I'd also like to acknowledge that I'm here today on the traditional, unceded and ancestral territories of the Algonquin peoples.

The focus of my remarks today will be on improving the sexual health of gender and sexual minority Canadians. I'm a gay man, a public health physician who's responsible for some sexual health services in B.C., and a public health researcher who has a focus on gay men's health, testing and digital initiatives around sexual health care. Those are the perspectives that I'll be bringing today. However, on the flip side, I just want to acknowledge that there are other perspectives related to issues of sexual health that I hope you'll get the chance to hear from during this study, including those of two spirit people and gender minorities.

I'll start by outlining some of the challenges that I see related to sexual health. As I'm sure it's no surprise to people in the room, there is a higher burden of sexually transmitted and blood-borne infections among gender and sexual minorities, and I'll call those STBBIs for short. This includes ongoing high or increasing rates of HIV and STIs, particularly syphilis, among gay, bisexual and other men who have sex with men.

Recent experience from Ontario tells us that there continues to be a lot of resistance in society to health education in schools that's relevant to today's youth. Even when that's available, it often is not as relevant for gender and sexual minority youth.

On the other side, we know that health care providers are often not trained or comfortable with providing appropriate sexual health care to gender and sexual minorities, so this lack of education and training really contributes to the many barriers that gender and sexual minority people face in accessing appropriate sexual health care. These include barriers that are common to many Canadians, such as factors like distance to a clinic, opening hours, or wait times for appointments. Also, everyone is affected by the stigma that still surrounds sex and infections in society, and that leads to people's being embarrassed to talk to people about their sexual health, or to providers' feeling uncomfortable asking questions.

Gender and sexual minority people face additional barriers, which are related to the need to talk about their identity or their orientation with their care provider. As you can imagine, many people fear negative reactions. They fear being judged or discriminated against when they do so. Unfortunately, all too often that's based on past negative experiences in health care.

While in some major urban centres—like Vancouver, where I'm from—people may be able to access quite friendly and culturally appropriate LGBT services around sexual health, all these barriers become more pronounced once you go into rural and remote communities.

Finally, there's a strong connection between sexual health and mental health for gender and sexual minority people. I know you've heard from a lot of witnesses already about mental health. As they've discussed, we know that stigma in society against gender and sexual minority people leads to negative experiences, which have an impact on mental health and could lead to a higher prevalence of mental illness.

These same negative experiences and mental health issues, such as substance use, can also lead to sexual risk-taking and a greater chance of infection. This is a concept that's known as syndemics, or synergistic epidemics of these types of factors, and it's been demonstrated from research for gay, bisexual and other men who have sex with men in Canada.

However, we still typically approach sexual health and mental health in silos. This leads to our not providing comprehensive care or tackling the factors that contribute to poor sexual health. For example, in B.C., research by Dr. Travis Salway, who spoke to this committee on Tuesday, has shown that it commonly is reported by members of sexual and gender minorities that they have unmet mental health needs when they're presenting for care in sexual health clinics. That suggests that these are services that are actually probably ideal forums for also thinking about mental health and are a way for engaging people in mental health.

I'll now move to focus on what I think are five opportunities for the federal government to address these challenges.

First, I think that current national sexual health guidelines and resources need to be re-examined to make sure that they're appropriate for all gender identities, such as the Canadian Guidelines on Sexually Transmitted Infections. As we've started to do in B.C., these need to use clinical approaches that are relevant after gender-affirming surgery; need to shift away from gender-binary approaches, talking about men and women or males and females; and need to adopt trauma-informed care as fundamental principles.

Second, there needs to be greater integration across sexual health and mental health. The Public Health Agency of Canada last year released the pan-Canadian STBBI framework for action. It's actually a good step in this direction because it integrates across different infections and also recognizes the impact of syndemics. Certainly, as federal actions follow from this framework, the needs of sexual and gender minorities should be a major focus.

However, I think we need to go further and pay attention to mental health within these sexual health services. Another way to support this nationally could be to incorporate mental health and substance use assessments, as well as brief mental health interventions, within federal guidelines related to STIs or sexual health where this is often not talked about in great detail, as well as within related resources for providers.

We also know that community-based agencies that are working with gender and sexual minority populations are already using integrated or holistic approaches across sexual health, mental health and other domains of health. These agencies are the front line of our society's response to these issues.

Federal community action funds are an important funding source for this work. In the past few years, the community action funds have been expanded from HIV to include hepatitis C. This is good, but it wasn't accompanied by an increase in funding. I think the scope of these funds should be expanded to more fully and embrace sexual health and mental health broadly, but this should be accompanied by an increase in funding.

Third, I would like to build on recommendations of the pan-Canadian framework for action related to testing. I believe we do need a greater range of testing approaches in Canada that make the best use of new and effective test technologies and that empower gender and sexual minority people to get tested. The federal government is already supporting this through the National Microbiology Laboratory's dried blood spot testing service for HIV and hepatitis C, as well as hepatitis B and syphilis. This is being used outside our traditional health care settings—sometimes by non-health care providers—and it has been very well received.

This program should be further expanded in Canada. It would also be important for the National Microbiology Laboratory to think about how similar approaches for other STIs like chlamydia and gonorrhea could also be implemented in this way. For example, this could include a greater focus on self-collected specimens for STBBIs, such as swabs and blood specimens, which a person collects themselves and sends to a lab for testing, and updating Canada Post regulations to allow for sending such specimens by regular mail. Similar programs do exist in many other countries.

One additional area to focus on federally is the licensing of new types of tests for STBBI, as Canada does lag behind other countries. For example, there are rapid tests performed by providers right at the point of care and that give results within minutes. We have one licensed rapid HIV test in Canada compared with seven in the States, and we have Canadian rapid tests for STBBIs that are being used internationally, but not here in Canada. Similarly, there are no home-testing or self-testing kits for HIV that are licensed in Canada. This is an approach that has been shown in other countries to be quite successful, very acceptable and to increase testing.

I imagine that the market size of Canada compared with other countries is one of the factors affecting why industries may not be pushing forward and getting test products licensed here, but I do recommend that Health Canada's therapeutic products directorate, which licenses these tests, consider how more of these products can be brought to the Canadian market. This could be done, for example, by somehow expediting the approval of tests that have already been approved in the U.S., by funding Canadian studies that are needed to validate existing test technologies or by providing special access to permits.

Fourth, there are opportunities related to federal initiatives on e-health or digital health, which is a rapidly growing area in Canada. Studies, including work we've done in B.C., have consistently shown that gender and sexual minority people are highly accepting of online or technology-based approaches that help to overcome the specific barriers I mentioned earlier in terms of accessing sexual health care. This has been shown for HIV prevention interventions.

We've seen this in B.C., where many gay, bisexual and other men who have sex with men have used our program GetCheckedOnline, which is a successful Internet-based testing program for STBBIs. In our research around this intervention, men have reported that they really value this service because it gives them control over testing and is a way to get testing without needing to talk to a provider about their sex lives.

Digital health initiatives also cross provincial borders, and with the ever-increasing access to the Internet does provide opportunities for the federal government to improve health directly. For example, the federal government could directly fund national digital health initiatives for campaigns for gender and sexual minorities, such as sexual health educational resources that can reach youth across Canada. However, there are few national digital health initiatives or research opportunities that are focused on digital health care for gender and sexual minority people, or even more broadly, for sexual health.

One way to improve this gap would be within Canada Health Infoway, which focuses on investments in e-health and digital health in Canada and is funded by the federal government. To date, the work of Infoway has largely focused on electronic medical records, chronic disease prevention and mental health. I recommend that digital health initiatives for sexual health and for gender and sexual minority people be made strategic priorities within Infoway's work.

Finally, the role of the federal government in funding new research related to sexual health for gender and sexual minority people is critical. I recognize there are many research efforts currently funded in this area, but there are other opportunities that should be considered. For example, moving forward with e-health or digital health as one of CIHR's strategic priorities could include funding dedicated to sexual and gender minority populations.

In closing, I am grateful to the committee for seeking to understand the health issues facing LGBTQ2 people in Canada, of which sexual health is just one component. I would encourage the federal government to continue with the excellent precedent that's being established with your study by making sure that sexual and gender minority peoples are meaningfully engaged at all stages in any federal initiatives arising from this study.

Thank you.

[The Vice-Chair, Conservative, Marilyn Gladu]

Excellent. You're right on time.

Dr. David Moore, you have 10 minutes.

[Dr. David Moore, Research Scientist, Epidemiology and Population Health Program, British Columbia Centre for Excellence in HIV/AIDS]

Thank you, Madam Chair.

On behalf of the BC Centre for Excellence in HIV/AIDS and our Executive Director, Dr. Julio Montaner, I would like to thank the committee for the opportunity to speak today. My name is David Moore. I'm a Research Scientist at the BC-CfE in Vancouver and a professor in the Faculty of Medicine at UBC.

I'd like to start by acknowledging that I am presenting from the unceded traditional territory of the Musqueam, Squamish and Tsleil-Waututh first nations.

The BC-CfE is a provincial agency dedicated to improving the health of British Columbians living with HIV and AIDS. The BC-CfE works in partnership with the B.C. Ministry of Health, health authorities, municipalities and community groups in B.C. to promote evidence-based programs and policies to improve the quality of life for those living with HIV and to protect people from acquiring the virus.

As you've already heard, gay, bisexual and other men who have sex with men—hereafter referred to as “gbMSM”—are disproportionately affected by HIV and other sexually transmitted and blood-borne infections in Canada. Despite great advances in our scientific knowledge, gbMSM continue to experience the largest number of new HIV diagnoses each year amongst all populations at risk. In 2016 they accounted for 48% of new HIV diagnoses in Canada, despite comprising only 3% to 5% of the adult male population. Nationally, the number of new diagnoses amongst gbMSM has remained largely unchanged over the last 10 years. HIV remains a fundamental threat to the health of gbMSM and results in significant costs to the Canadian health care system.

However, recent advances in HIV treatment and prevention have generated great optimism for the potential elimination of HIV as a public health threat among gbMSM. The BC-CfE was at the forefront of developing modern HIV treatment as a highly effective means of preventing the development of AIDS and premature death amongst people living with HIV. More recently, research has shown that effective HIV treatment is 100% effective in preventing HIV transmission. As such, the close to 90% of gbMSM in metropolitan Vancouver who are receiving HIV treatment and have achieved virologic suppression can now be assured that they will have near-normal life expectancy; equally important, they will not transmit HIV to their sexual partners.

The B.C. experience has shown that facilitated access to HIV testing and immediate access to free treatment amongst people living with HIV, or treatment as prevention, known as “TasP”, is the key to controlling the epidemic. TasP has now been adopted globally as part of the BC-CfE's proposed 90-90-90 targets for the global rollout of antiretroviral therapy. These targets propose that by 2020, at least 90% of people living with HIV will have been diagnosed, at least 90% of these will be receiving HIV treatment, and 90% of these will have achieved virologic suppression. It's estimated that meeting the 90-90-90 targets will lead to a 90% decrease in AIDS mortality by 2020 and a decrease in HIV infections of 90% by 2030. The 90-90-90 targets have now been formally adopted by the United Nations and by the Government of Canada, yet the implementation of TasP in Canada has been uneven. There is a growing concern that we will fail to meet the 90-90-90 targets on time.

More recently, it has been shown that taking a combination of two antiretroviral medications, or HIV pre-exposure prophylaxis, which is known as “PrEP”, is at nearly 90% effective in preventing HIV acquisition amongst gbMSM at high risk of infection. However, PrEP access across Canada remains suboptimal. Since January 2018 in B.C., PrEP has been available free of charge through BC-CfE for B.C. residents at high risk of acquiring HIV. Since full public funding for PrEP began in B.C., uptake has been very high, with more than 4,000 individuals, of whom 98% are gbMSM, initiating PrEP through the program as of the end of March 2019. As a result, B.C. is currently experiencing the lowest rates of new HIV diagnoses since the mid-1990s. We therefore call on the federal government to secure equitable and effective access to HIV testing and prevention programs, with support for and access to TasP and PrEP at no charge for people living with HIV or those at risk of HIV infection.

While the issues above highlight the great optimism felt about the control of the HIV epidemic, this is not the case for other sexually transmitted infections, blood-borne infections, or STBBIs. As we've heard from Dr. Gilbert, diagnosis rates of hepatitis C, syphilis, gonorrhea, and chlamydia continue to grow each year across the country, and again, gbMSM are heavily overrepresented in these epidemics. Therefore, we support the development and implementation of the government's STBBI action plan, coupled with significant new funding for programming, monitoring, evaluation and research. Without additional funding, our efforts will be diluted and will result in very limited impact for affected communities.

As mentioned by Dr. Gilbert, it's now understood that the syndemics of mental health and substance use disorders play a large role in increasing the vulnerability to STBBIs amongst gbMSM. Public policies developed over the last decades have likely reduced some of the stigma and discrimination faced by gbMSM in Canada. However, frequent and pervasive exposure to stigma and discrimination within the school, home, community and online environments due to one's sexual and/or gender minority status are still common and result in what has been termed “minority stress”. This minority stress is then reflected in much higher rates of substance use and mental health disorders. Compared with heterosexual men, sexual minority men are four times more likely to attempt suicide, two to three times more likely to develop depression and anxiety, and are twice as likely to develop drug dependencies. In order to have a sustainable impact on minority stress experienced by gbMSM, additional attention must be paid towards implementing evidence-based mental health and substance-use disorder services at the community level. We therefore recommend that the federal government work with provincial, territorial and indigenous partners to bridge the gaps in mental health and substance use services for gbMSM.

Another factor that has likely contributed to the continuing stigmatization of HIV, and by extension gbMSM, has been the over-criminalization of HIV exposure in Canada. While steps were taken federally to address this issue in late 2018, these had limited impact across the country. Therefore, we recommend that legislation be put forward to eliminate the over-criminalization of HIV exposure in Canada. We also recommend that the federal government unequivocally endorse the notion that undetectable equals untransmittable as it relates to the transmission of HIV.

As we've also heard, many gbMSM also use substances to cope with mental health challenges related to persistent societal stigma and discrimination. While cigarette smoking and hazardous alcohol use have not received as much attention in the press as illicit substances, they are highly prevalent amongst gbMSM, thus gbMSM are at greater risk of developing a host of illnesses related to tobacco and alcohol use, including cardiovascular disease, cancers, respiratory, kidney and liver diseases. Access to evidence-based smoking and alcohol cessation programming by gbMSM is quite low across the country and needs to be improved. The burden of smoking and hazardous alcohol use and the risks for developing diseases associated with these conditions are multiplied for HIV-positive gbMSM. Therefore, we support the inclusion of LGBTQ+ people as a key population in the federal tobacco control strategy, but recommend that additional funding for that strategy be secured to support community-based approaches to smoking prevention and cessation among LGBTQ+ people.

As well, the use of methamphetamine and other stimulants is highly prevalent among gbMSM. Among participants in our cohort study in Vancouver, 44% of HIV-positive and 10% of HIV-negative gbMSM report methamphetamine use in the previous six months. Participants who reported recent methamphetamine use were more likely to have been diagnosed with an anxiety disorder or depression and scored higher for symptoms for both anxiety and depression in comparison with individuals who did not report recent use. Therefore, we also recommend that additional funding be secured to support research and evidence-based programming to provide treatment and support for gbMSM who are affected by substance use disorders, particularly methamphetamine use and hazardous alcohol use.

In summary, in order to improve the health of gay, bisexual and other men who have sex with men in Canada, we recommend that the federal government take steps to realize the potential for HIV elimination among gbMSM in Canada and better control of other STBBIs. However, we must also work with provincial, territorial and indigenous partners to ensure that we are also addressing the syndemic problems of mental health and substance use disorders, which are important drivers of these epidemics.

Thank you.

[The Vice-Chair, Conservative, Marilyn Gladu]

Thank you very much.

Now we're going to go to Gary Lacasse from the Canadian AIDS Society.

[Gary Lacasse, Executive Director, Canadian AIDS Society]

Thank you for inviting CAS to appear before your committee to discuss LGBTQ2 health in Canada.

The Canadian AIDS Society is a national coalition of community-based organizations dedicated to strengthening Canada’s response to HIV and AIDS, which includes ongoing collaboration with community partners and Canadian stakeholders that ensure positive health outcomes for our LBGTQ2 populations, among others.

I would like to thank the committee for touring the different organizations across Canada. I see that you have thoroughly discussed chemsex, which includes crystal meth and other drugs that are devastating our communities of gay, bisexual and other men who have sex with men across the country, among other priorities and issues.

I would like to take my time today to focus on LBGTQ2 people living with HIV.

In the early years of the AIDS epidemic in Canada, 84% of the cases were gbMSM, most of whom died in the early years. Then, as drugs became available, they had to quit their jobs and go on social assistance to have access to these life-saving drugs. This created huge barriers for these individuals, their families and their communities, which created social and financial injustices through complacency from all levels of government.

Many of those who survived the epidemic are now facing their senior years with much trepidation. Imagine the double stigma of being gay and having HIV. We still have so much to do, but without an alignment from the federal government all the way down to local government, we will not be able to provide a place of peace and tranquillity for people living with HIV in their senior years.

Nationally today, depending on who does the statistics, 55.4% of new infections are gbMSM. Our work is having some impact, but we still have much to do, as gbMSM are overrepresented in HIV. We do have some good news, as rates in gay neighbourhoods seem to be on a downward trend, and targeted investments there seem to be working. Now we must also coordinate our efforts to reach them outside these neighbourhoods, as many of us who live outside these urban or rural areas are not exposed to prevention methods.

Complacency is truly at the root of the matter. As the Public Health Agency of Canada continues to centralize its efforts to reach gbMSM in gay neighbourhoods across Canada, and thus not effectively reaching all communities, better-aligned awareness campaigns must be developed and adapted accordingly.

Stigma remains one of the biggest issues for people living with HIV today. It is the one central issue that affects most of the social and health outcomes of people living with HIV. On top of all this, overall about 40% of people living with HIV have mental health issues.

Decriminalization of HIV remains one of the priorities for people living with HIV today. We had expected better from this government in addressing the criminalization of HIV. Although the justice minister announced a new directive to help limit unjust prosecutions on December 1 of last year, more should be done. The cases of HIV criminalization in Canada represent one of the highest rates in the world, and have significantly added to the stigma that people living with HIV already face on a day-to-day basis.

I would be remiss if I did not address the HIV funding landscape in Canada. We question the steps that Canada has taken to address HIV, hepatitis C and other sexually transmitted and blood-borne infections—or STBBIs—in recent years through the community action fund and the pan-Canadian STBBI framework for action.

Since the implementation of the CAF, both people living with or affected by HIV and other STBBIs and community-based organizations that serve them have felt its negative effects, as HIV and STBBI rates continue to rise in Canada. Those living with these infections are left behind, with decreased access to support and care. To progress toward the UNAIDS 90-90-90 targets that Canada aims to reach, we suggest the following three steps: reassess the priorities of federal funding; review the population-centred approach; and increase the funding for both testing and secondary prevention through care and support of those affected by, and most of all, at risk or vulnerable to HIV.

There must be a consistent and collaborative dialogue between community-based HIV movements and the federal government, which does not necessarily exist. It is only through long-term and committed engagement that we will reach these targets and reduce the overrepresentation of gbMSM in new infections.

I must also underline the fact that our own surveillance data is significantly flawed in Canada. To be a G7 country without a unified surveillance data reporting system in 2019 is shameful—and imagine, we have data on only 60% of the reported cases of HIV in Canada.

Unfortunately, concerns were raised in our letter to the minister of health in 2016 regarding the likely outcomes of the funding cycle of that year. The implementation of the CAF has left many community-based organizations without the necessary funds to address the priority populations, which represent the highest levels of vulnerability in their own areas. After seeing HIV rates increase by 17% in 2017, a second consecutive annual increase and the highest rate since 2009, it is clear that the new funding model under the CAF has not effectively achieved its goals set out by PHAC, and this is shameful.

Ironically, while the STBBI framework for action highlights the importance of positive prevention, it does not holistically address it. While positive prevention is identified as one of the seven funding priorities of CAF, there is a recognizable lack of emphasis on treatment and care in the descriptions of both CAF priorities and the programs or initiatives funded. We do recognize that treatment is a provincial jurisdiction, but the provinces take their lead from the federal government. If and when there is no leadership at the federal level, the provinces are more likely to let this slide.

With that specifically in mind, CAS launched a national HIV testing day last year, built on the success of the Saskatchewan HIV testing day. It is inconceivable that PHAC would not want, at the very least, to sponsor this effort that we're doing at CAS and coordinate this work at the federal level minimally. This project brings much-needed awareness of HIV and new HIV testing technologies to thousands of Canadians. The government’s refusal to support this initiative is indicative of the value it places on community-based organizations, many of whom provide vital services that people living with HIV could not receive anywhere else.

Community-based organizations do most of the same work as the health care sector at 20% of the cost and save more than $1.3 million over the lifespan of somebody infected with HIV. With more mission funding as opposed to only project-specific funding, organizations would be more able to ensure quality, long-term programming rather than constantly scrambling for new sources of funding. This would ensure a full spectrum of prevention, care and support for people living with HIV, specifically LGBTQ2 populations across Canada.

Mission funding would also alleviate the divides in community, as PHAC and Health Canada could ensure collaboration and support amongst community organizations instead of continually pitting them against each other.

We do have the tools to prevent infections: U equals U, that is, the undetectable equals the untransmittable, and PrEP, among others.

We are resolute in our mission of eradicating HIV and supporting those affected. At this precise moment in time, someone out there who is living with HIV or another STBBI and who is not aware of their status is transmitting it to someone else. Why is this? It is because our own health care system outside of our urban settings does not have the tools to prevent HIV and other STBBIs. The system is underfunded and is struggling to survive instead of thriving. How is it that a gay man in Gatineau, across the river, cannot walk into a clinic and be tested for HIV and other STBBIs without feeling stigmatized? Why is it that a gay man in New Brunswick cannot feel comfortable getting tested in New Brunswick? It is because the sexual health clinics are called “women's sexual health clinics”. That's why.

Our biggest roadblock to positive health outcomes for anyone in Canada is our own health care system. It is nearly impossible for the most vulnerable and marginalized to access it, and these are the people who are most at risk of HIV. The health care system is broken, and until we recognize that, we will not be able to move forward in a meaningful way that will positively influence the health outcomes of all Canadians, let alone those of the LGBTQ community.

I thank you for the opportunity. I would accept more dialogue around this, as we move forward.

Thank you.

[The Chair, Liberal, Bill Casey]

Thank you very much.

Now we'll go to Mr. Croteau.

[Gerry Croteau, Executive Director, Gilbert Centre for Social and Support Services]

Thank you for inviting me.

The Gilbert Centre is the largest 2SLGBT centre north of Toronto and south of Ungava Bay.

“The homophobia we experience as children spreads throughout our lives like ripples on a pond. I remember everything, and so will your children,” and my children.

The impact of being a teenager in the 1960s, at a time when support services for LGBTQ youth were unavailable was that to be gay was to be at risk of criminal prosecution. Disclosure was never an option. Support for many of us within the family structure centred on being normal, for a boy. For many of us, that was hockey, cars and woodworking, and never showing an interest in the arts, theatre or fashion. For girls, it meant home economics, being cheerleaders and never showing interest in activities perceived as male.

Health issues, if any, centred on cuts, concussions and broken bones. By the time the hormones kicked in, there was no sex education. Safer sex practices were not taught, and girls got pregnant if you held their hand—that's a Quebec thing.

Now fast-forward to 2019. The landscape has changed dramatically, in some instances for the better, but in others, it seems to have reverted to the 1990s, as it pertains to the 2SLGBTQ community.

Here I will cite the following. One, Ontario had a lesbian premier, Kathleen Wynne, from 2013 to 2018. Two, on November 2016, Randy Boissonnault was appointed special adviser on LGBTQ issues to Prime Minister Trudeau. Three, in May 2017, Ottawa apologized for past wrongs to the LGBTQ community. Four, in November 2018, Ottawa announced a $450,000 fund to improve the safety of LGBTQ Canadians. Moreover, in 2019 Ontario dropped references in all sex-ed curriculum, to sexual orientation, gender identity and same-sex relationships.

The first bullet point in my brief discusses health issues within urban and rural communities that centre on the 2SLGBTQ community. When it comes to health concerns, many seek out a “gay” doctor, in the hope of being able to be transparent and in a safe place. Discussing health issues such as condom use, STI and HIV testing, mental health and concerns such as the use of PrEP are not easily communicated by health care professionals who are unwilling and unaware or uncomfortable discussing these concerns with their 2SLGBTQ patients.

Stigma remains problematic for gay men, men who have sex with men and HIV-positive folks. In 2016, Health Canada approved Canadian Blood Services and Héma-Québec's application to reduce the men who have sex with men ineligibility period from five years to one year. It remains stigmatizing to cite gay men as somehow being carriers of the HIV virus, or any number of other STIs.

Note that HIV is not only found among gay men, who represent 47% of HIV-positive folks. There remain 53% of others—injection-drug users, women and children. This stigma feeds into the inability of gay men to access health care in a timely manner. Many gay men do not visit their health care professionals, due to stigma, and therefore are not always receiving the proper health care they require.

U=U—undetectable equals untransmittable—the prevention access campaign, is a worldwide message that HIV folks who are undetectable cannot transmit HIV. The medical discovery has been endorsed by over 850 organizations from nearly 100 countries. Some health care professionals remain doubtful of the U=U message, thereby preventing their HIV-positive patients from fully embracing the tremendous freedom that U=U brings.

U=U brings with it the need to adhere to meds, proper diet and exercise. Health care for HIV-positive folks is critical in this country. It's not just good physical health, but also mental health and emotional well-being.

The cost of HIV meds can well exceed $1,000 per month, which is affordable for those who have private insurance, or in Ontario's case, the Trillium drug program. What if you can't afford the meds? We need to make HIV meds available at no cost, as they are in B.C., as mentioned earlier, freeing up the stress of securing meds, and allowing HIV-positive folks to live a healthy life.

HIV specialists are often located in major urban centres, which makes accessibility difficult for rural populations that may have transportation challenges. For some from rural communities, access to a 20-minute appointment could involve a day's commitment, due to buses that run only twice a day, and often require a bus transfer. Bus and train schedules are not always convenient or available in rural Ontario.

With regard to transgender health, within the trans community, many encounter issues, for example, with the use of their preferred name. Government-issued IDs use the name assigned at birth. Using the name assigned at birth and not the preferred name can be triggering.

In many instances, hospital, medical and government forms fail to address transgender folks correctly. The incorrect use of pronouns, sex and health issues that are unique to transgender folks can be very problematic when accessing health care. For example, for a trans woman who hasn't had confirming surgery but is on hormone replacement therapy, it may be awkward, or a trans man may need to have a mammogram if they haven't had top surgery, or a pap smear for cervical cancer. These are areas of concern when accessing health care.

Regarding indigenous communities, in Simcoe County and Muskoka, we have Beausoleil First Nation, Wahta Mohawk First Nation and the Chippewas of Rama First Nation. The problems are many for Canada's indigenous people, including aboriginal, first nation, Métis and Inuit people. They range from higher incidence of mental health problems and lower access to appropriate care—despite greater willingness in the general population to seek mental health care—to systemic public health care issues. Health care is viewed as white man medicine by many in the indigenous communities.

Social media sites that connect men who have sex with men, such as Grindr, Squirt and Facebook have enabled men to access quick and often anonymous sex without much concern about transmission of STIs, such as HIV or HCV. I bring this to your attention, because in rural communities, isolation is a factor and social media tends to bring the 2SLGBTQ community closer together. Accessing sexual encounters is therefore easier—it's GPS-based—and therefore the possibility of transmission of STIs is higher. This increases not only health risks but also health care treatments in a timely manner.

I recommend—and it's a dream, right?—providing training to health care professionals to be more inclusive and diverse in their respective medical practices, from receptionists to the doctors; ensuring that health care professionals are current in their use of terminologies and pronouns; encouraging awareness on the part of health care teams of the need to be willing to assist the 2SLGBTQ clients with their health care concerns, even when it is not within their scope of practice; and ensuring that their medical forms are inclusive of the 2SLGBTQ community.

Government should be mindful when allocating program dollars for short-term funding agreements that this limits the ability to provide ongoing clinical and practical support. In addition, the ability to hire individuals with the needed skill sets is hindered when employers are only able to provide short-term contracts of six months to a year. Short-term contracts are not viable to social workers, as an example.

HIV and ARV medications, including PrEP and PEP, should be free to all Canadians, and trans health care should allow for affordable confirming surgeries to be possible in all provinces—and that includes feminization surgery and language therapy.

To wrap up with some historical context, remember that in Canada, even though our health system is not always up to par for the 2SLGBT community, our LGBT rights are some of the most advanced in the world. Same-sex sexual activity has been lawful in Canada since June 27, 1969. Historically, Canada has frequently been referred to as one of the most gay-friendly countries, with its larger cities featuring their own gay communities, such as Toronto's Church and Wellesley, Montreal's gay village, Vancouver's Davie village and Ottawa's Bank Street gay village.

Global surveys from March 2013 show that 80% of Canada's general population—87% of folks aged 18 to 29—favour social acceptance of the LGBT community. A large majority of Canadians support same-sex marriage, which has been legal since 2005. Polls show that 70% of Canadians agree that same-sex couples have the same rights as heterosexual couples to adopt children. Finally, polls show that 76% of Canadians agree that same-sex couples are just as likely as other parents to raise their children successfully.

In closing, Canada is very gay friendly. Our health care system ought to be as well.

[The Chair, Liberal, Bill Casey]

Thanks very much.

As you know, many of the committee members just went across the country, and in every community that we went to, we heard about the health care system and the stigmatization and the difficulties faced by the gay community.

Hopefully, we will make some progress at the end of this committee.

Right now, we're going to start our seven-minute round of questions with Mr. Ouellette.

[Robert-Falcon Ouellette, Liberal, Winnipeg Centre, MB]

Thank you very much, Mr. Chair and Mr. Casey. Thank you very much to the witnesses for your testimony and getting it on the record.

I just have a few questions. I am wondering if you could talk about PrEP and the health impacts on the gay community, both positive and negative aspects.

[Dr. David Moore]

Is that directed at any of us?

[Robert-Falcon Ouellette, Liberal, Winnipeg Centre, MB]

Anybody can jump in.

[Dr. David Moore]

Maybe I'll start. In Canada, the short answer is that we don't yet know. Until quite recently, even among gbMSM, where globally there's a lot of community interest in PrEP, PrEP uptake in Canada has been very low. In most provinces, that was thought to be due to an absence of public funding for PrEP, but PrEP has actually been part of the provincial medicare program in Quebec since 2016. Even in Quebec, it seems like uptake there was not as great as might have been expected.

However, it does seem like that's changed recently. Researchers from Quebec have been presenting a lot of data on PrEP uptake and the acceptability of PrEP in Quebec. As I mentioned, in our studies of gay men in B.C. prior to public funding of PrEP, only about 2% of our participants reported using PrEP. Now we're seeing maybe 20% or 30% of participants using PrEP.

Public funding and increasing awareness over time are certainly fostering interest in PrEP, primarily among gbMSM. There's always a concern or perhaps an over-concern that this is going to adversely affect sexual behaviour and that we're going to see an increase in epidemics of other STIs. It's important to remember that PrEP is really targeted to individuals who are already at high risk of acquiring not just HIV but other STIs.

When we see very high rates of syphillis, gonorrhea and chlamydia diagnoses among PrEP users, that's really what we expect. That says we're actually targeting the people who really need this. It remains to be seen whether those rates will continue over time or whether we might in fact get better control of these other STIs, now that we're engaging these people at high risk of acquiring other STIs in regular medical care.

I think it's probably important to mention what we've heard, at least anecdotally, are the mental health benefits of being on PrEP. A lot of people report that their sex lives have improved now that they don't have to worry about catching HIV.

That's my take on it. We're interested in measuring many of these things over time but right now we don't have a lot of information about the real-world use of PrEP in Canada.

[Robert-Falcon Ouellette, Liberal, Winnipeg Centre, MB]

The next question I have is related to the needs of gay men and even lesbians. Obviously, it's mostly men who are answering, though, so probably we have a better experience related to that population.

As older gay men become older, what are the health concerns of that population in relation to whether or not they have HIV or AIDS? What are they encountering, not only within the health care system but also within home care and other institutions of the state?

[Gary Lacasse]

I can address that because I'm aging at the moment myself.

The issue is our doctors. When we go to see our doctors—I live here in Ottawa, I live in Aylmer in Quebec—they do not understand holistically what a gay man is or what an LGBTQ2 person is. When we say that we would like to have testing for different things, they say, "You're married and shouldn't be having risky sex”, or whatever—but that's part of the holistic approach to health care for anybody. We don't know what the risk factors are or if we have a dormant case or whatever.

For me as an aging gay man, one of the biggest priorities is really to be able to have an honest discussion with health care providers, one that is free of stigma and judgment. I am also wondering if, later on, there are going to be some facilities that will take me, a gay man, open-armed.

[Robert-Falcon Ouellette, Liberal, Winnipeg Centre, MB]

Do they exist in Canada?

[Gary Lacasse]

Some do exist in different pockets in cities across Canada.

[Robert-Falcon Ouellette, Liberal, Winnipeg Centre, MB]

Do you know where they exist? Where they might be gay-friendly...?

[Gary Lacasse]

There are some in Montreal. I guess there are some in Toronto and in B.C., I think, in Vancouver.

[Dr. Mark Gilbert]

I think there's one in Vancouver.

[Gary Lacasse]

Yes, but rurally, no.

[Robert-Falcon Ouellette, Liberal, Winnipeg Centre, MB]

As gay, lesbian and LGBTQ2 communities age, do they then become asexual?

[Voices]

Oh, oh!

[Robert-Falcon Ouellette, Liberal, Winnipeg Centre, MB]

Obviously not. That's a no.

[Gerry Croteau]

I'd like to add to that.