The Ministerial Council On HIV/AIDS

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Annual Report April 1, 2004 - March 31, 2005

6.3 Effective and responsive structures and strategies to fight the epidemic, including adequately resourced initiatives

Overview

In 2004 the Government of Canada announced a step-wise doubling of funding for HIV/AIDS from the level of $42.2 million in 2003-2004 under the Canadian Strategy on HIV/AIDS to a level of $84.4 million by fiscal year 2008-2009 under the new Federal Initiative to Address HIV/AIDS in Canada. Some of this funding will support the development of pan-Canadian collaborative approaches under the Action Plan, Leading Together: Canada 's HIV/AIDS Action Plan 2005-2010, which will involve all stakeholders and levels of government. The draft Action Plan resulted from extensive consultation and partnership by all stakeholders while the Federal Initiative is the Government of Canada's framework for the federal component of the Action Plan. See sections 2.0 and 6.3.1 for further details.

6.3.1 Pan-Canadian Action Plan and the Federal Initiative

The issue

During 2003-2004, all stakeholders engaged in intensive work on a renewed framework for the Canadian Strategy on HIV/AIDS, which had been in place since 1998. A Five-Year Review of the Strategy, completed in 2003, documented lessons learned, identified gaps and recommend directions for the next five years. The Review called for increased funding from the present annual level of $42.2 million to a level of $85 million or $106 million, representing enhanced levels of commitment to managing or getting ahead of the epidemic.

In a parallel initiative, a draft Action Plan, developed in 2003 by partners in the Strategy following a consultation across Canada, will finalized in 2005. The draft Action Plan, Leading Together: Canada 's HIV/AIDS Action Plan 2005-2010, is the culmination of several years of development work on renewed directions for the Strategy by all stakeholders, including provincial governments. The draft Action Plan incorporates a social justice, human rights and determinants of health framework. Its vision statement is: By 2010, the end of the HIV/AIDS epidemic is in sight. The goals of the draft Action Plan are:

• Reduce the social inequities, stigma and discrimination that threaten people's health and well-being
• Prevent HIV transmission
• Provide timely, safe and effective care, treatment and support for all persons living with HIV/AIDS
• Contribute to global efforts to fight the epidemic and find a cure.

The six strategic actions of the draft Action Plan are:

• Increase awareness of the impact of HIV/AIDS and increase the commitment to sustained funding for HIV/AIDS programs and services
• Address the social factors and inequities driving the epidemic
• Increase prevention efforts
• Strengthen care, treatment and support
• Provide leadership in global efforts
• Enhance the front-line capacity to act early and stay the course.

Click to view draft Action Plan.

During 2003, the House of Commons Standing Committee on Health delivered a report on its review of the Canadian Strategy on HIV/AIDS. The report called for increased funding for the Strategy at an annual level of $100 million with targeted funding for initiatives involving inmates, Aboriginal peoples, and vaccine development. The report also called for a stronger coordination role for Health Canada as the lead federal department, targeted prevention activities for youth, Aboriginal peoples and those affected by stigma and discrimination, and harm reduction strategies for inmates.

The Government of Canada responded to these initiatives by defining a renewed federal role in the context of the draft pan-Canadian Action Plan. The new framework to the year 2010, The Federal Initiative to Address HIV/AIDS in Canada, builds on the achievements of the Canadian Strategy on HIV/AIDS and incorporates a social justice, human rights and determinants of health approach. The Federal Initiative emphasizes an integrated response by the federal government. Federal partners in the Initiative are the Public Health Agency of Canada, Health Canada, Correctional Service Canada and the Canadian Institutes of Health Research. Other federal departments and agencies have involvement in HIV/AIDS issues either on specific issues or as part of an integrated determinants of health approach to HIV/AIDS and will be invited to join the Federal Initiative. In order to foster integration of federal approaches, the Federal Initiative includes the creation of a committee of Assistant Deputy Ministers of concerned departments and a Responsibility Centre Committee.

The goals of the Federal Initiative are:

• Prevent the acquisition and transmission of new infections
• Slow the progression 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 disease.

The policy directions of the Federal Initiative are: partnership and engagement; integration; and accountability. The five priority action areas of the Federal Initiative with their funding allocations by 2008-2009 are:

• Program and policy interventions ($35.4 million)
• Knowledge development ($31.9 million)
• Coordination, planning, evaluation and reporting ($10.2 million)
• Communications and social marketing ($4.7 million)
• Global engagement ($2.2 million).

The Federal Initiative targets the priority populations of gay men, Aboriginal peoples, injection drug users, prison inmates, youth, women, persons from countries where HIV is endemic and persons living with HIV/AIDS.

Lead responsibility for HIV/AIDS rests with the new Public Health Agency of Canada. Funding for the Federal Initiative will increase from $42.2 million in fiscal year 2003-2004 to $84.4 million in fiscal year 2008-2009. Funding during the present fiscal year (2004-2005) is $47.2 million. Other federal departments and agencies such as the Canadian International Development Agency contribute funding to HIV/AIDS programs in addition to the funds allocated to the Federal Initiative.

The Ministerial Council participated actively in all phases of the development of the pan-Canadian Action Plan and gave advice on the development of the Federal Initiative.

Work done during 2004-2005

• The Ministerial Council provided policy advice on all aspects of the Action Plan and the Federal Initiative and sent several representatives to key meetings.
• At its January 2005 meeting, the Ministerial Council had a special presentation about the draft Action Plan from officials of the Public Health Agency of Canada. The Council provided advice on clarifying the Action Plan and ensuring that it was consistent with the values that the previous Strategy had espoused. The Ministerial Council then wrote to the Public Health Agency of Canada stating:
  • reservations about the realism of the draft Action Plan and Federal Initiative goal of "preventing" transmission of infection. The Council advised that this could lead to failure and suggested that "reducing" transmission might be more realistic and achievable.
  • the need to publicly present the Federal Initiative in the context of the Action Plan
  • the need for federal leadership in championing the Action Plan
  • the need for obtaining community support for the Action Plan across Canada ; the Council suggested using a train-the-trainer model
  • the need to present the Action Plan to stakeholders in a variety of ways based on the specific issues and needs confronting each population
  • the need to explicitly recognize women and youth in the Action Plan and the Federal Initiative.

The Ministerial Council agreed to consider using the Action Plan as a key input to the Council in fulfilling its mandate.

• The Ministerial Council advised the Minister and federal officials on the development and launch of the Action Plan. The Council held a special meeting on the draft Action Plan in February 2005 and provided extensive feedback to the Public Health Agency of Canada, focusing on strengthening and clarifying the Action Plan. At the invitation of the Public Agency of Canada, the Ministerial Council discussed opportunities and strategies for championing the Action Plan.
• The Ministerial Council advised the Minister of Health that more extensive multi-stakeholder consultation should be held before the Federal Initiative was finalized.
• The Ministerial Council had a special presentation at its January 2005 meeting about the Federal Initiative from officials of the Public Health Agency of Canada. The officials invited the Council to provide advice on inter-governmental and inter-departmental alignment of approaches, program review, review of coordinating and advisory bodies, and population-specific approaches. As a follow-up to this discussion, the Ministerial Council wrote to the Public Health Agency of Canada:
  • asking whether the Public Health Agency of Canada (PHAC) would receive funding under the Federal Initiative as a discrete envelope of HIV/AIDS funds
  • asking whether the Canadian Institutes of Health Research (CIHR) would receive funding directly or indirectly under the Federal Initiative and whether a Memorandum of Understanding would be signed between CIHR and PHAC and who would have input into this process
  • expressing support for the accountability framework of the Federal Initiative and the associated committees
  • expressing reservations about the realism of the draft Action Plan and Federal Initiative goal of "preventing" transmission of infection. The Council advised that this could lead to failure and suggested that "reducing" transmission might be more realistic and achievable.
  • stressing the need to: publicly present the Federal Initiative in the context of the Action Plan ensuring that appropriate links are made between the two; show leadership in championing both the Action Plan and Federal Initiative; and obtain community buy-in for the Action Plan and the Federal Initiative; the Council suggested using a train-the-trainer model
  • stressing the need to ensure that the Federal Initiative addresses HIV/AIDS on a prevention-care-treatment-support continuum
  • recommending that women and youth be explicitly mentioned in both the Federal Initiative and the Action Plan
  • stressing the need to ensure that funding reaches groups that are doing excellent work but who may not be skilled in the application process for funding. The Council expressed the hope that this would be taken into account in review processes.
  • highlighting the need to ensure protection of HIV/AIDS funding resources in any program integration with Hepatitis C initiatives. The Council expressed strongly that HIV/AIDS must continue to receive discrete funding.
  • stating the Ministerial Council's desire to provide advice on the Government of Canada approach to HIV/AIDS (inter-departmental and inter-governmental), program review, coordinating and advisory bodies review, and population-specific approaches.
• Following its meeting with the Minister of Health, the Ministerial Council offered to assist the new inter-departmental Assistant Deputy Minister Committee envisaged in the Federal Initiative and requested the Minister to keep the Council informed about further developments on the work of this committee.
• The Ministerial Council studied materials developed for the communications and social marketing initiatives funded by the Federal Initiative.

Future activities

The Ministerial Council will continue to be involved in the process of advising the Minister and public officials on the Action Plan and the Federal Initiative.

6.3.2 Social justice framework and the determinants of health

The issue

A social justice framework for dealing with HIV/AIDS addresses the social, economic and political factors that worsen the epidemic, such as gender-based inequalities, racism, poverty, discrimination, lack of affordable housing, social conditions and legal and government policy. It looks at the range of social determinants and their impact on health and recognizes that protecting, promoting and fulfilling human rights are fundamental to realizing social justice. The development of a social justice framework based on human rights concepts and principles, and linked to the determinants of health, builds on the work of HIV/AIDS pioneer Jonathan Mann. Support for this approach also derives from international human rights law and the positions that form part of the Declaration of Commitment of the United Nations General Assembly Special Session on HIV/AIDS (UNGASS) in June 2001, to which Canada is a signatory (see section 6.5.2). In his preface to the Federal Initiative to Address HIV/AIDS in Canada, the Chief Public Health Officer underlined that the Federal Initiative will continue to build on population-based and health determinants approaches to HIV/AIDS so that the root causes of the epidemic can be addressed and overcome.

Both the draft pan-Canadian Action Plan and the Federal Initiative are based on the framework of social justice, human rights and determinants of health. These frameworks evolved from decades of experience in responding to HIV/AIDS and were strongly promoted by all stakeholders involved in the process of renewing Canada's response to HIV/AIDS. The commitment to a social justice framework necessitates the strong involvement of all stakeholders and the collaboration of a wide range of government and community partners.

Work done during 2004-2005

• In its World AIDS Day message, the Ministerial Council stated that vulnerable populations, including women, gay men and youth, need additional attention and that all approaches must be addressed from a social justice perspective.
• The Ministerial Council worked actively with the Public Health Agency of Canada, Health Canada and stakeholders on the development of the social justice framework for the Action Plan and Federal Initiative.
• In its meeting with the Minister of State (Public Health), the Ministerial Council raised the need for approaches to HIV/AIDS to be guided by a determinants of health and social justice approach rather than the traditional public health approach as lead responsibility for HIV/AIDS was transferred to the new Public Health Agency of Canada. The Minister expressed support for a social justice framework.

Future activities

The Ministerial Council will continue to monitor these issues and provide advice to the Minister.

6.3.3 Federal Initiative funding adequacy

The issue

In May 2004 the Government of Canada announced that funding for HIV/AIDS would be doubled from the level of $42.2 million under the Canadian Strategy on HIV/AIDS to $84.4 million by fiscal year 2008-2009 under the Federal Initiative to Address HIV/AIDS in Canada. The funding level will be increased by increments each year until 2008-2009. For fiscal year 2004-2005, the funding level is $47.2 million, with the additional $5 million being targeted to community-based organizations serving specific vulnerable populations. The Ministerial Council played an important role in securing increased funding for HIV/AIDS.

The planned federal funding for HIV/AIDS under the Federal Initiative is:

• 2003-2004: $42.2 million
• 2004-2005: $47.2 million
• 2005-2006: $55.2 million
• 2006-2007: $63.2 million
• 2007-2008: $71.2 million
• 2008-2009: $84.4 million.

Work done during 2004-2005

• The Ministerial Council expressed its concern to federal officials about the apparent slowness in disbursing the additional $5 million to community-based organizations during the present fiscal year.
• The Ministerial Council met with the Minister of Health and raised the issue of releasing the $5 million in additional funding for 2004-2005. The funds were released and the Council thanked the Minister for his action on this.
• In its World AIDS Day message, the Ministerial Council applauded the increased funding for HIV/AIDS but stated that it would like to see an accelerated disbursement of the new funds.

Future activities

The Ministerial Council will continue to monitor these issues and provide advice to the Minister.

6.3.4 Federal Initiative resource allocation

The issue

Funding for the Federal Initiative to Address HIV/AIDS in Canada is allocated to specific action areas: By 2008-2009, the allocations of the total $84.4 million will be:

• $35.4 million Program and policy interventions
• $31.9 million Knowledge development
• $10.2 million Coordination, planning, evaluation and reporting
• $4.7 million Communications and social marketing
• $2.2 million Global engagement.

The four Government of Canada partners in the Federal Initiative will receive the following share of the total $84.4 million by 2008-2009:

• Public Health Agency of Canada $51.9 million
• Health Canada $5.7 million
• Canadian Institutes of Health Research $22.6 million
• Correctional Service Canada $4.2 million.

Several other federal departments and agencies, such as the Canadian International Development Agency, contribute additional funds from their own budgets to support their involvement in HIV/AIDS.

An annual accountability report is released by the Minister of Health and the Minister of State (Public Health) on World AIDS Day, December 1. The 2004 report, Strategic Approaches: Renewing the Response.

Work done during 2004-2005

The Ministerial Council wrote to the Minister of Health with respect to the allocations foreseen under the new draft Action Plan and Federal Initiative. At the time, the strategic areas of the new approaches had not been fully defined and the Council recommended that the strategic areas of the Canadian Strategy on HIV/AIDS remain in effect until a broad multi-stakeholder consultation could be held to address the allocation of the new funding.

• The Council discussed allocations on an ongoing basis with officials of the Public Health Agency of Canada in order to remain informed and offer advice.

Future activities

The Ministerial Council will continue to monitor allocations and provide advice to the Minister and to the Public Health Agency of Canada.

6.3.5 Health care reform

The issue

The Commission on the Future of Health Care in Canada (the Romanow Commission) released its report in late 2002. The Romanow report included recommendations for Canadian home care and pharmacare programs. Following the release of the Romanow report, the First Ministers' Accord on Health Care Renewal was reached in February 2003. The Accord focused on primary health care, home care, catastrophic drug coverage, access to diagnostic/medical equipment and information technology, and electronic health records. The First Ministers met again in 2004 and announced a 10-year plan to strengthen health care, focusing on increased funding to the provinces and territories, wait times, health human resources, community-based services including home care, a pharmaceuticals strategy and effective health promotion and disease prevention. Aboriginal health was specifically addressed in a separate communiqué. The proposed pharmaceuticals strategy is of particular interest to those living with HIV/AIDS (see section 6.3.6). The components of the 10-year plan are under discussion at the federal/provincial/territorial level.

At issue in the debate about health care reform is the future of public health care in Canada, and specifically the Canada Health Act. The public health system is a vital support for all Canadians, and particularly for vulnerable populations and people living with HIV/AIDS.

In September 2004 the Government of Canada launched the new Public Health Agency of Canada to address public health issues. The Agency is now the lead federal responsibility centre for HIV/AIDS.

Work done during 2004-2005

The Ministerial Council remained informed about health care reform and in particular about efforts by the Canadian Treatment Action Council to hold consultations and develop recommendations on a national pharmacare program.

Future activities

The Ministerial Council will continue to monitor these issues and provide advice to the Minister.

6.3.6 Access to treatments

The issue

The emergence of highly active antiretroviral treatments in the late 1990s has prolonged and improved quality of life for many persons living with HIV/AIDS, but difficulties in accessing treatments, treatment failures, toxic side effects and drug resistance have become more common. Health Canada is responsible for the approval of new drugs and the post-approval surveillance of drugs. The HIV/AIDS community has consistently pressed for a more efficient review and approval process, and for more extensive post-approval surveillance of drugs. The Common Drug Review Process was established in 2002 by federal/provincial/territorial ministers of health (except Quebec ) to harmonize drug review and formularies (list of drugs reimbursable under the public health plan). This process is being coordinated by the Canadian Coordinating Office for Health Technology Assessment (CCOHTA) and is still in development. During 2003-2004, national stakeholders sought consumer representation on the committees and board of the CCOHTA and were refused. Stakeholder concerns centered on: timeliness of access to new drugs; accountability; an objective and informed process; an appeal process; the use of best clinical data; and the inclusion of relevant stakeholders in the Common Drug Review process. These are still active concerns.

Stakeholders have consistently raised the need for post-approval surveillance of drugs in order to track side effects. Advocates for women have asked for more clinical trials for women and better post-approval surveillance involving women because most clinical trial participants are men and the effect of drugs can differ significantly between men and women

A new issue has emerged more recently with the advent of internet pharmacies in Canada selling cheaper Canadian drugs to customers in the United States where prices are commonly at least 30% higher for the same drugs. There are concerns that shortages of drugs may result in Canada and that the major pharmaceutical firms will withhold supplies from Canada in an effort to halt cross-border sales of drugs. The situation is complicated by the selective enforcement by the United States Food and Drug Administration of the US law prohibiting importation of most of the drugs being supplied by internet pharmacies.

The Patented Medicine Prices Review Board (PMPRB) protects patents for 20 years and sets drug prices in Canada but its reviews do not apply to generic drugs manufactured in Canada (those no longer under patent protection). Most cross-border sales to the United States involve newer drugs rather than generics. Canada has provisions to allow for distribution of patent-protected drugs at lower prices in case of emergency such as drug shortages. Some Canadian physicians are signing prescriptions for American patients they have never seen, which raises questions of medical ethics, patient safety and professional disciplinary action.

Work done during 2004-2005

• The Ministerial Council monitored the Common Drug Review Process through its own review and through its links to FPT-AIDS and concerned national stakeholder organizations.
• The Ministerial Council discussed ongoing concerns with Health Canada about the Common Drug Review Process, focusing on the reality that the process appears to have lengthened, rather than shortened, the time taken to get drugs on provincial/territorial drug formularies because there are now two review processes: drugs go through the national process and most provinces and territories have maintained their own review process. Advocates estimate that it now takes 26 weeks longer for approval than in the past. This has caused problems with access to urgently needed new drugs.
• The Ministerial Council wrote to the Minister of Health about the lack of citizen engagement in the Common Drug Review Process.
• The Ministerial Council wrote to the Minister of Health affirming the need to achieve equal and timely access to new HIV drugs across Canada. The Council asked the Minister to raise this issue with his provincial and territorial counterparts and to raise the possibility of having the issue discussed by the Council of Deputy Ministers of Health.
• The Ministerial Council wrote a letter to the Minister of Health concerning drug pricing. The letter:
  • recommended that generic drugs be added to the mandate of the Patented Medicine Prices Review Board
  • recommended against any action that would weaken Canada's system of price regulation; the letter recommended that the Canadian government not allow pressure from pharmaceutical companies over internet pharmacies to be used as a pretext for weakening Canada's regulation of drug prices
  • noted that issues raised by internet pharmacy sales to the United States arise because of excessive prices and access difficulties in the United States and that these problems must be solved in the United States.
• The Ministerial Council studied disparities between provinces and territories with respect to HIV drugs currently on their formularies.
• In its meeting with the Minister of State (Public Health), the Ministerial Council raised the need for post-approval surveillance of drugs among women, particularly immigrant women who are often isolated.
• The Ministerial Council had a special presentation on Internet pharmacies at its June 2004 meeting from an official of International Trade Canada (ITC). The presentation focused on the regulatory situation in Canada and the United States and on the conflicting political pressures in the United States to legalize importation of drugs for personal use and to protect the interests of powerful pharmaceutical manufacturers. The ITC official agreed with the Council that further study of this issue is required.

Future activities

The Ministerial Council will continue to monitor these issues and provide advice to the Minister.

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