The Ministerial Council On HIV/AIDS

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Annual Report April 1, 2004 - March 31, 2005

6.0 Ministerial Council areas of work in 2004-2005

The following report provides details on major areas of work for the Ministerial Council in 2004-2005. Some readers of this report may choose to read selectively depending on their interests; there is therefore some repetition in the sections that outline issues so that all readers may have a full understanding of the work done by the Ministerial Council.

In addition to the areas of work described, the Council also studied many ongoing and developing issues in order to remain informed and be prepared to provide advice to the Minister of Health when necessary.

6.1 Intra- and inter-departmental collaboration in response to HIV/AIDS

Overview

Promoting both intra- and inter-departmental collaboration at the federal level is an important aspect of the draft pan-Canadian Action Plan and the Federal Initiative to Address HIV/AIDS in Canada because the issues raised by HIV/AIDS fall within the mandates of several federal departments and agencies. The Public Health Agency of Canada and the Canadian Institutes of Health Research, which both report to Parliament through the Minister of Health, are partners in the Federal Initiative with Health Canada and Correctional Service Canada, which reports to Parliament through the Solicitor General. The Public Health Agency of Canada is the lead centre of responsibility for HIV/AIDS for the federal government. In addition, the departments of Foreign Affairs and International Trade, International Cooperation, Citizenship and Immigration have been involved in HIV/AIDS issues during the past year. Several other federal departments will be approached for involvement in the Federal Initiative in order to address the links between HIV/AIDS and determinants of health such as housing, disability, social justice, employment and income security. As part of the Federal Initiative, a committee of Assistant Deputy Ministers will be established to foster intra-and inter-departmental collaboration. It is vital that federal ministries work in a collaborative way in order to make the Federal Initiative and the Action Plan most effective.

In addition to inter-departmental collaboration within the Government of Canada, the Ministerial Council is concerned with inter-governmental collaboration and has strong links to the Federal/Provincial/Territorial (FPT) Advisory Committee on HIV/AIDS (FPT-AIDS). The provincial Co-Chair of FPT-AIDS is an ex-officio member of the Ministerial Council.

The Ministerial Council has consistently encouraged the Minister of Health to foster intra- and inter-departmental collaboration within the federal government. Both the Federal Initiative and the draft pan-Canadian Action Plan place a strong emphasis on government collaboration at all levels, which makes this a priority issue for the Ministerial Council.

This year the Ministerial Council continued to disseminate two of its discussion papers in order to stimulate discussion and action on inter-departmental and inter-governmental collaboration:

• Towards a Broader Vision of Health: Strengthening Inter-Ministerial Collaboration on HIV/AIDS in Canada (Ministerial Council on HIV/AIDS, 2001)
• HIV/AIDS and Health Determinants: Lessons for Coordinating Policy and Action (Ministerial Council on HIV/AIDS, 2002, with the support of the Federal/Provincial/Territorial Committee on HIV/AIDS), which is intended to guide inter-departmental collaboration according to a population health framework.

Both of these papers are available on the Ministerial Council's website at:

6.1.1 Correctional Service Canada

The issue

Correctional Service Canada (CSC) provides health services, including services related to the prevention, care and treatment of HIV/AIDS to persons sentenced to imprisonment for two years or more. Correctional Service Canada reports to Parliament through the Minister of Public Safety and Emergency Preparedness.

The rate of HIV infection in Canada's prisons is ten times higher than in the general population and the rate of seroconversion due to exposure in prison is thought to be high. A total of 223 inmates in federal penitentiaries (1.8% of the inmate population) were reported to be HIV-positive at the end of 2001. The HIV infection rate among female inmates is significantly higher than among male inmates. Adequate prevention, care, treatment and support for inmates are ongoing concerns. Co-infection, particularly with HIV/AIDS and Hepatitis C, is also a growing issue.

Correctional Service Canada is a partner in the Federal Initiative to Address HIV/AIDS in Canada and will be allocated $4.2 million annually by 2008-2009, a significant increase over previous annual allocation of $600,000 under the Canadian Strategy on HIV/AIDS. The increased funding will enable CSC to undertake a range of prevention and education activities in federal prisons and to enhance care, treatment and support. In addition to providing health care, CSC has developed training programs in palliative care and staff training for self-protection against infectious diseases. CSC has also developed prevention messages for target populations, including Aboriginal inmates, injection drug users and women, as part of peer education and counselling programs which have been partially implemented. The Special Inmates Initiatives Program, available in a limited number of federal institutions, enables inmates to become directly involved in developing programs to improve HIV/AIDS awareness.

Although injection drug use and sexual activity occur in prison, access to needle exchange, condoms and methadone maintenance is limited. Approximately 500 inmates across Canada are participating in a methadone maintenance treatment program.

An international policy dialogue on HIV/AIDS and prisons involving United Nations agencies and the Canadian government is being planned for late 2005.

Work done during 2004-2005

• The Ministerial Council recommended that the Minister of Health and the Minister of State (Public Health) meet with the Minister for Public Safety and Emergency Preparedness to discuss HIV/AIDS issues in the prison system.
• In its meeting with the Minister of Health, The Ministerial Council raised the importance of making progress on prison issues, including a needle exchange program. The Council was encouraged by the Minister's support for this issue and suggested that this could be raised with the new inter-departmental Assistant Deputy Minister Committee that is part of the Federal Initiative to Address HIV/AIDS in Canada.
• The Ministerial Council raised the need for a sterile needle distribution program in prisons with the Minister of State (Public Health) and thanked her for her willingness to encourage her colleagues to act on this issue.
• The Ministerial Council wrote to Correctional Service Canada (CSC) to express concern about CSC's failure to provide a report on its activities under the Canadian Strategy on HIV/AIDS and its apparent lack of accountability.

Future activities

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

6.1.2 Citizenship and Immigration Canada

The issue

In January 2002, HIV testing became mandatory for prospective immigrants 15 years of age and over. Citizenship and Immigration Canada (CIC) and the Canada Border Services Agency have jurisdiction over entry into Canada. The present policy of Citizenship and Immigration Canada is based in part on advice given in 2001 by the Minister of Health to the effect that mandatory testing was recommended by Health Canada and that HIV-positive persons should not be automatically excluded because of public health concerns. According to officials of Citizenship and Immigration Canada, in 2004, 614 immigration applicants tested positive and 87 percent were admissible; the majority were refugee claimants and their spouses. The only ground for refusal of admission of migrants testing positive for HIV is excessive demand on Canadian health and/or social services. "Excessive demand" in the case of HIV is defined as that for which the anticipated costs would exceed the average Canadian per capita costs over a ten-year period or if the admission would negatively impact waiting lists for health and/or social services. Refugees, spouses, protected persons or dependent children are exempt from this criterion.

The Ministerial Council does not support the mandatory testing policy, and has argued since 2000 that prevention education is an approach more consistent with respect for human rights. In 2001, the Ministerial Council recommended that mandatory testing should follow the Canadian Medical Association Counselling guidelines for HIV testing. Pre- and post-test counselling are now part of the immigration procedure, with post-test counselling following the Canadian Medical Association guidelines. The Council further advised CIC that, when determining if an HIV-positive person would be excluded on the grounds that they could cause excessive demand on the health care and social service system, CIC should use a cost-benefit approach that takes into account both the economic and non-economic contributions that the potential immigrant could make to the Canadian economy. The potential for lack of adequate follow-up and referral to services for those who have positive test results continues to be a concern. All of these issues are pressing concerns for communities from countries where HIV is endemic (see section 6.2.1).

Media reports in 2004 commented on an apparent tripling in the number of HIV-positive immigrants to Canada in 2003, an increase that was explained by Citizenship and Immigration Canada as likely being due to the implementation of mandatory HIV testing rather than a spike in real numbers.

This year the Ministerial Council was particularly focused on the possible obstacles facing visitors working for or attending the 2006 International AIDS Conference in Toronto (see section 6.5.6 for further details on the Ministerial Council's involvement in immigration issues connected with the Conference).

Work done during 2004-2005

• The Co-Chairs of the Ministerial Council met with the Deputy Minister of Citizenship and Immigration Canada (CIC) and other CIC officials to discuss HIV testing of potential immigrants. The Co-Chairs raised the issues of:
  • the inappropriate way in which some CIC officials had portrayed HIV-positive immigrants as public health risks in media reports. CIC officials agreed to look into its communication with the media.
  • lack of confidentiality and sensitivity in communicating test results. CIC officials said they would take steps to resolve the problem.
  • linking HIV-positive immigrants to appropriate services. CIC agreed that more needs to be done.
  • fear of denial of entry to Canada by refugees who test positive. CIC officials said they would add a statement to CIC pamphlets that being HIV-positive does not negatively affect a refugee claim.

The CIC Deputy Minister asked for advice on the issue of partner notification in the case of a positive test. The Co-Chairs brought this issue to the full Council for discussion and then wrote to CIC suggesting a meeting to define the issues and determine the best process for addressing them.

• The Ministerial Council had special presentations on immigration at its January 2005 meeting and a teleconference with officials of CIC and members of the 2006 International AIDS Conference in February and March of 2005.
• The Ministerial Council raised concerns with officials of CIC about reports that counselling, communication of test results, and referral to services were sometimes poorly handled by CIC and that confidentiality was not always respected. The Ministerial Council recommended to CIC that firmer guidelines and better training be provided for all officials involved in HIV testing and offered to work with CIC to solve these problems.
• A presentation to the Ministerial Council by community leaders at its January 2005 meeting focused on the barriers and challenges faced by immigrant and refugee persons living with HIV/AIDS, including gender-based problems for women, homophobia in some immigrant communities and lack of culturally-appropriate services. The presenters recommended more effective approaches for dealing with these issues, including a Canadian strategy for immigrant and refugee persons living with HIV/AIDS and greater federal/provincial/territorial coordination.
• The Ministerial Council recommended that a meeting be arranged in the near future between Citizenship and Immigration Canada (CIC) and members of immigrant communities to address the concerns raised by community leaders. The Council informed the Minister of Health that it had met with community representatives and that it would participate as an observer at a meeting between CIC and the community.

Future activities

The Ministerial Council will continue to advise the Minister of Health on these issues and will dialogue and work with officials of Citizenship and Immigration Canada.

6.1.3 Other federal departments

The issue

Effective response to HIV/AIDS requires the involvement of many federal departments, particularly with the strong emphasis in both the draft pan-Canadian Action Plan and the Federal Initiative to Address HIV/AIDS in Canada on determinants of health that render individuals and communities at increased risk of HIV infection. The Ministerial Council's 2001 paper, Towards a Broader Vision of Health: Strengthening Inter-Ministerial Collaboration on HIV/AIDS in Canada and its 2002 paper, HIV/AIDS and Health Determinants: Lessons for Coordinating Policy and Action, both call for the involvement of federal departments concerned with issues of homelessness, disability and income support (Social Development Canada), Aboriginal issues (Indian and Northern Affairs), health technology, international affairs and so on, in addition to those departments that are current partners in the Federal Initiative to Address HIV/AIDS in Canada. The Ministerial Council's work with Foreign Affairs Canada and International Trade Canada is discussed in section 6.5 of this report and programs of the Canadian International Development Agency (CIDA) are discussed in more detail in section 6.5.4.

Work done during 2004-2005

The Ministerial Council actively encouraged the Minister and other federal officials to work collaboratively at the inter-departmental level on all issues addressed by the Council.

Future activities

The Ministerial Council will continue to encourage the Minister and other federal officials to collaborate at the inter-departmental level and will engage in collaborative and coordination efforts where possible.

6.1.4 Public Health Agency of Canada

The issue

In September 2004, the new Public Health Agency of Canada (PHAC) was launched and became the lead federal agency for HIV/AIDS. The PHAC is responsible for the overall coordination of the Federal Initiative to Address HIV/AIDS in Canada, including: joint planning, monitoring and evaluation; communications; social marketing; national and regional programs; policy development; surveillance; laboratory science; and global engagement focusing on technical assistance and policy advice. By 2008-2009, the Agency will receive annual funding of $51.9 million under the Federal Initiative.

The HIV/AIDS Policy, Coordination and Programs Division is housed within the Agency's Centre for Infectious Disease Prevention and Control. The Agency's regional offices across Canada also play a role in carrying out the Federal Initiative. The Agency has a direct reporting relationship to the Minister of Health, which some analysts think may raise the profile of HIV/AIDS and other diseases. Others are concerned that the distinct needs of HIV/AIDS may not be met in the new environment with its emphasis on public health and a variety of diseases. A particular concern has been the potential for erosion in the new environment of the frameworks of social justice and determinants of health on which HIV/AIDS work has been built. In his message prefacing the Federal Initiative on HIV/AIDS, the Chief Public Health Officer, who leads the Public Health Agency, underlined the need to continue to build on population-based and health determinants approaches to HIV/AIDS so that the root causes of the epidemic can be addressed.

Further information on the Public Health Agency of Canada can be found at www.phac-aspc.gc.ca.

Work done during 2004-2005

• During the course of the transition from the Canadian Strategy on HIV/AIDS to the Federal Initiative to Address HIV/AIDS in Canada and the transfer of leadership on HIV/AIDS issues from Health Canada to the Public Health Agency of Canada, the Ministerial Council engaged in dialogue with the Minister of Health, the Minister of State (Public Health) and officials of Health Canada and the Public Health Agency of Canada. The Council voiced strong concerns about the effect on HIV/AIDS of using the traditional public health model with its primary emphasis on prevention. The Council stated that the continuum of prevention, care, treatment and support must be maintained. The Council also emphasized the need for community participation at all levels within the new structures. The Ministerial Council had overarching concerns about the preservation of human rights, social justice and determinants of health approaches as the federal role in HIV/AIDS was renewed.
• The Ministerial Council met with the Minister of State (Public Health) and raised its concerns about:
  • the need to maintain the social justice and determinants of health frameworks in all approaches to HIV/AIDS. The Council stressed the importance of speaking out against discrimination. The Council was encouraged by the Minister's support for the social justice approach and her stands on stigma and discrimination.
  • the need to maintain the integrity of the HIV/AIDS programs that had been developed at Health Canada
  • the need to maintain accountability
  • the need for adequate HIV/AIDS funding that would be maintained in a separate envelope from other Agency budgets.
• The Ministerial Council requested input into the selection process for the new Chief Public Health Officer and sent its suggestions for defining competencies to the Minister of State (Public Health).
• The Minister of State (Public Health) asked for the Council's advice regarding proposed membership for an advisory body representing diverse stakeholder communities, including those concerned with HIV/AIDS, to provide advice on the transition to the new Agency and to address the question of ongoing stakeholder involvement. The Council provided guidelines for the selections of individuals and a list of organizations that should be contacted.
• The Ministerial Council offered to participate in advisory bodies and roundtables.

Future activities

The Ministerial Council will continue to advise the Minister of Health and the Minister of State (Public Health) regarding the Public Health Agency of Canada.

6.1.5 Health Canada

The issue

Under the new Federal Initiative to Address HIV/AIDS, the lead federal responsibility centre for issues related to HIV/AIDS is now the Public Health Agency of Canada rather than Health Canada ; both the Public Health Agency of Canada and Health Canada report to Parliament through the Minister of Health. Health Canada is a partner in the Federal Initiative with responsibility for community-based HIV/AIDS education, prevention and related health services for First Nations on-reserve and some Inuit communities. Health Canada is also responsible for program evaluation and coordination of global (international) engagement. Health Canada's annual share of the $84.4 million federal investment in HIV/AIDS will be $5.7 million by 2008-2009.

The Canadian Institutes of Health Research (CIHR), a partner in the Federal Initiative to Address HIV/AIDS, is an independent agency that also reports to Parliament through the Minister of Health. CIHR receives funding through the Federal Initiative (see section 6.4.1).

During the past year, as the transfer of lead responsibility for HIV/AIDS passed from Health Canada to the Public Health Agency of Canada, several policy questions were raised about the implications of a public health approach to HIV/AIDS and the importance of maintaining the population health approach on which HIV/AIDS work is based and which has been the policy framework within which Health Canada has operated for several years.

Work done during 2004-2005

• The Ministerial Council advised the Minister and officials of both Health Canada and the Public Health Agency of Canada on the policy and process issues involved in the transfer of lead responsibility for HIV/AIDS from Health Canada to the Public Health Agency of Canada.
• The Ministerial Council had a special presentation at its November 2004 meeting from Health Canada's International Health Division as part of a session devoted to international issues. The discussion centred on the Ministerial Council's 2003 paper, Meeting the Challenge: Canada's Foreign Policy on HIV/AIDS, With a Particular Focus on Africa, and how the paper's recommendations could be implemented by Health Canada.
• The Ministerial Council engaged in dialogue with Health Canada's International Health Division about the international component of the Federal Initiative. The International Health Division coordinates Canada's international response to HIV/AIDS and works closely with other federal departments and agencies involved in HIV/AIDS through its leadership on the Consultative Group on Global HIV/AIDS Issues. The Ministerial Council is considering whether to request a seat on the Consultative Group.
• The Ministerial Council discussed the evaluation component of the Federal Initiative with Health Canada officials.
• The Ministerial Council was briefed about HIV/AIDS initiatives of Health Canada's First Nations and Inuit Health Branch. The National Aboriginal Council on HIV/AIDS (NACHA) is primarily responsible for providing advice to Health Canada and the Public Health Agency of Canada on Aboriginal peoples and HIV/AIDS. The Ministerial Council and NACHA maintain communication links (see section 6.2.9).
• The Ministerial Council met with the Minister of Health and discussed a variety of issues, including World AIDS Day, the new Federal Initiative to Address HIV/AIDS, needle exchange programs in prisons and funding allocations under the Federal Initiative.

Future activities

The Ministerial Council will continue to advise the Minister on the role now played by Health Canada and will provide assistance to Health Canada as appropriate.

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