A Comparative Analysis

Strengthening Ties – Strengthening Communities

An Aboriginal Strategy on HIV/AIDS in Canada for First Nations, Inuit and Métis People – CAAN July 2003 and Leading Together, Canada Takes Action on HIV/AIDS 2005-2010

and

Leading Together
Canada Takes Action on HIV/AIDS 2005-2010

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1.0 Visions and Missions

Leading Together has as its’ Vision:

The end of the HIV/AIDS epidemic is in sight.

The Mission:

• To champion the needs and rights of people living with HIV/AIDS and people at risk
• To work collaboratively to build effective responses and lead the fight against HIV/AIDS at home and abroad
• To act boldly and strategically to stop the HIV/AIDS epidemic

ASHAC has as its’ Vision:

Aboriginal People in Canada will achieve and maintain strong, healthy, and fulfilling lives, free of HIV/AIDS and related issues.

The Mission:

To support meaningful, lasting efforts for Aboriginal communities to address HIV/AIDS and related issues in a culturally relevant manner.

The Vision and Mission of the ASHAC are more comprehensive than that described by Leading Together. This is due to the addition of the words, “related issues” which reflects the family-based reality and the world view of the Aboriginal community. It will not be enough to see an end to the epidemic in sight but rather to repair the damage to the family and thus, the community left in its wake. The Aboriginal population has experienced a legacy of similar assaults and is aware of the need for a process to allow for healing so that the people are not only free from the epidemic but are also, strong, healthy and fulfilled. As a result, the benchmark of 2010 may not be realistic within the Aboriginal population.

In addition, the lack of long term, sustained funding for Aboriginal AIDS Service Organizations and Aboriginal communities under CSHA I and II has put the Aboriginal response to HIV/AIDS ten years behind other ASOs.

Leading Together however, recognizes the need to support the long term efforts of Aboriginal people in the fight against HIV/AIDS and supports an integrated/holistic approach that is reflective and respectful of Aboriginal cultures.

2.0 Goals

The goals identified in Leading Together have been strengthened from the direction set by the FI.

To the year 2010, we will pursue four main goals. All four are intricately linked. The second and third goals are a continuum:

1. Reduce the social inequities, stigma and discrimination that threaten people’s health and well-being.
2. Prevent the spread of HIV.
3. Provide timely, safe and effective diagnosis, care, treatment and support for all people living in Canada with HIV/AIDS.
4. Contribute to global efforts to fight the epidemic and find a cure.⁵

The goals identified in ASHAC are as follows:

Two broad goals will be supported by the ASHAC, which are:

• Ensure the best possible efforts, in all areas, are placed to meet the needs of Aboriginal people living with HIV/AIDS; and
• Prevent the further spread of HIV/AIDS among Aboriginal populations, through education, awareness and whatever means available and necessary.

Underlying these broad goals, is the recognition that because Aboriginal people are family-based, support is also needed for those affected by this disease such as family members, partners, and HIV/AIDS workers to name a few.⁶

The goals identified by both Strategies are complimentary with the possible exception of goal #4 identified by Leading Together. However, it is important to note again that the ASHAC goes further with the incorporation of the needs of those affected by the disease.

3.0 Strategies

Leading Together has identified nine strategic areas and while the ASHAC may not use the same language many of the nine strategies identified in Strengthening Ties - Strengthening Communities are a good fit.

Leading Together Strategy #1 Commitment to Social Justice and Human Rights

This strategy recognizes individual and cultural differences as well as diversity. It speaks to fairness in terms of access to services and health outcomes. It supports programs that meets everyone’s basic life needs, self esteem and seeks to reduce inequities in wealth, income and life chances. It encourages participation by all even the most disadvantaged.

The Strategy supports responses to HIV that “recognize[s] and address[es] the broad determinants of health that make people vulnerable to HIV and to disease progression”

While ASHAC does not identify a specific Strategy to address “determinants of health” and social justice, Strengthening Ties – Strengthening Communities was developed within this context as follows:

Determinants of health which are factors known to affect or influence a person’s health, can be either negative or positive. Negative determinants can be such things as living in poverty, having inadequate or no housing, as well as childhood traumas that remain unresolved. Positive determinants can be getting higher education, having stable home environments, or strong cultural connections. Generally, the main factor affecting the health of Aboriginal people is socioeconomic status, in addition to environmental factors. Many Aboriginal people experience higher rates of disease and extensive health issues, mainly because these social determinants of health are much lower for far too many Aboriginal people. When there are too many negative determinants in a person's life, the risks for HIV/AIDS and other diseases increase. Aboriginal communities have experienced major negative forces, like the Residential School Legacy. While Aboriginal peoples’ experiences are not all the same, there are some common issues, such as: a loss of language, culture, and traditional use of land. As well, systemic discrimination; gender inequality and displaced roles; are just some of the other forces that have shook the foundations that Aboriginal cultures once thrived upon. It is easy to see how many of these underlying issues can complicate intervention strategies. For many Aboriginal people, achieving holistic health after generations of trauma and losses, is necessary to re-building our societies and in order for our health conditions to improve, including removing much of the risk for HIV and AIDS. Holistic health is about finding balance emotionally, physically, spiritually, and mentally. Northern and isolated communities face challenges brought on simply by their geographic location, such as access to adequate resources and health systems. Language can also be a factor.⁷

Leading Together Strategy #2 Leadership and Innovation

This Strategy speaks to the need for “leadership at all levels…in local communities…and within Aboriginal, provincial/territorial and federal governments. We need committed people who are willing to speak out to convince the public and policy makers that HIV deserves focused, discrete attention.”⁸

The ASHAC does not designate a Strategy to Aboriginal Leadership but prefaces the Strategic Plan with “a message to Aboriginal leadership”.

“There is a critical role that Aboriginal Leaders can play in each of these strategic areas and in the overall struggle to overcome all the challenges that come with HIV/AIDS. Aboriginal Leaders need to speak publicly about HIV/AIDS so that Aboriginal communities hear their Leaders talking about these issues and begin to take it more seriously.”⁹

Leading Together Strategy #3 Meaningful Participation of People Living With HIV/Communities at Risk

This strategy highlights the value of engaging people living with HIV and communities at risk to reduce the stigma associated with the disease, prevent the spread of the virus, improve care, living conditions and end the epidemic. It recognizes that people living with HIV/AIDS have a right to participate in the decisions that affect them. It also educates care givers and others and it provides a social support network.

The ASHAC identifies a Strategy “Engaging Aboriginal Groups with Specific Needs” and also devotes an entire chapter to “Diverse Groups Many Needs.”

This Strategy states the following:

“The purpose here is when working with specific groups, it is best to meaningfully engage members of these groups in all aspects of how a program or service can best meet their needs. Cross-cultural training, increasing awareness among service providers, and respecting individual choices are some examples of where work is needed. As well, increasing Aboriginal participation in HIV/AIDS program planning, implementation and evaluation is another area.”¹⁰

Leading Together Strategy #4 Early Intervention

Early intervention includes needle exchange programs, testing for pregnant women and early diagnosis.

The ASHAC addresses early intervention under the Strategic direction, Supporting Broad-Based Harm Reduction Approaches. The area speaks to substance use including alcohol, injection drug use and other substances and the potential for risk behaviours as a result of substance use and addiction. In terms of testing for women during pregnancy, the issue is raised in the document under Diverse Groups, Many Needs, under Aboriginal women¹¹ but it does not specifically address testing. Under ASHAC’s Strategic area, Prevention and Education, one of the objectives refers to “to examine and develop appropriate initiatives to address mother-to-child transmission.”¹² This could be an area where “testing and even early diagnosis” could be addressed, however there appears to be a gap on the part of ASHAC to address this issue in a targeted manner.

Leading Together Strategy #5 Research/Evidence

This strategy seeks to get ahead of the HIV/AIDS epidemic through basic scientific research, evaluation and epidemiological, clinical, psychosocial, community-based and health services research. The research and evidence will:

• Help to track and monitor the spread of HIV
• Contribute to worldwide efforts
• Help us understand the needs of people with HIV and communities at risk
• Lead to stronger care and treatment programs
• Inform policy
• Help us make better use of limited resources

The ASHAC addresses the Research/Evidence Strategy under the Research and Evaluation Strategic direction. Strengthening Ties – Strengthening Communities focuses attention on the need for accurate epidemiological evidence across Canada with respect to Aboriginal people and HIV. The Strategy also addresses intellectual property, the OCAP philosophy (Ownership, Control, Access and Possession), the need to build research capacity within the Aboriginal community and the need to establish Aboriginal ethics review processes. The outcomes largely reflect the outcomes identified in Leading Together however, this may be an area within the ASHAC that requires a renewed approach especially given the continuing disparity in accurate epidemiological evidence with respect to the Aboriginal population from one province to the next.

Leading Together Strategy #6 A Sustained Response

The Strategy highlights the need to ensure a response to HIV prevention and treatment that is long-term and comprehensive. The focus is on changing and adapting prevention messages as new knowledge is gained, messages that are developed by PHAs and treatment of PHAs that are now living with the disease for longer periods of time.

The ASHAC addresses sustainability under the Strategic Area, “Sustainability, Partnerships and Collaboration” The section notes the following:

“Sustainability is about designing comprehensive efforts that can ensure HIV/AIDS work gets incorporated into all relevant services and agencies…Sustainability rests on how well efforts can influence and create positive outcomes.”¹³

In terms of Prevention, ASHAC devotes a Strategic direction to the subject under Prevention and Education and indicates the following outcomes:

• enhanced prevention and education messages/approaches
• expanded, working knowledge of broad and targeted deliveries
• increased and updated resources
• formalized appropriate and current education messages
• increased awareness of issues facing hard-to-reach groups
• increased collaboration with shared expertise
• shared knowledge of current trends and emerging issues
• enhanced awareness campaigns
• mobilized regions and communities
• broadened support through more knowledgeable communities
• effective delivery and refined approaches
• appropriately developed and maintained programs
• broadened awareness and support
• cross-jurisdictional approaches
• better informed children and youth
• healthier life approaches to sex and sexuality, alcohol and drug use, and other related issues
• enhanced and relevant educational delivery
• up-to-date information delivery
• enhanced and relevant educational delivery
• informed and appropriate treatment choices¹⁴

Leading Together Strategy #7 Culture, Gender and Age- Appropriate Programs and Services

This strategy deals specifically with the Aboriginal population as follows:

“Programs and services for First Nations, Métis and Inuit people must ‘first and foremost, show respect and honour for all Aboriginal beliefs, practices and customs’ and reflect the ‘pride and dignity that Aboriginal heritage demands”¹⁵

The Strategy also addresses the specific needs of:

• Youth
• Gay men
• Women and
• People from different ethnocultural and ethnoracial groups

The entire ASHAC is, of course, directed to the Aboriginal population but there are specific areas that address issues such as “respect and honour” for example:

• Under the Strategy that addresses Sustainability, Partnerships and Collaboration two of the objectives are complimentary to the intent of Leading Together; “to support and utilize where appropriate, cross-cultural sensitivity training for non-Aboriginal workers/agencies who work with Aboriginal people.” And “to insist government departments engage Aboriginal input regarding decisions affecting policy and programs related to HIV/AIDS and the determinants of health”.¹⁶
• Under the Strategy that addresses Legal, Ethical, and Human Rights Issues this section deals with the need for both Aboriginal service providers and decision makers and non-Aboriginal service providers to become more aware of individual rights and respect and protect these rights.
• Under the Strategy that addresses Engaging Aboriginal Groups with Specific Needs this area addresses the diversity within the Aboriginal population and supports the notion that “one size does not fit all”. Not only is the Aboriginal population comprised of First Nations, Métis and Inuit people, it is comprised of people who speak different languages, practice different customs and live in a variety of settings.

Objectives under this Strategy address “population-specific approaches” as follows:

• to encourage and support development of appropriate programs and activities
• to ensure Aboriginal women are provided access to current and accurate information and support regarding testing, prevention, sexual assault issues, choices and treatment options around pregnancy and HIV/AIDS to address perinatal HIV and HCV transmission, as well as female-specific research on care and treatment issues, which is both culture and gender specific
• to continue to examine and respond to specific issues related to the role of unprotected sex in the spread of HIV/AIDS within all groups
• to ensure an increase in youth-specific efforts are designed to provide access to current and accurate information and support regarding testing and prevention, as well as care and treatment needs
• to increase knowledge and education on Inter-sexed and transgendered issues/needs regarding HIV/AIDS and related issues
• to expand efforts that respond to issues facing Aboriginal men in regards to HIV/AIDS and related issues
• to continue and expand efforts that respond to issues facing Two-Spirited people in regards to HIV/AIDS and related issues
• to recognize, design and implement efforts that address needs and issues, within a "family-based" cultural context, and in consideration of impacts on Support and Prevention Workers in the HIV/AIDS field
• to recognize unique and special needs and challenges in terms of mental health issues, and developmental learning issues, including Fetal Alcohol Spectrum Disorder, Attention Deficit Disorder, among others. ¹⁷

Leading Together Strategy #8 A Commitment to Monitoring, Evaluation and Quality Improvement

Leading Together states the following:

“To stop the epidemic, our programs must be better than they are today. We must:

• Monitor and evaluate the impact of what we do
• Learn from our experiences
• Continually refine and monitor our services”¹⁸

The ASHAC makes reference to monitoring throughout the Strategic Plan and speaks to evaluation under Research and Evaluation. The ASHAC notes:

“It has been often said that Aboriginal people have been researched to death and the time is here to research us back to life. The time is long overdue for Aboriginal people themselves to use research as a tool for designing efforts that can support greater opportunities to collect and analyze data, so as to respond appropriately and effectively. There remains a need to train and increase the number of Aboriginal researchers.”¹⁹

Leading Together Strategy #9 Shared Responsibility

Leading Together recognizes the need to undertake an holistic approach to addressing issues and factors that impact HIV/AIDS and this is an approach that has long been recommended by Aboriginal people. It is not enough to target the disease alone but the social determinants of health and economic circumstances must also be addressed. This will require a concerted effort across jurisdictions to impact services and systems such as:

• Income programs
• Social and housing services
• The justice system
• The education system
• Correctional services
• The private sector (e.g. employment)

The ASHAC addresses the above as an overriding principle but also is more specific in two Strategic areas namely, Holistic Care, Treatment and Support and Coordination and Technical Support. Both areas speak to the need to address interjurisdictional issues at the national/provincial/territorial and local levels. They also speak to mental health issues, co-infections etc.

It is important to note that before Aboriginal groups can fully “share responsibility” there is a need for additional Community Development, Capacity Building and Training. ASHAC devotes a Strategic area to this effort and notes the following:

“Community development, capacity building and training are key to the success of the ASHAC, as well as the Aboriginal HIV/AIDS movement in Canada. Capacity building can include informal learning, whereas training generally (not always) involves more formal learning environments. In large part, Aboriginal communities are doubly burdened, both with the challenge of playing catch up to the rest of Canada in regard to HIV/AIDS, but also because significant social, economic and other health issues continue to exhaust resources. Greater efforts are required to plan, design, create and support implementation and/or adoption of preferred practices to ensure the best possible use of both human and financial resources. It is also critical to understand that Aboriginal communities have generations of negative impacts from failed government policy such as Residential Schools and assimilation in general. These have contributed directly and indirectly, to the multitude of underlying issues that Aboriginal people experience.”²⁰

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⁵ Leading Together, PHAC 2005 p.5

⁶ ASHAC, CAAN, 2003 p.3

⁷ ASHAC, CAAN 2003 p.4-5

⁸ Leading Together, PHAC 2005 p.15

⁹ ASHAC, CAAN 2003 p.11

¹⁰ IBID p.18

¹¹ ASHAC, CAAN 2003 p.26

¹² IBID p.14

¹³ ASHAC, CAAN 2003 p.15

¹⁴ IBID p. 14

¹⁵ Leading Together, PHAC 2005 p.17

¹⁶ ASHAC, CAAN 2003 p.14

¹⁷ ASHAC, CAAN 2003 p.19

¹⁸ Leading Together, PHAC 2005 p.17

¹⁹ ASHAC, CAAN 2003 p.23

²⁰ ASHAC, CAAN 2003 p.13