Public Health Agency of Canada
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Government of Canada Report to the Secretary General of the United Nations on the United Nations General Assembly Special Session on HIV/AIDS Declaration of Commitment on HIV/AIDS January 2003 - December 2005
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III. National responses to the AIDS epidemic
Canada is responding to the epidemic on both domestic and global fronts. This response involves all levels of governments, the community as well as the scientific and medical sectors and necessitates coordination amongst these different jurisdictions and the various federal government players.
The pan-Canadian responseCanada is a federation, with responsibilities for health shared amongst the federal government and provinces and territories. Provinces and territories deliver health care and hospital services for the majority of the population. The Government of Canada is responsible for ensuring the availability of, and/or access to, health services for First Nations people living on reserve and the Inuit in northern Canada, federal prisoners and those in the armed services. In partnership with provincial and territorial governments, the Government of Canada works to develop health policy, fund the health system, enforce health regulations, and promote disease prevention and healthy living. These shared jurisdictional responsibilities mean that coordination among many levels of government is necessary to ensure the most consistent, effective and comprehensive response to HIV/AIDS within Canada.
Since the 2003 report, there has been significant progress made in outlining a pan-Canadian response to HIV/AIDS with the release of Leading Together: Canada Takes Action on HIV/AIDS (2005-2010). The document was developed after a large-scale consultative process involving stakeholders from across the country, including community groups, people living with and/or at-risk of HIV/AIDS, health care providers, researchers, and governments across Canada. It calls for consolidated action on all fronts and lays out specific actions and targets to achieve its bold vision, namely that "the end of the epidemic is in sight." Currently, a multi-sectoral body is being formed to champion the widespread use of the document, to strengthen engagement and to monitor its use.
The federal response
In January 2005, the Government of Canada launched the Federal Initiative to Address HIV/AIDS in Canada and increased ongoing federal HIV/AIDS funding of the domestic response from $42.2 million per annum to $84.4 million by 2008-09 . The Federal Initiative is a partnership between four federal departments and agencies: the Public Health Agency of Canada, Health Canada, Canadian Institutes of Health Research, and Correctional Service Canada. The Federal Initiative has the following goals:
- Prevent the acquisition and transmission of new infections;
- Slow the progress of the disease and improve quality of life;
- Reduce the social and economic impact of HIV/AIDS;
- Contribute to the global effort to reduce the spread of HIV and mitigate the impact of the diseases.
The Federal Initiative builds on the previous Canadian Strategy on HIV/AIDS (1998-2004) and reinforces the importance of partnership and engagement with players across governments, civil society, health care providers, researchers, and those living with or at risk from HIV. It is an approach grounded in human rights and the determinants of health. As part of its strategy, the Federal Initiative will develop population-specific approaches for the following groups: people living with HIV/AIDS, gay men, people who use injection drugs, Aboriginal people, federal inmates, youth and women at risk for HIV and people from countries where HIV is endemic. These specific approaches will address policies and programs affecting the lives of people from designated populations, with specific attention to integrated approaches involving people who fall within more than one population (e.g. women and people living with HIV/AIDS) and issues that cross populations. Specifically, the Federal Initiative policy direction of integration states that programs will address barriers to services for people living with, or vulnerable to, multiple infections and conditions that have an impact on their health.
The global response
Canada has contributed over $600 million to the global effort to address HIV/AIDS since 2000. Canada's International Policy Statement identifies health, including HIV/AIDS, as a key priority for official development assistance with gender equality as a cross-cutting issue in all of the Canadian International Development Agency (CIDA)'s policies and programming. Foreign Affairs Canada has developed a strategy to effectively address the foreign policy dimensions of HIV/AIDS, including such issues as human security, human rights, multilateral and bilateral advocacy, workplace guidelines and complex humanitarian emergencies. CIDA is currently developing a Strategic Directions Paper for Health, including HIV/AIDS, which flows from CIDA's HIV/AIDS Action Plan (2000-2005).
A further contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria of $250 million for 2006-07 was announced in September 2005, bringing Canada's total commitment to the Global Fund to $530 million. In addition, Canada has made significant contributions to UNAIDS, the WHO "3X5" Initiative, the International AIDS Vaccine Initiative, the International Partnership for Microbicides, United Nations Population Fund (to ensure strong linkages with sexual and reproductive health and access to condoms and other reproductive health commodities), and a number of large bilateral and regional programs in Africa, Asia, Eastern Europe, Latin America and the Caribbean.
Partnerships across federal departments and agencies are a key component of the Government of Canada's approach in order to coordinate HIV/AIDS related activities and to address the determinants of health.
Provincial and territorial responses
Provinces and territories in Canada are responsible for the provision of health care. Treatment is available across Canada, and there are programs in place to ensure that low-income does not prevent people from accessing antiretrovirals. Most provinces and territories have adopted or are developing strategies to address HIV/AIDS. In Quebec, Alberta, Saskatchewan, Northwest Territories, an integrated blood-borne pathogen and sexually transmitted infection approach has been adopted, recognizing that HIV/AIDS, hepatitis C and sexually transmitted infections affect similar population groups. In British Columbia, Manitoba, Ontario, Nova Scotia, Newfoundland, Nunavut Territory and the Yukon Territory, provinces and territories have focussed on HIV/AIDS. Most provinces and territories promote principles related to population health and respect for human rights in order to reduce vulnerability and address the epidemic in the long term.
The community response
From the very beginning of the epidemic, Canadian civil society mounted a vigorous response to the challenge of HIV/AIDS. With governmental and societal support, community organizations are playing a key role in designing and delivering front-line services and in helping to identify emerging policy issues and develop appropriate policy responses. Community organizations participate in national planning and expert panels, the development and championing of innovative approaches in prevention and support, and delivering programs. Canada endorsed the principle of greater involvement of people living with HIV/AIDS in developing a national response to the epidemic at the Paris AIDS Summit in 1994, and this principle continues to be a fundamental tenet of Canada's approach.
Key to the response in Canada are national non-governmental HIV/AIDS organizations:
- Canadian Aboriginal AIDS Network
- Canadian AIDS Society
- Canadian AIDS Treatment Information Exchange
- Canadian Association for HIV Research
- Canadian Foundation for AIDS Research
- Canadian HIV/AIDS Information Centre
- Canadian HIV/AIDS Legal Network
- Canadian HIV Trials Network
- Canadian Treatment Action Council
- Canadian Working Group on HIV and Rehabilitation
- Interagency Coalition on AIDS and Development
- International Council of AIDS Service Organizations
Under the Federal Initiative, the Government of Canada supports non-governmental organizations at the national, regional and community levels. Many provinces and larger municipalities also fund community organizations. National HIV/AIDS funds contribute to the goals of the Federal Initiative by supporting a strong voluntary sector response, supporting the engagement and meaningful involvement of those living with and at risk of HIV/AIDS, encouraging strategic collaboration and partnerships, enhancing capacity, gathering and exchanging information and knowledge, enabling the development of policies and programme interventions, and enhancing a broader response to the HIV/AIDS epidemic and its underlying causes. For example, the AIDS Community Action Programme, a funding program under the Federal Initiative, supports community-based organizations across Canada to: create supportive environments to reduce or eliminate social barriers that prevent people living with or at risk of HIV/AIDS from accessing health care and/or social services; carry out health promotion for people living with HIV/AIDS; carry out prevention initiatives; and strengthen community based organizations. Funding in 2004-05 was targeted specifically to address populations most at risk of infection and those already living with the disease.
IV. Major challenges faced and actions needed to achieve the UNGASS goals/targets
Resources to support the response
In May 2004, an increase in federal funding was announced to support the Canadian response with an increase in ongoing federal HIV/AIDS funding from $42.2 million per annum to $84.4 million by 2008-09. The Government of Canada is working with a range of partners to address the challenge of ensuring the effective use of this funding and measuring the impact of the response. Many of the provinces and larger municipalities also make significant financial contributions to the response to the epidemic.
Developing discrete approaches to address the epidemic for populations most vulnerable to HIV/AIDS
The incidence of new infections within Canada has been rising in certain populations - gay men, people who use injection drugs, women, Aboriginal peoples, and people from countries where HIV is endemic. There are challenges in reaching these vulnerable groups as many are marginalized and do not access traditional prevention, care or treatment services. Reflecting lessons learned from the response to HIV/AIDS over the past two decades, the Federal Initiative has initiate the development of a population-specific framework which will result in evidence-based, culturally appropriate responses that are better able to address the realities that contribute to infection and poor health outcomes for the target groups. Population-specific approaches also allow people at risk of infection and those living with HIV/AIDS to directly shape policies and programs that affect them.
The hidden epidemic
Of the 56,000 people in Canada estimated to be infected with HIV in 2002, it is thought that about a third, or 17,000, are unaware of their infection2. Policies and programmes that target this hidden epidemic include social marketing to increase awareness and the development of tailored population-specific approaches. For instance, the implementation of second generation surveillance which looks at trends in disease prevalence and risk behaviours amongst key population groups - gay men, people who use injection drugs and people from countries where HIV is endemic - will allow for more effective targeting and monitoring of the response within each distinct population, in turn allowing for more appropriate planning of future activities to best meet any remaining gaps.
Addressing the determinants of health
The HIV/AIDS epidemic is driven by social, cultural and economic determinants, and is fuelled by stigma and discrimination. Factors, such as poverty, homelessness, stigma, addiction, violence, untreated mental health problems, lack of employment opportunities, powerlessness, lack of choice, lack of legal status and lack of social support increase people's vulnerability to HIV, limiting their ability to protect themselves from HIV, and, for those living with HIV/AIDS, limiting their ability to access support and to maintain their health. Many of these factors lie outside the purview of health ministries. The Government of Canada is addressing this issue through actions across government that seek to improve the health status of all Canadians by improving the determinants of health. The Government of Canada will bring greater focus to these activities through the creation, in 2005, of the Government of Canada Assistant Deputy Minister Committee on HIV/AIDS. This is an interdepartmental committee which includes representation from 14 federal departments and agencies with mandates that have an impact on, or are related to, Canada's HIV/AIDS response . This committee provides a common platform to promote horizontal coordination and interdepartmental action across the Government of Canada and will promote linkages and alignment of policies and programs, particularly as they relate to HIV/AIDS and related determinants of health issues such as employment, affordable housing, disability, immigration and social justice . This increased government collaboration is a key element of the Federal Initiative.
Addressing non-disclosure
The issue of non-disclosure of HIV/AIDS by persons infected with the virus to sexual partners and persons with whom they share drugs remains a complex one, and one which presents challenges for AIDS service providers in reaching out to people living with HIV/AIDS. In R vs Cuerrier (1998), the Supreme Court of Canada outlined a criminal law approach to the issue. The case addressed whether non-disclosure of one's HIV status constitutes fraud, thereby vitiating consent to sexual acts and subjecting a person with HIV to the possibility of an assault conviction. The Court held that for fraud to exist, three factors must be established: 1 a reasonable person must consider the behaviour to be dishonest (non-disclosure of one's HIV status may constitute such misconduct);2 the dishonesty must result in significant risk of bodily harm (it appears from the reasoning in Cuerrier that protected sex with condoms may not be considered to pose a significant risk of harm) and; 3 the person would not have consented to engage in sexual acts had the HIV positive person disclosed.
In 2005, the conclusions of a working group on the issue of persons who are unwilling or unable to disclose their status , organized by the Federal/Provincial/Territorial Advisory Committee on AIDS, were published. The experts - representing a diverse range of backgrounds including public health, physicians, mental health, legal, epidemiological, people living with HIV and AIDS, and community-based service organizations - endorsed an approach rooted in public health rather than a criminal law approach and which emphasized prevention as the primary objective, flexibility, risk assessment, counselling and respect of the Canadian Charter of Rights and Freedoms3.
Addressing stigma and discrimination
Stigma and discrimination continue to lead to increased vulnerability of people to HIV and isolation and marginalization of those who are living with or at risk for HIV/AIDS. For those in marginalized groups - such as gay men, people who use injection drugs, Aboriginal people, people from countries where HIV is endemic and sex workers - the stigma associated with HIV can be compounded by other forms of discrimination such as racism and homophobia. There are great challenges for health service providers in reaching these marginalized groups, particularly those engaged in illegal activities such as injection drug use or some forms of sex work. In these situations, public health approaches aimed at reducing the harms experienced by marginalized groups are the preferred interventions as they have demonstrated their ability to reduce the amount of harm experienced by marginal groups. Harm reduction measures -- such as needle exchange, safe drug use equipment and practices, and methadone maintenance -- are in place to varying degrees across the country. Reaching people who use injection drugs and sex workers remains a complex and shifting public policy issue with health, social, legal, ethical and human rights implications.
The Federal Initiative supports national and community-based organizations to carry out communications and social marketing activities to improve Canadians' knowledge of HIV, to address community and societal attitudes, and to reduce the stigma and discrimination that fuel the epidemic . For example, through funding from the Federal Initiative, in January 2005, the Canadian HIV/AIDS Legal Network launched A Plan of Action for Canada to reduce HIV/AIDS-related stigma and discrimination. The plan highlights the responsibility of governments at all levels to lead both by example and by rigorously applying anti-discrimination laws and measures to reduce stigma.
Linkages with other infectious diseases
Many people living with and vulnerable to HIV/AIDS have complex health needs and may be vulnerable to other infectious diseases such as those transmitted sexually or by injection drug use. The Federal Initiative addresses this possibility by linking with other health and social programs, where appropriate, to ensure an integrated approach to program implementation. These programs address barriers to services for people living with or vulnerable to multiple infections and conditions that have an impact on their health. Canada, for instance, has a significant population of individuals co-infected with HIV and hepatitis C. Separate federal programs that target hepatitis C and sexually transmitted infections operate in tandem with the Federal Initiative to address common risk factors. Some provinces and territories have adopted an integrated approach to addressing HIV along with other bloodborne pathogens and/or sexually transmitted infections.
The resurgence of syphilis in Canada
As recently as 1997, the elimination of syphilis in Canada seemed imminent. However, since that time, the rates of syphilis in Canada have increased dramatically with preliminary rates for 2004 showing a greater than 900 percent increase when compared to 1997. These rapidly increasing rates are being fuelled by outbreaks across the country particularly affecting men who have sex with men and sex trade workers . Syphilis increases the risk of transmitting and acquiring HIV; thus, its resurgence in Canada can only negatively impact the HIV epidemic. However, evidence has shown that the early detection and treatment of sexually transmitted infections such as syphilis can have a major impact on reducing the sexual transmission of HIV. As such, the Public Health Agency of Canada continues to monitor the rates of syphilis in Canada and works closely with the provinces and territories to raise awareness of the resurgence of syphilis and the need to respond in a coordinated manner both rapidly and effectively to such a public health threat.
Strengthening the national response
Under Canada's federal system, different provinces and territories and the federal government each have their own role in the national response to HIV/AIDS. Different provinces and territories face different epidemics, both in the size of the epidemic and in the populations affected. While this facilitates a response that is tailored to the unique needs of each jurisdiction, differing priorities and implementation structures can present challenges in setting and tracking national goals and progress. To help address this challenge, the Federal/Provincial/Territorial Advisory Committee on AIDS promotes intergovernmental collaboration and public policy development. In addition, a national surveillance system is in place that collects data from provinces and territories to assist with developing national summaries and analyses. To facilitate collaborative action, Leading Together, a pan-Canadian approach to HIV/AIDS identifies common approaches and values in addressing HIV/AIDS at a national level.
In May 2004, the Government of Canada passed Bill C-9, the Jean Chrétien Pledge for Africa Act, legislation aimed at changing patent laws to allow for the manufacturing of lower-cost versions of patented medicines to least developed/ developing countries in order to address public health problems such as HIV/AIDS, tuberculosis and malaria. Canadian civil society played a key mobilizing role in the advocating for this legislation, and the Government of Canada worked closely together to ensure inter-departmental policy coherence. The Government of Canada is committed to facilitating and encouraging participation in the Pledge for Africa regime and, through Health Canada and Foreign Affairs Canada, has been engaging in a number of outreach initiatives in order to increase the understanding of the potential benefits of the Pledge for Africa regime.
V. Support required from country's development partners
Not applicable.
