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 2006 - December 2007

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V Major challenges and remedial actions

Developing discrete approaches to address the epidemic for populations most vulnerable to HIV/AIDS
The incidence of new infections within Canada continues to affect certain populations in disproportionate numbers. The unique nature of a subpopulation’s respective vulnerabilities and the shortcomings derived from using a uniform approach to address diverse prevention, care or treatment needs require a more tailored response in order to be more effective.

The Public Health Agency of Canada (PHAC) is developing population-specific HIV/AIDS status reports in collaboration with representatives from the eight populations identified under the Federal Initiative. The information generated aims to support work undertaken in the provinces and territories and by front line organizations, to more positively affect the health and well-being of individuals living with HIV/AIDS or at risk of infection. These reports will identify the current status of the epidemic in each population, look at the burden of and vulnerability to HIV/AIDS, provide a comprehensive overview of current research and responses, provide information on emerging issues and the lived experience of the population and identify opportunities to inform future policy and program development, research priorities and strategic action.

The PHAC has also created a Population Specific HIV/AIDS Initiatives Fund, which provides funding to community organizations to support relevant national policy, program and social marketing projects to prevent HIV infection, increase access to appropriate diagnosis, care, treatment, and support and increase healthy behaviours amongst populations most affected by HIV/AIDS and most vulnerable to HIV infection.

Reaching the undiagnosed
An estimated 58,000 Canadians are currently living with HIV, and an estimated 27% of them are unaware that they are infected. While the majority of these individuals fall under the vulnerable groups referenced above, they are not being reached by existing prevention programs and social marketing messages or are choosing not to get tested. Second generation surveillance which looks at trends in disease prevalence and risk behaviours amongst key population groups – gay men, people who use injection drugs, street-involved youth and people from countries where HIV is endemic – will allow for more effective targeting and monitoring of interventions within each distinct population, in turn allowing for more appropriate planning of future activities to best meet their needs.

The Public Health Agency of Canada is working in collaboration with provinces and territories and various experts and community groups, to develop an HIV testing and counselling policy framework that will aim to increase the number of HIV positive Canadians that are aware of their HIV status. This policy framework will be based on: the best evidence related to the HIV epidemic; medical, public health, legal, ethical and human rights considerations; and, representative of major points of view and jurisdictional considerations and approaches.

Addressing the determinants of health
Evidence demonstrates a strong linkage of health inequities in populations and their vulnerability to HIV/AIDS. The Government of Canada integrates a determinants of health approach to address the root causes that drive the HIV/AIDS epidemic. In 2005, the Government of Canada Assistant Deputy Minister Committee on HIV/AIDS was created, whose members represent 13 federal departments and agencies, and whose respective mandates have an impact on Canada’s HIV/AIDS response. This Committee provides a common platform to promote horizontal coordination, interdepartmental action and alignment of policies and programs, particularly as they relate to HIV/AIDS. Increased government collaboration is a key element of the Federal Initiative.

Strengthening the national response
Under Canada’s federated system, each level of government has a role in the national response to HIV/AIDS. The epidemic varies depending on geographic location, both in size and in the populations it affects, requiring a tailored response to the unique needs of each jurisdiction. Differing priorities, approaches and implementation structures within jurisdictions limit the ability to set and track national goals and progress.

To help address these challenges to work across jurisdictions and to ramp up the resources necessary to meet an increasingly complex epidemic, several mechanisms have been put in place to promote intergovernmental collaboration and coordination. In 2005, the Pan-Canadian Public Health Network was established as one mechanism for different levels of government to work together to address public health issues. This Network builds on existing strengths in public health, and aims to strengthen public health infrastructure and capacity at the local, provincial, territorial and federal levels. The Federal / Provincial / Territorial Advisory Committee on AIDS (FPT-AIDS) has also been established to provide public health policy and program advice and to promote intergovernmental collaboration in the area of HIV/AIDS. FPT-AIDS has reported to the Network since 2006.

In addition, a national health surveillance system is in place to collect data from provinces and territories and to develop national summaries and analyses. FPTAIDS is working to implement the HIV /AIDS Surveillance and Targeted Epidemiological Studies Plan, finalized in 2005, which emphasises enhanced surveillance, targeted epidemiological studies, and improved knowledge transfer of HIV/AIDS epidemiological and surveillance information. A series of sentinel behavioural surveillance studies were planned and implemented in 2006 and 2007. Future plans include maintaining the current surveillance projects and expanding to other vulnerable populations for 2008.

Twenty five years after the emergence of HIV/AIDS in Canada, significant progress has been achieved in building community and research capacity and strengthening inter-governmental collaboration. As the nature of the epidemic continues to evolve and treatments prolong the lives of people living with HIV/AIDS, new strategic partnerships, engaging a broader range of players, must be developed to prevent the acquisition and transmission of new infections and to improve the health outcomes of those living with or vulnerable to HIV.

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. In R v Cuerrier (1998)³², the Supreme Court of Canada outlined a criminal law approach to the issue. The case determined that failure to disclose one’s serostatus to sexual partners constitutes fraud, thereby vitiating consent to sexual acts and subjecting a person with HIV to the possibility of conviction of serious criminal offences.

A number of cases have been prosecuted in this vein, with the lower courts following the Supreme Court of Canada’s jurisprudence. Distinct from some countries, Canada’s convictions rest on the failure to disclose alone and do not require that transmission of HIV be proven. Concerns have been expressed about a possible disconnect between this criminal justice approach and communitybased and public health prevention messages. A harmonized approach to address the common underlying social issues surrounding the failure to disclose HIV status to sexual partners should be encouraged.

In 2005, a working group was organized by the Federal/Provincial/Territorial Advisory Committee on AIDS to examine the issue of persons who are unwilling or unable to disclose their HIV status. Members represented public health, medical, mental health, legal and epidemiological experts, community-service organizations, in addition to people living with HIV/AIDS. The working group concluded that an approach rooted in public health should be adopted, rather than criminal law, emphasizing prevention as its primary objective, further emphasizing flexibility, individual risk assessment, counselling and respect for human rights ³³.

Addressing stigma and discrimination
A national public opinion survey conducted in 2006 revealed that people with and vulnerable to HIV/AIDS continue to face stigma and discrimination in Canada for several reasons including a general lack of knowledge regarding how HIV is transmitted. Stigma and discrimination surrounding HIV/AIDS inhibit people living with and at risk of HIV from accessing the information, prevention, diagnosis, care, treatment and support services they need.

A National Social Marketing Campaign has been developed by the Public Health Agency of Canada (PHAC) to improve Canadians' knowledge of HIV, to address negative public attitudes, and to ultimately reduce stigma and discrimination. Created with input from an expert panel, and a national committee comprised of people living with HIV/AIDS, representatives from community-based and national AIDS Service Organizations, public health, and provincial/territorial governments, and based on extensive quantitative and qualitative research, the multi-year campaign proposes to use a range of marketing tools and tactics to target two primary audiences.

Two studies were commissioned by PHAC in support of the campaign's development – the HIV/AIDS Attitudinal Tracking Survey 2006 and the Aboriginal HIV/AIDS Attitudinal Survey 2006. Analysis indicated that the segment of both the general and aboriginal population most likely to have stigmatizing and discriminatory attitudes towards people living with HIV/AIDS, and be the most open to attitudinal and behaviour change, is men between the ages of 18-25 years old. The campaign will focus on two targets audiences, the first will be 18-25 year old males, and the second will be focused in settings and environments where people living with HIV/AIDS experience stigma and discrimination, and may include health care or employment settings. Opinion leaders and the media will also be engaged and educated on HIV/AIDS-related stigma and discrimination issues.

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.

The Public Health Agency of Canada has established an internal working group that is mandated to maximize synergies and identify opportunities for collaboration to address issues related to HIV, hepatitis C, tuberculosis and sexually transmitted infections including common risk factors, co-infections, and the co-morbidities associated to these infections. Some provinces and territories have adopted an integrated approach to addressing HIV in consideration of the linkages of HIV with other blood-borne pathogens and/or sexually transmitted infections.

Increasing global access to medicine
Access to affordable medicines has been a focus of international advocacy for years, with protests against patent regimes that make anti-retrovirals unaffordable to the vast majority of those living with HIV/AIDS in the developing world. To address this challenge, Canada developed the Canada Access to Medicines Regime (CAMR), which came into force on May 14, 2005. It implements a decision made by the General Council of the World Trade Organization (WTO) in 2003 that waived certain trade obligations thought to be a barrier to developing countries’ access to lower-cost drugs. The goal of CAMR is to facilitate timely access to generic versions of patented drugs and medical devices, especially those needed by least-developed or developing countries to fight HIV/AIDS, malaria, tuberculosis and other diseases. CAMR enables Canadian generic manufacturers to apply to Canada's Commissioner of Patents for an authorization to manufacture and export lower-priced versions of patented drugs to countries unable to manufacture their own. Drugs exported under CAMR must also meet the same safety, efficacy and quality standards as those approved for sale in Canada. On September 19, 2007, Canada's Commissioner of Patents granted the first-ever authorization under the terms of the WTO waiver to a Canadian generic drug manufacturer to export an HIV/AIDS drug to Rwanda.

In addition to CAMR and the Canadian HIV Vaccine Initiative (CHVI), Canada introduced a new tax incentive in Budget 2007 for pharmaceutical companies who donate drugs to developing countries. Last January, the Government announced that it would double Canada’s contribution, from $100 million to $200 million, to the Advance Market Commitment, a global effort to create a pneumococcal vaccine that will benefit the world’s poorest nations. The government also recently committed $111 million, with the Bill & Melinda Gates Foundation ($28 million), to support the CHVI and accelerate the development of a HIV/AIDS vaccine. Canada is also chairing the World Health Organization Intergovernmental Working Group on Public Health, Innovation and Intellectual Property, whose mandate is to prepare a global strategy and plan of action on essential health research to address conditions affecting developing countries disproportionately.

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³² R. v. Cuerrier 1998 CanLII (S.C.C), 1998-09-03

³³ Persons who fail to disclose their HIV Status: Conclusions Reached by an Expert Working Group. Canada Communicable Disease Report. Vol. 31-05. March, 2005

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