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The carnage from HIV/AIDS is staggering. No part of the globe is immune, but sub-Saharan Africa has been the vortex of impact: tens of millions dead, hundreds of millions of lost years of life expectancy, famine, orphaned children, weakened economies, stressed government capacities, increased security threats and states threatened with collapse. The challenge to the international humanitarian conscience and to the self interest of virtually every country is profound.
This report, prepared for the Ministerial Council on HIV/AIDS, responds to an invitation from the Minister of Health to develop a review of Canada's approach to HIV/AIDS on the international stage. The Minister of Health had received a request along these lines from the Minister of Foreign Affairs.
The foundations for Canadian policy are rooted in the values embodied in our public health system, international human rights commitments, and multilateral development and health accords. These values also include support for the participation of civil society, vulnerable groups and people living with HIV/AIDS in the development and implementation of policies and programs; and the recognition of the centrality of gender as a factor in development. The response to HIV/AIDS must be governed by human rights principles and norms.
A tragedy of the magnitude of HIV/AIDS requires a response that is commensurate in size and scope. Unfortunately, the response to date has not been commensurate. The fundamental international development objectives to which Canada is committed, and the goals contained in the United Nations General Assembly Special Session (UNGASS) Declaration of Commitment on HIV/AIDS, will not be met unless the challenge of HIV/AIDS is confronted on a massive scale. For Canada, scaling up means providing significantly more resources, sharing best practices, and taking a leadership role in addressing global HIV/AIDS issues. It means giving HIV/AIDS a much higher profile than it currently has in the Department of Foreign Affairs and International Trade (DFAIT) and in the other federal departments and agencies that are involved in global issues. It means greater coordination of theactivities of these departments and agencies. It means developing and executing HIV/AIDS-specific strategies.
To meet the global challenges of HIV/AIDS will require a greatly increased level of material and political support from industrialized nations. This is something that Canada can and should be championing. As a wealthy country with a history of internationalism, Canada is well positioned to demonstrate leadership. DFAIT is one of the principal government agencies involved in the global response, so its role is critical. To fulfill this role, DFAIT will need to mainstream HIV/AIDS into all of its operations.
Canada needs to build coalitions for action both within the G8 and industrialized "donor" countries, but also with like-minded countries, whether developed or developing, to break political and resource log-jams that block action to reverse the deadly course of the disease in Africa and to prevent the further escalation of infections in regions such as Russia and many parts of Asia. Canada can also influence the global response to HIV/AIDS through its bilateral relationships, not least with African countries and with its neighbour, the United States.
To develop a comprehensive approach, the Canadian government must ensure coherence of relevant international policies - with respect, for example, to overseas assistance, the actions of multilateral economic institutions, trade negotiations and agreements - with an international strategy for HIV/AIDS that prioritizes human rights, including the right to health. A critical first step is to provide for a human rights evaluation of current policies, and to champion the respect for, protection of, and promotion of, human rights through diplomacy at all levels, with particular attention to commitments relevant to HIV/AIDS.
Lives - millions of lives - can and must be extended and saved. The international community has both the capacity and the resources to provide treatment for HIV/AIDS to a rapidly escalating number of people. Intellectual property provisions and practices that have privileged the profits of multinational pharmaceutical corporations over the right to health must be amended or set aside. Health systems and public services that can ensure that education, prevention and care go hand-in-hand with the effective provision and support of ongoing treatment must be reinforced and expanded.
Trade policies, particularly in the areas of intellectual property, services, investment and government procurement, that are not coherent with the objectives of an international HIV/AIDS strategy governed by human rights principles should be amended, whether these policies are in the context of multilateral, regional or bilateral negotiations and agreements. Investment in research is essential to support the development of vaccines and new treatments and to support national and international research infrastructures. Leadership is clearly required to ensure the development of a longer term strategy for research for medicines appropriate to neglected diseases and the diseases of the poor and marginalized, together with measures that will provide access to medicines for the people who need them.
Resource provision on the part of donor countries must be increased not by percentages but by multiples, if millions of lives are to be saved. Expenditure on war has recently demonstrated that the capacity in dollars exists, and that the necessary resources could be found if the will were present. Canada should significantly increase its contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria. Debt relief, the ending of multilateral conditionalities which subvert the ability of the governments of developing countries to respond to the HIV/AIDS crisis, the need to inform and redirect poverty eradication policies by mainstreaming HIV/AIDS dimensions - these are all elements of a potentially effective strategy.
Canada has played a distinguished role in encouraging and implementing inclusive and participatory approaches to the development of domestic and international policy on HIV/AIDS, and in representation in international fora where multilateral policy is advanced and strategies are reviewed. In its bilateral and multilateral relations, DFAIT should advocate for the inclusion of NGOs, persons living with HIV/AIDS, and vulnerable groups in the development, design, implementation and monitoring of HIV/AIDS programs and policies.
Canada has been a leader in international policies for human security. Africa presents particular challenges. While security forces are both seriously affected by HIV/AIDS and can be a significant engine of further infection, they can also be instruments of education and prevention. HIV/AIDS training for African forces, peacekeepers and mine action personnel is a necessity. The integration of an HIV/AIDS dimension in international security and peace-keeping planning is also important. The dangers present in conflict and peace-keeping are often visited upon transitional and post-conflict situations, as well as in related refugee movements. The violations of human rights, particularly those of women and children, require a strong response involving government-led preventive action and attentive international policy.
Governments in sub-Saharan Africa are under particular stress. Public services have been decimated by illness, absence and death. Response, while slow to develop, is occurring, including national strategies to save lives and research on ways to strengthen governance. Canada has played a role in strengthening public services and public institutions, but can and should contribute more. At the same time, Canada should refrain from supporting multilateral trade, investment and debt policies that weaken governments and the provision of public services.
The linkage between HIV/AIDS, food insecurity and starvation has been increasingly apparent in sub-Saharan Africa and requires an enhanced response.
Canada has had positive experiences with needle exchange programs and has recently authorized a trial of two supervised injection sites. Canada is well placed to champion the use of harm reduction strategies with other countries and to share Canadian best practices in this area and in other areas.
Canadian businesses, significant players in a number of international theatres, can and must be part of an effective response to HIV/AIDS, in their own self-interest and because of the social and economic impact of unchecked expansion of infection. Leadership in response to the HIV/AIDS challenge, both within international and domestic business communities, is developing, so an exchange of guidance and best practices should be encouraged. At the same time, respect for, and implementation of, the International Labour Organization's ILO Code of Practice on HIV/AIDS and the World of Work should be strongly encouraged. Canada should champion the adoption of the new Draft Norms on the Responsibilities of Transnational Corporations and other Business Enterprises with Regard to Human Rights.
There is an opportunity, now, for Canadian leadership in the international response to HIV/AIDS. The recommendations in this report are the basis for the development of a comprehensive strategy involving considerable initiative on the part of DFAIT, but also for the engagement of other relevant federal departments and agencies, and collaboration with relevant non-governmental sectors. Such a strategy calls for a high-intensity, sustained and significant scaled-up investment of Canadian capacities and resources. Canada can and should invest significant leadership capacity and resources in building an unprecedented response by the international community which will literally save lives on a massive scale.
Below is a list of the recommendations contained in this paper, organized by section and sub-section.
1. | We recommend that Canada make a clear commitment to base its comprehensive response to HIV/AIDS internationally on human rights principles and norms as embodied in international instruments. |
Scaling Up Canada's Response
13. | We recommend that DFAIT work with other governments, international agencies and NGOs to champion the development of an international strategy and action plan to massively scale up support to save and extend lives, reinforce health systems and halt and reverse the spread of HIV/AIDS in Africa; and that DFAIT use its experience in this initiative to inform actions in other regions confronting the epidemic. |
14. | We recommend that the DFAIT develop and implement a plan for mainstreaming HIV/AIDS in its operations, and that DFAIT seek advice on the development of this plan from Canadian non-governmental organizations with experience in the area. The plan should: |
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Promoting Human Rights
Saving Lives: Access to Treatments
18. | We recommend that DFAIT, in collaboration with Health Canada, the Canadian International Development Agency and other relevant agencies and departments, champion an international agreement on defined targets and timelines for provision of access to essential medicines, including antiretroviral therapy, for the treatment of HIV/AIDS, with specific attention to sub-Saharan Africa. |
19. | We recommend that DFAIT support the target of the World Health Organization (WHO) of three million people receiving treatment with antiretroviral therapies by 2005, and support the definition and adoption of more comprehensive, ambitious and realistic targets beyond this initial WHO target. |
20. | We recommend that Canada commit significant resources to the achievement of international targets for the provision of access to essential medicines; and that DFAIT advocate for this to happen. |
21. | We recommend that DFAIT support, and where necessary initiate, international cooperation to ensure the provision of affordable quality supplies of medicines by encouraging of regional generic production facilities, where possible; that DFAIT encourage the formation of an international consortium of generic-producing countries to scale-up production, distribution and sustainable supply, with appropriate changes in Canadian patent law to facilitate Canadian production of generics for export; and that DFAIT secure public commitments by World Trade Organization (WTO) Members at the Fifth WTO Ministerial Conference (Cancún, September 2003) that will facilitate and support this strategy. |
22. | We recommend that Canada support an amendment to the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) that will ensure a simple and non-restrictive system for enabling countries with limited or no pharmaceutical manufacturing capacity to make effective use of compulsory licensing, including the removal of any remaining impediments in TRIPS that prevent such use; and that Canada support developing countries in their efforts to avail themselves of this solution, and oppose efforts to pressure them into not using it. |
23. | We recommend that DFAIT, in collaboration with other federal government departments and agencies, work with developing countries to implement ways to significantly lower the prices of antiretroviral therapies and other HIV-related rugs, including the establishment of workable laws that give full effect to compulsory licensing. |
24. | We recommend that a full evaluation of the implications of a more stringent intellectual property regime for the right to health and for development be undertaken on an urgent basis as part of human rights assessment of trade negotiations (see Recommendation 15). |
25. | We recommend that DFAIT's current policy of encouraging further implementation of intellectual property obligations by developing countries be suspended pending the human rights assessment of trade negotiations; and that the policy be amended, if appropriate, in light of the findings of that assessment. |
26. | We recommend that DFAIT oppose provisions such as the TRIPS-plus proposals in the Free Trade Area of the Americas negotiations, and similar provisions in any bilateral trade negotiations, that would extend intellectual property rights and limit states' policy options in balancing intellectual property protection against other policy objectives, such as protecting and promoting human rights, including the right to health. Instead, DFAIT should undertake to secure a development-friendly model for governance of intellectual property that does not mandate minimum length and scope of intellectual property protections and that increases national decision-making authority, allowing states to set public policy according to domestic considerations such as levels of development and health needs. |
27. | We recommend that in further development of Canadian strategies, initiatives and leadership in confronting HIV/AIDS internationally, DFAIT and collaborating departments and agencies give priority to a comprehensive approach to strengthening public health systems. |
28. | We recommend that DFAIT advocate among the industrialized nations for the adoption of an equitable contributions framework for contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria. |
29. | We recommend that, based on this equitable contributions framework, Canada significantly increase its contributions to the Global Fund; and that DFAIT advocate for such an increase. Canada's contribution to the fund should be over and above established levels of official development assistance. |
30. | We recommend that Canada establish and publicly announce a series of incremental targets (with timelines) that will enable it to quickly meet the goal of 0.7 percent of gross national product for official development assistance; and that DFAIT advocate for such targets. |
31. | We recommend that DFAIT initiate consultations with Finance Canada, Health Canada, the Canadian International Development Agency and relevant NGOs to review the impact of current World Bank and International Monetary Fund conditionalities on the ability of developing countries to mobilize resources for an effective response to HIV/AIDS. |
32. | We recommend that DFAIT work with the Finance Canada and the Canadian International Development Agency to encourage the rapid mainstreaming of HIV/AIDS considerations into poverty reduction strategies administered by the World Bank, utilizing such tools as the Checklist for Mainstreaming HIV/AIDS in Poverty Reduction Strategies, developed by the United Nations Population Fund. |
Engaging Civil Society: Participation of People Living with HIV/AIDS, Vulnerable Groups and NGOs
33. | We recommend that DFAIT, in its bilateral relations with the governments of most-seriously affected countries, encourage and support the engagement of community-based organizations, NGOs, persons living with HIV/AIDS, and vulnerable groups in the development and design of HIV/AIDS policies and programs, and in their implementation and evaluation. |
34. | We recommend that in multilateral fora, DFAIT champion the involvement of community-based organizations, NGOs, persons living with HIV/AIDS, and vulnerable groups in all aspects of the response to the epidemic. |
35. | We recommend that representatives of civil society and persons living with HIV/AIDS be included in the Canadian delegations that attend the annual United Nations General Assembly UNGASS debates. |
36. | We recommend that DFAIT support the Joint United Nations Programme on HIV/AIDS (UNAIDS) in its efforts to involve civil society in assessing the United Nations Secretary-General's annual progress report on the UNGASS Declaration of Commitment; and that in its bilateral relationships and in multilateral fora, DFAIT promote the involvement of civil society in critiquing the reports that individual states prepare on progress in implementing the commitments contained in the Declaration. |
Human Security
Humanitarian Crises, Post-Conflict and Refugee Challenges
46. | We recommend that in its bilateral and multilateral relationships, DFAIT, in cooperation with the Canadian International Development Agency (CIDA) and the Department of National Defence, promote the inclusion of HIV/AIDS awareness, prevention and care programs in post-conflict initiatives and humanitarian interventions. In post-conflict situations, these programs should target not only combatant personnel but also their families and communities, as well as victims of sexual, physical and psychological violence. Where appropriate, DFAIT, in cooperation with CIDA, should also promote and support the restoration of health systems to enable them to deal with HIV/AIDS and other threats. |
47. | We recommend that DFAIT advocate for and support the integration of HIV/AIDS awareness, prevention and care programs into post-conflict initiatives and humanitarian interventions in which Canada is involved as a sponsor, funder or participant. |
48. | We recommend that DFAIT, in cooperation with CIDA and Finance Canada, work to ensure that the United Nations operational agencies involved in post-conflict and humanitarian work have adequate resources to enable them to play an effective role in the response to HIV/AIDS. |
Food Security
49. | We recommend that in its bilateral and multilateral relations, DFAIT raise awareness about the impact of HIV/AIDS on food security and nutrition, and about the impact of food insecurity on people living with HIV/AIDS, and support the initiatives of multilateral agencies and NGOs to respond to these challenges. |
Governance
50. | We recommend that DFAIT, through its bilateral relations and its relations with African regional organizations, including the African Union and the New Partnership for Africa's Development (NEPAD) initiative, support the further development of national strategies for HIV/AIDS that address the need to sustain and strengthen the capacity of government and the public provision of services, that are based on effective community-level engagement, and that embody implementation of a human rights approach to the disease; and that DFAIT encourage the exchange and study of "best cases," and champion increased resources for the implementation of these strategies. |
51. | We recommend that DFAIT, in collaboration with the Canadian International Development Agency and Human Resources Development Canada, undertake an assessment of how and where Canada might most effectively reinforce public service human resource training in countries most seriously affected by HIV/AIDS illness and death among public employees. |
Sharing and Promoting Best Practices
Research
54. | We recommend that Canada, in addition to strengthening support for Canadian HIV-related research, including through developing a national HIV vaccine plan and strengthening research into microbicides, increase its contribution to international HIV vaccine and microbicide research efforts; and that DFAIT advocate for this to happen. |
55. | We recommend that DFAIT, through its bilateral and multilateral relations, promote international HIV vaccine and microbicide research efforts. |
56. | We recommend that DFAIT, through its bilateral and multilateral relations, promote international research initiatives designed to assist efforts to scale up the provision of HIV/AIDS treatments in resource-poor settings including, in particular, research on simplified treatment regimens. |
57. | We recommend that DFAIT, through its bilateral and multilateral relations, promote the advocacy work of international NGOs to accelerate access to HIV vaccines, microbicides and treatments. |
58. | We recommend that DFAIT, through its bilateral and multilateral relations, promote the development of national plans to accelerate research and development of HIV vaccines, microbicides and treatments. |
59. | We recommend that DFAIT assist Canadian companies operating in Africa and in other countries to develop expertise on HIV/AIDS workplace policy and programming by: |
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60. | We recommend that DFAIT promote with Canadian companies operating in Africa and elsewhere the adoption as a minimum standard for their HIV/AIDS workplace policies the principles and policies contained in the International Labour Organization's ILO Code of Practice on HIV/AIDS and the World of Work; and that DFAIT publish an annual report based on information from the companies on progress in implementing these principles and policies. |
61. | With respect to countries where people living with HIV/AIDS are unable to access antiretroviral therapies and other HIV-related treatments, we recommend that DFAIT encourage Canadian companies to (a) provide these medications free of charge to their employees; (b) work with the governments of these countries to find ways to make these medications accessible to people in the communities where the companies are located; and (c) work with the governments of these countries to develop national policies and programs designed to make these medications accessible to all people who need them in each country. |
62. | We recommend that at upcoming meetings of the United Nations Commission on Human Rights, and its sub-committees and working groups, DFAIT champion the adoption of the Draft Norms on the Responsibilities of Transnational Corporations and Other Business Enterprises with Regard to Human Rights. |