Findings from the Tracks survey on sexually transmitted and blood-borne infections and related factors among 2S/GBTQ+ people in Canada

Abstract

Background: Population health data are scarce for sexual- and gender-diverse communities who are disproportionately affected by sexually transmitted and blood-borne infections (STBBI). The Tracks survey of Two-Spirit people, gay, bisexual, trans and queer men and non-binary people (2S/GBTQ+) collected data from 43 Pride and community events in 19 cities across Canada in summer 2024.

Objective: To describe the self-reported prevalence of STBBI, including HIV, and associated factors among 2S/GBTQ+ people.

Methods: The self-administered questionnaire collected information on sociodemographics, social determinants of health, sexual behaviours, substance use, use of STBBI prevention services, HIV pre-exposure prophylaxis (PrEP), care and treatment for HIV and experiences of discrimination and abuse. Descriptive analysis was performed.

Results: Of the 4,880 participants, 52.2% described their sexual orientation as gay, 26.5% as queer and 24.1% as bisexual; 62.2% identified as a man and 22.4% as non-binary; 28.5% identified as trans; and median age was 30 years. Of participants aged 18 years or older, 63.3% experienced discrimination in the past 12 months and 45.5% had sex forced upon them in their lifetime. In the past 12 months, 5.6% of participants self-reported having been diagnosed with gonorrhea, 5.2% with chlamydia and 2.3% with syphilis; overall, 4.2% of participants self-reported living with HIV. Among participants who self-reported being HIV-negative, 17.5% were currently taking HIV PrEP.

Conclusion: High levels of discrimination and abuse were found among study participants. While most participants were aware of HIV PrEP, fewer than one in four currently used it. Findings from this survey will help inform STBBI programs and policies. The intentional inclusion of diverse participants provides important information on populations who have been previously less engaged in STBBI research.

Introduction

In Canada, sexual- and gender-diverse populations, including Two-Spirit people, gay, bisexual, queer and trans men, trans women, pansexual people and non-binary people, face numerous health and social inequities as a result of homophobia, transphobia, ableism, colonization, racism and other intersecting forms of discrimination ^{Footnote 1Footnote 2}. Gay, bisexual and other men who have sex with men (GBMSM), a subset of the sexual- and gender-diverse communities, continue to be disproportionately affected by sexually transmitted and blood-borne infections (STBBI) ^{Footnote 3Footnote 4Footnote 5}. In 2023, among the 2,434 newly diagnosed cases of HIV in Canada, 40.5% were among GBMSM ^{Footnote 3}. Further, despite a faster increase in infectious syphilis cases in the non-GBMSM population since 2018, data from eight provinces and territories in 2023 found that 27% of all infectious syphilis cases were among cisgender GBMSM ^{Footnote 4}.

While more STBBI data exist for GBMSM, very little population health data are available for Two-Spirit, trans and non-binary people in Canada, making it a challenge to quantify the burden of STBBI in these populations ^{Footnote 6}. This is, in part, because data on variables such as gender identity or being Two-Spirit are not widely captured through routine and notifiable disease surveillance systems; therefore, to better understand the current STBBI trends and related factors among Two-Spirit people, gay, bisexual, trans and queer men and non-binary people (2S/GBTQ+), enhanced surveillance data are needed ^{Footnote 7}.

As part of efforts to collect enhanced surveillance data, the Public Health Agency of Canada (PHAC) implemented the Tracks surveillance program in 2002. This program monitors the prevalence of HIV, hepatitis C, syphilis and other STBBI, and associated factors in key populations in Canada by conducting periodic, biobehavioural surveys (questionnaire and biological sample). With provincial, regional and local public health partners, two phases of the Tracks survey among GBMSM were previously conducted: Phase 1 (2005–2007) in five cities (Victoria, Winnipeg, Toronto, Ottawa and Montréal) (N=4,838); and Phase 2 (2008–2010) in two cities (Vancouver and Montréal) (N=3,042) ^{Footnote 8Footnote 9}. For Phase 3 (2024), PHAC collaborated with the Community-Based Research Centre (CBRC) to conduct a survey with 2S/GBTQ+ people ^{Footnote 10}. This shift in study population from GBMSM to 2S/GBTQ+ reflects a need to be inclusive of broader communities and understand their varied experiences ^{Footnote 6}.

The Tracks 2S/GBTQ+ Phase 3 survey is also referred to as the in-person Sex Now 2024 survey. It is one survey in a series of periodic "Sex Now" community-led surveys undertaken by CBRC since 2002 to collect sexual health, HIV and other STBBI data ^{Footnote 11}. The Sex Now survey has evolved from originally being a provincial study of sexual relationships between men in British Columbia to a Canada-wide survey on the health of people with diverse sexual orientations and gender identities ^{Footnote 11Footnote 12}.

This article presents descriptive findings from the national Tracks 2S/GBTQ+ Phase 3 survey, conducted from June 1, 2024 to September 15, 2024. The objectives are to describe 1) self-reported prevalence of HIV, syphilis and other STBBI and 2) care and treatment for HIV. It also reports on social determinants of health, experiences of discrimination and abuse, sexual behaviours, substance use, and use of prevention services.

Methods

Tracks Phase 3 (Sex Now 2024) survey of 2S/GBTQ+ people in Canada is a biobehavioural survey involving the administration of a questionnaire and the collection of a biological sample to test for HIV, hepatitis C, syphilis and hepatitis B. The current report presents only the results from the questionnaire component of the 2024 biobehavioural survey since only 39.4% of participants who were invited to provide a biological sample opted to do so. An analysis of biological test results will be conducted and presented in a future report.

Sampling methods

Similar to other Tracks surveys of key populations and previous Sex Now surveys, venue-based sampling was used for the Tracks 2S/GBTQ+ Phase 3 survey. Local study teams, trained by the CBRC research team, actively recruited at venues by approaching potential participants and providing them with information (e.g., survey objectives, what participation entails, eligibility) as outlined in the recruitment script. Recruitment of participants took place at Pride festivals or other 2S/GBTQ+-related venues/events (e.g., picnics, community dinners, Pow Wows, bars) across Canada in summer 2024. Promotion of the survey included social media posts, mainstream media engagement, word-of-mouth and leveraging relationships with Pride Societies and local community-based organizations.

With the aim to include at least one study site per province, the following factors were considered when selecting study sites: large 2S/GBTQ+ population; higher prevalence of HIV than the general population in the region; local community support; ability of local partners to implement the survey; and study site participation in prior Sex Now surveys.

Eligibility and consent

Eligible participants had to self-identify as 1) Indigenous Two-Spirit, OR 2) a non-binary person or trans man OR 3) a gender other than woman (cis or trans) and either gay, bisexual, queer or another non-heterosexual identity or report having engaged in sexual activity with a man (cis or trans) in the past five years. Survey participants also had to be 1) 15 years of age or older, 2) living in Canada and 3) able to provide informed consent and complete the questionnaire in English, French or Spanish. Individuals who had already participated in the current survey were excluded from participating again.

Eligible participants were presented with a consent form on the study tablet or their personal device. Participants had the opportunity to ask any questions to local study team members. Consent was then obtained by clicking on a standard checkbox. Consenting participants completed the self-administered questionnaire and had the option to provide a biological sample in the form of a dried blood spot (DBS) specimen. Only participants 18 years or older were invited to provide a DBS specimen. Participants had the option to have the results of their DBS specimen test returned to them by trained CBRC peers.

Participants who reported a blood disorder in which their blood does not clot properly (e.g., hemophilia or von Willebrand disease) or who recently underwent chemotherapy were excluded from the option to provide a DBS specimen. The total number of individuals approached and reasons for declining to participate were not recorded.

Questionnaire

The questionnaire was based on questions used in prior Tracks or Sex Now surveys and demonstrated both face and content validity. Questionnaire development was also informed by a review of the epidemiology and literature of 2S/GBTQ+ people and STBBI; a review of published GBMSM questionnaires; and consultations by CBRC with community partners to ensure questions reflected the experiences, data needs and concerns of community members.

The Tracks 2S/GBTQ+ Phase 3 (Sex Now 2024) questionnaire asked about the following: socio-demographic characteristics; social determinants of health; sexual behaviours and relationships; substance use; use of STBBI health and prevention services (including testing); care and treatment for HIV and hepatitis C; knowledge and use of HIV pre-exposure prophylaxis (HIV PrEP), doxycycline PrEP (doxy PrEP) and doxycycline post-exposure prophylaxis (doxy PEP) ^{Footnote 13}; experiences of discrimination and abuse; community and social connections; and mental health. This questionnaire took an average of 27 minutes (interquartile range [IQR]=17–30 minutes) to complete.

The questionnaire was programmed into LimeSurvey version 3 software and piloted by PHAC and CBRC staff, as well as 2S/GBTQ+ community members. Piloting was conducted to estimate the time required to self-complete the questionnaire and identify any of the following: errors in skip logic or validation rules; unclear questions or response options; typing or editing errors; and formatting issues. The English questionnaire was subject to four rounds of piloting and the French and Spanish questionnaires to two rounds. This pilot testing included multiple members of the study population. Local study teams were trained on survey processes. The self-administered questionnaire, with optional assistance from the study team, CBRC staff or volunteers, was accessible on electronic tablets provided by the study team or on a participant's own device via scanning a QR code. Questionnaire data were stored on secured PHAC servers. Participants who completed the questionnaire and were aged 18 years or older had the option to provide a finger-prick blood sample collected on a DBS filter card for STBBI testing. As mentioned previously, given the low uptake of DBS, results from STBBI testing are not presented in this article.

Participants received $10 CAD cash for their participation in the questionnaire and a Sex Now branded tote bag for providing an optional DBS sample. The protocol and questionnaire were approved by research ethics boards at Health Canada-PHAC (REB 2023-042P), University of Victoria (BC24-0135), University of British Columbia (H24-00806) and Simon Fraser University (H24-00806). Data sharing agreements were established between PHAC, CBRC and the University of Victoria.

Analysis

Overall, 4,880 eligible participants were recruited from 43 events in 19 Canadian cities from June 1, 2024 to September 15, 2024. The purpose of this report and the analyses undertaken were descriptive in nature and focused on questionnaire data. The DBS test result data will be reported in future articles. Small cell counts (i.e., questionnaire response categories with a limited number of observations) were assessed to determine the risk of identifying individual participants and were left in when it was determined that there was no risk of re-identification, as per PHAC's Directive for the Collection, Use and Dissemination of Information Relating to Public Health ^{Footnote 14}. Where data in the table contain small cell counts, the results should be interpreted with caution. All descriptive statistics were computed using R Statistical Software version 4.3.2 ^{Footnote 15}.

Participants who selected questionnaire response options "I don't know", "Prefer not to answer" or "Unsure" were included in the analyses. Participants who selected the questionnaire response option "Not Applicable" or whose response option was manually coded as "skipped" (i.e., did not meet criteria to view and answer question), "blank" (i.e., did not answer question and proceeded to answer next question) or "exited" (i.e., exited questionnaire before completion) were excluded from analyses for that variable. As a result, denominators differ across variables depending on the number of participants who provided valid responses for each item. Of the 4,880 eligible individuals who consented to participate, 4,640 (95.1%) completed the entire questionnaire.

Descriptive analyses were performed to characterize the study population. Categorical variables are presented as frequencies (n) and proportions (%). Age was analyzed both categorically (using age groups) and continuously (using the median and range).

Select subgroup comparisons were conducted to explore potential differences in key variables. Pearson's chi-square tests of independence were calculated for these comparisons. These analyses were exploratory in nature and future manuscripts will provide more detailed characterisations of specific subgroups.

Results

Sociodemographic characteristics

Participant recruitment occurred in all ten Canadian provinces with approximately half of participants recruited from one of the following three cities: Toronto (25.0%), Ottawa (13.0%), and Vancouver (9.4%) (Table 1). The median age of participants was 30 years old, with ages ranging from 15 to 84 years. Overall, 28.5% of participants identified as a person with a disability. The most commonly reported ethnicity was white (64.2%), followed by Indigenous (11.2%). Of the 547 Indigenous participants, 63.4% were Two-Spirit.

Just over half of participants (52.2%) identified as gay, with queer (26.5%) and bisexual (24.1%) as the next most common sexual orientations. Around two-thirds of participants identified as a man (62.2%), and 22.4% as non-binary. About two-thirds of participants were GBMSM (69.4%). Of GBMSM participants, 39.7% (1,345/3,386) were between the ages of 15 and 29 years (data not shown in table). More than one-quarter of participants identified as trans (28.5%). Half (n=710/1,390, 51.1%) of trans participants were between the ages of 15 and 24 years, compared with only 18.5% (n=646/3,490) of participants who did not identify as trans (data not shown in table); this difference was statistically significant (p<0.001).

Social determinants of health

Two-thirds of participants (66.5%) had completed post-secondary school (e.g. certificate, diploma), a bachelor's degree or higher (Table 2). In the six months prior to the survey, 71.9% of participants were employed, 17.6% were students, 15.4% were unemployed and 7.2% were on government assistance. More than one-third (37.6%) of participants experienced financial strain (i.e., had to cut back or could not make ends meet) and 10.6% were unstably housed in the past six months. Overall, 5.3% of participants had been incarcerated in their lifetime.

Just under half of participants (45.5%) had sex forced upon them in their lifetime, and half (n=1,425/2,787, 51.1%) had experienced verbal, physical and/or sexual abuse by a partner in their lifetime (data not shown in table). More than half (56.3%) of participants reported currently being in a relationship and the majority of participants (94.8%) had at least one person they can count on for support. Only 54.5% of participants were satisfied with their connection to Two-Spirit, lesbian, gay, bisexual, trans, queer, questioning, intersex, asexual and other sexual and gender diverse (2SLGBTQQIA+) communities.

Box 1 presents information on experiences of discrimination among study participants aged 18 years or older. Two-thirds of participants (63.3%) have experienced at least one form of discrimination in the past 12 months.

Box 1: Experiences of discrimination among participants aged 18 years or older in the Tracks survey of 2S/GBTQ+ people in Canada, Phase 3, 2024^{Footnote a}

Overall experience of discrimination:

• 63.3% (1,733/2,738) of participants experienced at least one form of discrimination in the past 12 months
• 22.1% (620/2,805) of participants avoided healthcare services due to fear of, or concern about, stigma or discrimination in the past 12 months

Experiences of discrimination among specific participant groups, past 12 months:

• Among non-binary participants, 61.1% (408/668) experienced discrimination based on their gender expression
• Among GBMSM, 25.1% (487/1937) experienced discrimination based on their sexual orientation
• Among trans participants, 64.2% (522/836) experienced discrimination based on their trans experience
• Among participants with a disability, 52.6% (437/831) experienced discrimination based on their disability status
• Among Indigenous participants, 40.1% (112/279) experienced discrimination based on their Indigenous identity
• Among participants who self-reported living with HIV, 25.0% (27/108) experienced discrimination based on their HIV status

Sexually transmitted and blood-borne infection risk exposure: sexual behaviours and substance use

Sexual behaviours

Overall, 831 participants (17.8%) did not have any sexual partners in the past six months and thus were not asked any subsequent questions about sexual activity (Table 3). Of these, 282 participants (33.9%) reported having never had sex (data not shown). Among GBMSM participants in this study, a higher proportion of trans GBMSM (17.0%, 90/529) than non-trans GBMSM (9.2%, 238/2,593) reported having no sexual partners in the past six months (data not shown in table). This difference was statistically significant, (p<0.001).

Among those who reported having had sex in the previous six months, 42.0% had one sexual partner, 35.3% had two to five sexual partners, 6.9% had six to nine sexual partners and 15.8% had ten or more sexual partners. Three-quarters (76.0%) of participants had sex with a man (cis or trans), 19.4% had sex with a woman (cis or trans) and 19.8% had sex with a non-binary person in the past six months.

The most common type of sexual activity reported by participants in the past six months was oral sex (85.7%) (Table 3). Around two-fifths of participants engaged in anal sex as the bottom (42.0%) or anal sex as top (41.1%) in that timeframe. Among those who had anal sex in the past six months, 14.0% always used condoms with their recurring sex partner(s) and 19.3% always used condoms with their one-off sex partner(s). Around one-quarter (22.7%) of participants engaged in sex between three or more people (i.e., threesome, group sex) in the past six months. As a measure of transactional sex, 3.6% of participants received money, goods or services in exchange for sex in the past six months.

Substance use

Three-quarters (74.9%) of participants reported using substances in the past six months (Table 3). Of those, 24.5% have used substances to enhance sexual experience during that timeframe. Among participants who have used substances to enhance sexual experience, the most common substances used were cannabis (68.1%), alcohol (52.8%) and poppers/amyl nitrite (40.5%). Other substances used to enhance sexual experience include erection drugs (19.5%), tobacco or nicotine (14.7%), ecstasy (14.6%), psychedelics (12.0%), cocaine (11.5%), crystal meth (10.0%), gamma-hydroxybutyrate (GHB) or gamma-butyrolactone (GBL) (8.0%) and ketamine (5.8%). The vast majority of participants (95.0%) had never injected substances for non-medical uses.

Access to and use of healthcare, sexually transmitted and blood-borne infection prevention and testing services

Primary healthcare and mental health

Two-thirds of participants (68.4%) currently had a regular family doctor or nurse practitioner. Of those, 67.9% said their regular healthcare provider was aware of their sexual orientation (Table 4). Lifetime HIV testing was more prevalent among participants whose healthcare provider was aware of their sexual orientation (n=1,610/1,903, 84.6%) as compared to participants whose healthcare provider was not aware of their sexual orientation (n=260/484, 53.7%) (data not shown in table). This difference was statistically significant (p<0.001). Among trans participants, 72.3% (n=699/966) said their regular healthcare provider was aware of their gender identity (data not shown in table). Over one-third of participants (38.9%) reported having fair or poor mental health status. Half of participants either accessed (41.4%) or tried to access (11.1%) mental health counselling services in the past 12 months.

Sexually transmitted and blood-borne infection prevention: HIV PEP/PrEP, doxy PrEP/PEP and vaccinations

Awareness of HIV PEP was lower than for HIV PrEP (60.1% vs. 80.3%) (Table 4) and HIV PrEP awareness was higher among GBMSM than non-GBMSM study participants (85.4% vs. 68.8%); this difference was statistically significant (p<0.001). Among all participants who self-reported being HIV-negative, 17.5% were currently taking HIV PrEP and 7.4% had previously taken HIV PrEP but were not currently using it. Of those who had stopped taking or had never taken HIV PrEP, 24.7% were interested in using HIV PrEP, and 37.8% were unsure if they would be interested in using it.

Less than half of participants (46.3%) were aware of doxy PrEP/PEP, and only 11.4% of participants had ever taken doxy PrEP/PEP (Table 4). Among participants who haven't taken doxy PrEP/PEP or who don't know whether they have taken it, 30.2% were interested in using it and 32.5% were unsure if they would be interested in using it. In terms of vaccinations, 60.6% of participants reported vaccination for hepatitis B, 44.8% for human papillomavirus (HPV), and 19.3% of participants had received two or more doses of the mpox vaccine.

Sexually transmitted and blood-borne infection testing

In the past 12 months, 48.8% of participants reported testing for HIV, 37.2% for hepatitis C, and 49.2% for other sexually transmitted infections (STIs). Testing for HIV in the past 12 months was more common among GBMSM than other study participants (55.6% vs. 34.1%; p<0.001) while less common among trans than other study participants (32.4% vs. 55.8%; p<0.001). One-quarter of participants (24.4%) have never been tested for HIV, 22.0% for hepatitis C and 19.9% for other STI.

HIV care cascade and sexually transmitted and blood-borne infection prevalence

All estimates of prevalence for HIV, hepatitis C and other STBBI are based on self-reported data from the questionnaire (Table 5). No DBS data are presented here, and thus awareness of infection status (i.e., comparison of a participant's self-reported status with their DBS test result for each infection) cannot be determined.

HIV prevalence and care cascade

Among study participants, 4.2% self-reported living with HIV. Of these, almost all participants (98.0%) had a clinic or provider for their HIV care and 96.8% were currently taking antiretroviral therapy. Among participants currently taking antiretroviral therapy, 92.6% reported a suppressed viral load on their most recent viral load test. Only 5.5% of participants living with HIV reported avoiding HIV medical care or treatment in the past 12 months due to fear of, or concern about, stigma or discrimination.

Hepatitis C prevalence

Among all study participants, 0.3% reported currently having hepatitis C and 2.5% previously had hepatitis C but had since cleared the virus. Among participants with a current hepatitis C infection, 53.3% had a hepatitis C healthcare provider (data not shown).

Sexually transmitted and blood-borne infection prevalence

In the past 12 months, 5.6% of participants self-reported having been diagnosed with gonorrhea, 5.2% with chlamydia, 2.5% with herpes (genital or anal) and 2.3% with syphilis.

Discussion

The 2S/GBTQ+ population in Canada is diverse, with people who have varying experiences related to ongoing STBBI epidemics. This survey provides essential information to better understand STBBI prevalence, access to STBBI prevention, STBBI testing and treatment, related sociodemographic characteristics, and risk exposure within the study sample. Overall, 4.2% of participants self-reported living with HIV and, while most participants were aware of HIV PrEP, fewer than one in four currently used it. High levels of discrimination and abuse were found among study participants.

While previous Tracks surveys have focused on GBMSM ^{Footnote 8Footnote 9}, this Phase 3 survey included the broader 2S/GBTQ+ community. As a result, this survey is not directly comparable with previous surveys that included only participants identifying as men. Further, previous Tracks surveys among GBMSM have only been eligible to men who have had sex with another man. Similar sexual activity-based eligibility criteria were not applied to this study, and thus some participants were eligible even if they have never had sex. Accessing this population is essential for primary prevention and health promotion efforts to educate and support STBBI knowledge and harm reduction practices. The current survey also recruited primarily from Pride festivals, while Tracks Phase 1 (2005–2007) and Phase 2 (2008–2010) surveys involved more recruitment from bars, associations, businesses and bathhouses. These differences in sampling location may further contribute to differences in the study populations, in addition to historical and societal changes.

Previous research has been done with the 2S/GBTQ+ population in Canada, but results of this study are also not directly comparable with these other studies. For example, there are meaningful differences in diversity and representation within the study population as compared to Sex Now 2018, a previous in-person Sex Now survey of 2S/GBTQ+ people at Pride festivals; the proportion of trans participants and non-binary participants more than quadrupled between the two surveys ^{Footnote 16}. The current study also had higher proportions of all racial/ethnic minority populations, with an increase in Black participants from 4.1% in 2018 to 7.6% in 2024 ^{Footnote 16}. While the current study composition may not reflect the actual composition of the 2S/GBTQ+ population in Canada, it does provide valuable information on specific populations of this broader community.

As compared with Sex Now 2018, a higher proportion of participants in this 2024 survey have never been tested for HIV (8.4% vs. 24.4%), hepatitis C (9.3% vs. 22.0%) or other STI (7.9% vs.19.9%) ^{Footnote 16}. Testing for HIV was less common among trans than other participants in this study. Lower STBBI testing uptake among trans and non-binary people as compared with cisgender people has been found in previous research with the 2S/GBTQ+ population ^{Footnote 16}. There are several reasons why trans and non-binary participants may be less likely to test for STBBI. First, as a result of cisnormative policies (e.g., gender segregated clinic hours), a lack of provider knowledge about trans identities and trans-specific healthcare needs and various forms of discrimination, trans and non-binary people often face barriers to accessing STBBI testing services ^{Footnote 17Footnote 18}. Further, a study using data from the Sex Now 2015 survey found that the proportion of trans GBMSM who were sexually inactive in the last 12 months was significantly higher than for cisgender GBMSM ^{Footnote 19}. This may contribute to a lower perceived or actual risk of STBBI, and thus lower testing uptake. Among GBMSM participants in this study, a higher proportion of trans GBMSM than non-trans GBMSM reported having no sexual partners in the past six months (17.0% vs. 9.2%).

The self-reported prevalence of HIV in this study (4.2%) is nearly 25 times higher than the estimated HIV prevalence in the general Canadian population in 2022 of 0.17% ^{Footnote 3}. Nevertheless, it is likely to be an underestimation of the true prevalence within the study sample, given that it is based on self-reported data and because of the younger age skew of the study sample. Nearly one-quarter of the sample reported having never been tested for HIV, and even among participants who had previously tested negative for HIV, it is possible that some may have seroconverted since their most recent HIV test. Subgroup analyses of HIV prevalence will also be important, as half of people living with HIV in Canada as of 2022 were GBMSM ^{Footnote 3}. The Engage Cohort Study of GBMSM in Canada has also found HIV prevalence estimates in Montréal, Toronto, and Vancouver that are three-to-five times higher than the estimate in this study, highlighting the need for further population- and geographic-specific analyses ^{Footnote 20}.

At a federal level, Canada has made commitments to meeting the 95-95-95 global targets to end HIV/AIDS as a public health concern ^{Footnote 21}. While progress towards the first target, awareness of HIV status, cannot be determined from these self-reported data, this study provides insights into the remaining two targets among the study population. Among participants in this study who self-reported living with HIV, 96.8% reported currently taking HIV antiretroviral therapy drugs. Of those currently taking antiretroviral therapy drugs, 92.6% reported a suppressed viral load on their most recent viral load test. These are similar to HIV care continuum metrics from studies among GBMSM in Canada in 2017–2019 ^{Footnote 3}.

Sexual behaviours and substance use are important risk exposures related to STBBI. Among participants who have used substances to make sex more intense, less inhibited or last longer, the most commonly used substance was cannabis, followed by alcohol and poppers. These results are similar to a 2021 study among 2S/GBTQ+ people, which found that poppers were the most commonly used substance to enhance sexual experiences, followed by cannabis and alcohol ^{Footnote 22}.

In this study, one in five participants (19.3%) who had anal sex with one-off sex partner(s) and 14.0% who had anal sex with recurring sex partner(s) in the past six months reported consistent condom use. Consistent condom use is lower than was observed in a previous Tracks survey with GBMSM in 2005–2007 ^{Footnote 9}. While this may, in part, be due to differences in study population, decreasing trends in condom-protected sexual events were also found in other Canadian studies among GBMSM ^{Footnote 23}. An Australian study among GBMSM from 2013 to 2017 found a rapid decrease in consistent condom use alongside a rapid increase in HIV PrEP use ^{Footnote 24}.

In addition to sexual behaviour and substance use data, this study also collected information on STBBI prevention and healthcare services. Previous studies have shown increasing knowledge about HIV PrEP from 2015 to 2019 and increasing use of HIV PrEP between 2018 and 2020, among 2S/GBTQ+ people in Canada ^{Footnote 25}. The present study shows slight decreases in both of these measures as compared with 2019 and 2020, respectively, although comparison with these studies is challenging. This decrease reflects greater study participation from non-GBMSM people, among whom HIV PrEP uptake is lower compared with GBMSM study participants. An analysis of data from the 2019 Trans PULSE survey among trans and non-binary people in Canada found current HIV PrEP use was 0.9% ^{Footnote 26}, which is drastically lower than 17.3%, the proportion of participants who reported currently using HIV PrEP in a Sex Now study of 2S/GBTQ+ people in the same year ^{Footnote 25}.

Doxycycline, an antibiotic commonly used to treat chlamydia and sometimes used to treat syphilis in Canada, is increasingly being prescribed off-label to prevent bacterial STI. Several large-scale studies have shown promising results for doxy PEP ^{Footnote 27Footnote 28Footnote 29}. Most of this research on doxy PEP has been among GBMSM, and less research data exists for doxy PrEP ^{Footnote 13}. In this study, 46.3% of participants were aware of doxy PrEP/PEP, and 11.4% had ever taken doxy PrEP/PEP. Work is currently underway by the National Advisory Committee on Sexually Transmitted and Blood-Borne Infections at PHAC to investigate the effectiveness of doxycycline prophylaxis and concerns of antimicrobial resistance ^{Footnote 30}.

One-third of participants (31.6%) did not have a regular primary healthcare provider. Of those who did, 67.9% said that their provider was aware of their sexual orientation. Provider awareness of the participant's sexual orientation may be an important factor related to HIV testing. For participants whose provider was aware of their sexual orientation, 84.6% were ever tested for HIV, compared with only 53.7% of participants whose provider did not know their sexual orientation. This aligns with existing literature that disclosure of sexual orientation to one's healthcare provider is associated with increased uptake of HIV testing ^{Footnote 31Footnote 32}. One reason for non-disclosure may be fear of stigma and discrimination ^{Footnote 32}. This highlights the importance of continuing to advance access to sexuality-affirming health care ^{Footnote 33}.

The majority of study participants experienced discrimination (63.3%) in the 12 months prior to the study, with many participants having experienced multiple forms of discrimination based on their intersecting identities. Experiences of stigma and discrimination create stressful environments that can place sexual and gender minorities at increased risk of poor mental health and prevent them from seeking care ^{Footnote 34}. In the present study, only 33.0% of participants rated their mental health as excellent or very good, compared with 53.7% of the general population in Canada in the same year ^{Footnote 35}.

Experiences of intimate partner violence and forced sex were common among study participants. Previous studies in Canada have similarly found that sexual and gender minorities are at increased risk of experiencing these types of violence ^{Footnote 36Footnote 37}. An analysis of data from the 2018 Survey of Safety in Public and Private Spaces found that, since the age of 15 years, sexual minority men were almost two times more likely to have experienced physical or sexual assault by an intimate partner, and three times more likely to have experienced sexual assault by anyone, as compared with heterosexual men ^{Footnote 36}. This study also found that compared with cisgender people, trans and non-binary people were more likely to have experienced physical and sexual assault since the age of 15 years ^{Footnote 37}.

Strengths and limitations

The Tracks 2S/GBTQ+ Phase 3 survey involved recruitment from all ten provinces during the summer of 2024. Expansion of the eligibility criteria for Sex Now surveys over the years has resulted in the current sample being inclusive of Indigenous Two-Spirit people and a wide range of sexual orientations and gender identities and containing a large sub-sample of trans participants. This is an important source of information at local, provincial and federal levels to inform public health action; however, these results may not be generalizable to the whole 2S/GBTQ+ population in Canada, or in any specific city, because non-probability-based sampling was used to recruit participants. While no gold standard data on the 2S/GBTQ+ population exists to be able to assess the representativeness of the sample, research has shown that nonprobability sexual minority community venue-based samples may underrepresent certain subgroups, such as those who are unemployed or have lower incomes ^{Footnote 38}. Further, some sites, such as Montréal, also experienced bad weather and/or logistical challenges for survey recruitment in 2024, leading to lower sample sizes than originally anticipated. Since this study relies on self-reported data (with the exception of DBS test results), it is possible that certain factors are under- or over-represented.

Conclusion and next steps

This survey provides information on the health and well-being of a diverse sample of 2S/GBTQ+ people across Canada. High levels of experiences of discrimination and abuse were found among study participants. The intentional inclusion of diverse participants provides important information on populations who have been previously less engaged in STBBI research, such as non-binary people, while still allowing for future sub-analyses with populations more commonly known to be disproportionally impacted by STBBI, such as GBMSM. These further sub-analyses focusing on specific population groups (e.g., Two-Spirit people, trans men, GBMSM, non-binary people) are important for informing STBBI programs and policies. Collaboration with Indigenous researchers and organizations will provide key pathways for analysis and mobilization of data from Indigenous Two-Spirit and Indigenous GBTQ+ participants. Broader engagement with researchers, community organizations and populations affected by STBBI will help ensure these data are effectively applied to STBBI prevention and care efforts. Qualitative research with 2S/GBTQ+ people in Canada can also help contextualize these findings and provide input into topics to be included in future surveys with this population.

Authors' statement

MB — Methodology, formal analysis, writing–original draft, writing–review & editing
NL — Conceptualization, methodology, supervision, writing–review & editing
BK — Conceptualization, methodology, supervision, writing–review & editing
EW — Conceptualization, methodology, formal analysis, writing–original draft, writing–review & editing
HA — Methodology, writing–review & editing
TC — Conceptualization, writing–review & editing
KR — Conceptualization, methodology, formal analysis, writing–review & editing
AA — Methodology, formal analysis, writing–review & editing
CC — Methodology, resources, supervision, writing–review & editing
SK — Methodology, resources, writing–review & editing
JC — Conceptualization, methodology, writing–review & editing
JA — Conceptualization, funding acquisition, supervision, methodology, writing–review & editing

Competing interests

None.

ORCID numbers

Megan Butler — 0009-0008-1851-7012
Nathan Lachowsky — 0000-0002-6336-8780
Benjamin Klassen — 0000-0002-8203-724X
Herak Apelian — 0000-0003-0553-2172
Anthony Amato — 0000-0002-7978-6514
Catherine Card — 0000-0002-2561-9649
Joseph Cox — 0000-0002-7041-1556
Josephine Aho — 0000-0003-1518-9582

Acknowledgements

The authors would like to thank all study participants who took the time to complete the questionnaire, including those who additionally provided a biological sample; staff at the Community-Based Research Centre and University of Victoria; and volunteers. We acknowledge the excellent technical expertise of the National Laboratory for HIV Reference Services (NLHRS) of the National Microbiology Laboratory in all aspects related to the use of dried blood spots (DBS) in this survey. We especially thank J Kim and P Lacap from the NLHRS for their technical guidance and work in the testing of DBS samples. We would also like to thank S Totten for guidance in study conception, data analysis, and manuscript development. A special thank you to A Fahlman for the coding of the questionnaire and S Ambrose and T Le for their expertise in knowledge mobilization. We recognize the valuable input of A Amson and J Helwig in their review of this manuscript. Finally, we would like to thank the community partner organizations who supported local recruitment, including Ribbon Community, Queer & Trans Health Collective, Centre for Sexuality, Our Own Health Centre, The 519, Muslim Pride Toronto, MAX Ottawa, RÉZO, PEERS Alliance, AIDS Coalition of Newfoundland and Labrador and Quadrangle NL.

Funding

The Tracks survey of 2S/GBTQ+ people in Canada was funded by the Public Health Agency of Canada as part of its HIV and Hepatitis C Enhanced Surveillance System (Tracks Surveys).

• Previous Page
• Table of contents
• Next page