A Report on Governments' Responses to the HIV/AIDS Epidemic in Canada

A National Portrait

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3. HIV/AIDS by Jurisdiction (cont)

3.4 Saskatchewan

Surveillance Highlights

• the number of newly reported AIDS cases remains relatively small and stable.
• the number of newly reported cases of HIV infection was higher in 2003 than in 1995. The MSM exposure category was responsible for over 43% of newly reported cases in 1995 compared to 36% in 2003. IDU meanwhile was responsible for 25% of new cases in 1995 but only 19% in 2003. In 2002, however, IDU was the exposure category for 54% of newly reported cases. The sharpest increase has occurred among those in the heterosexual exposure category, i.e. 7% in 1995 and 17% in 2003.
• the percentage of new HIV+ cases involving Aboriginal people has increased from 32% in 1996 to almost 50% in recent years.
• 27% of all reported HIV cases, 1985-2003, involved women. This represents a 3:1 male/female ratio compared to a ratio of 6:1 for Canada as a whole.

Saskatchewan

Indicator	Year
	2002	2001	2000	1995
AIDS Cases
Number of AIDS cases reported by year	10	8	13	18
Cumulative number of AIDS cases reported	192	182	174	118
Newly reported AIDS cases by sex
male	6	5	12	17
female	4	3	1	1
HIV Infection
Total number of reported HIV cases	26	40	35	28
Newly-reported cases of HIV Infection by risk factor
MSM	1	10	10	12
MSM/IDU	0	2	0	5
IDU	14	10	10	8
Heterosexual contact	7	8	10	2
HIV/AIDS-endemic countries	3	7	1	1
NIR/Perinatal/Occupational/Other	1	3	4	2
Newly-reported cases of HIV Infection by sex46	1985-December 31, 2003
Men	330
Women	120
Newly-reported cases of HIV Infection by age (1998)47	2002	2001	2000	1995
Perinatal	0	0	1	1
1-19	1	0	1	1
20-29	6	9	7	11
30-39	5	15	13	12
40-49	10	12	7	4
50+	4	4	6	1

Organization

The Saskatchewan Department of Health, Regional Health Authorities, community-based organizations and the Saskatchewan Advisory Committee on HIV/AIDS are together responsible for the province's response to the epidemic. The Department of Health has one person primarily responsible for coordination issues while the Advisory Committee has 16 regular and five liaison members. It includes representatives of different health professions, Aboriginal groups, government departments (Health, Learning, Community Resources and Employment, and Justice), the Saskatchewan Federation of Labour, needle exchange programs and AIDS Service Organizations.

The provincial Strategy Team developed the 2002 At Risk report that offered an extensive series of recommendations for prevention, care and treatment initiatives. It placed a heavy priority upon addressing injection drug use and, beyond that, recommended:

• providing education and outreach services;

• addressing the social determinants of health with respect to injection drug use;

• expanding harm reduction services;

• providing accessible and adequate addiction treatment services; and

• supporting research on injection drug use and addictions to enhance understanding of the issue.⁴⁸

The At Risk report has not become a provincial strategy per se but it has served to build awareness and to provide direction. It is described as a "living document." Importantly, its two year developmental process itself enhanced awareness.

There are 13 Regional Health Authorities in Saskatchewan each having service responsibility for hospitals, health centres, wellness centres, social centres, supportive care, community health services, rehabilitation services and health promotion. Additionally, there are five AIDS Service Organizations in the province funded both by the provincial government (approximately $325,000) and PHAC through its AIDS Community Action Program. One of these organizations, AIDS Programs South Saskatchewan, has been operating and providing information and support for 19 years.

Coordination and Cooperation

The Saskatchewan Advisory Committee on HIV/AIDS provides a forum for cooperation and coordination across agencies. The provincial Department of Health has a good working relationship with the PHAC regional office but few links to Correctional Service Canada.

There are community-based AIDS service organizations in Regina, Saskatoon and Prince Albert that serve both those communities and their surrounding areas. Ensuring a reasonable level of service consistency across the province's Regional Health Authorities is a challenge although this structure does enable local authorities to tailor their response, to HIV/AIDS and other conditions, to the needs and circumstances of their local area. Consistency is also an issue in the relationship between the community HIV/AIDS organizations and the Regional Health Authorities.

In Regina and Prince Albert, the community organizations, municipal authorities and two orders of government are said to work well together, responding quickly and effectively to new issues as they arise. This partnership is said to be less well developed with the Regional Health Authorities outside of the province's main centres, perhaps a reflection of the epidemic's geographic concentration. Certain key informants also suggested that the political organizations representing Aboriginal people in the province - unlike the Aboriginal community groups - are not significantly or sufficiently engaged in AIDS-related efforts.

Testing, Prevention, Care and Treatment

Saskatchewan tests pregnant women as part of their prenatal care regimen using an opt-in model for consent.

As of 2002, there were well-established needle exchange programs in Regina, Saskatoon and Prince Albert as well as new ones in Moose Jaw and Ile a la Crosse. The Saskatoon program had about 500 registered clients, 50% of whom were women, and provided its services through both a fixed site and a mobile unit. The Regina program had approximately 430 clients in 1999 while the Prince Albert program had slightly over 500 clients. In 1999, the programs distributed approximately 600,000 needles.⁴⁹ In response to the province's At Risk report, Saskatchewan recently expanded its methadone program with the number of prescribing doctors increasing from 6 in 1997 to 17 in 2000. The program's capacity expanded from 20 clients in 1996 to 550 in 2000.

In Regina, the Saskatchewan All Nations Hope AIDS Project - developed initially as part of AIDS Programs South Saskatchewan - now has an independent Board and operates autonomously. It has received both provincial and ACAP funding for local projects in Regina and Prince Albert as well as for projects that are provincial in scope. It has undertaken work related to both hepatitis C and HIV/AIDS in correctional institutions. The two Regina organizations are also participating, along with the Regina Health Region and the municipal government, in the South Saskatchewan Harm Reduction Initiative.

Knowledge

The Regina and Prince Albert Health Districts, along with Saskatchewan Health and PHAC, have undertaken studies "to define the burden of these public health problems [HIV and hepatitis C] in this risk group and to help guide the development and refinement of prevention policies and programs."⁵⁰ The studies provided some important insights into the group of people injecting drugs, finding for example that in Regina:

• only 30% of the subjects had completed high school or pursued higher education;
• 96% reported "fairly stable housing conditions;"
• 73% relied upon welfare as their primary source of income;
• 32% were currently supporting children;
• 37% had lived outside of Saskatchewan during the past five years; and
• 20% were using methadone at the time of the study.

About 44% of the sample reported using borrowed equipment and using condoms only infrequently when with regular or casual partners. A large percentage reported histories of family dysfunction, childhood abuse, learning disabilities and suicidal thoughts or attempts. Eighty percent reported alcohol abuse and most had engaged in some criminal activities. The Regina study led to important policy considerations, for example:

• programs must address the underlying determinants of health if they are to be successful;
• the Aboriginal population must be involved in planning and delivering new programs in order to ensure they are culturally appropriate;
• different program models are required for men and women, in part because of the latter's responsibility for their children and in part because of their greater incidence of abuse both as children and as adults; and
• needle exchange programs need to be expanded and decentralized.⁵¹

The Regina study also recommended efforts to move the community effort "upstream" in order to prevent drug use. This last conclusion was strongly supported by the Prince Albert study which found that 12% of IDUs had begun injecting between the ages of 10 and 14 years and another 41% between the ages of 15 and 19 years.⁵²

Strengthening the Effort

Key informants and other sources suggested the following measures to strengthen the province's response to HIV/AIDS:

• adopt a "multifaceted, intersectoral approach ... to build capacity and foster collaboration between communities and governments ... The key to long-term prevention of blood-borne diseases is the willingness of all stakeholders to address the determinants of health underlying injection drug use."⁵³
• more fully involve a broader range of Aboriginal organizations in the effort to address HIV/AIDS.
• shift "new health funding from acute care to prevention, from technology and salaries and wait lists to addressing the root causes of disease."
• rebuild public awareness and political will given that HIV is no longer "new or news."
• integrate HIV with other efforts to address blood-borne pathogens in order to raise its profile and since we are "past the time of treating it as a separate issue."
  

 

3.5 Manitoba

Surveillance Highlights

• in contrast to national trends, the number of newly reported cases of HIV infection has increased significantly over time, from 51 cases in 1995, to 70 in 2002 and 111 in 2003.
• in 2003, 81 of the 111 (73%) newly reported HIV+ cases were in Winnipeg. Similarly, six of the 12 new AIDS cases reported in Manitoba were in Winnipeg with the geographic location of the other six cases being unknown.
• in 2003, women represented 36% of all newly reported cases. Aboriginal people represented 27% of all cases for whom ethnicity was identified while African people represented 23% and Caucasians 19%.
• MSM represented only 11% of all newly reported HIV+ cases for whom the exposure category was known in 2003. IDU represented 17%, heterosexual contact 28% and endemic countries 20%.
• incidence among the Winnipeg IDU population has increased significantly, from 9% of all infections in the period 1986-1990 to 31% in both 1998 and 2002.
• there are nearly as many female as male injection drug users in Winnipeg and a disproportionate number are Aboriginal.⁵⁴

Manitoba⁵⁵

Indicator	Year
	2003	2002	2001	2000	1995
AIDS Cases
Number of AIDS cases reported by year	12	13	9	7	16
Cumulative number of AIDS cases reported	224	212	199	190	141
Newly reported AIDS cases by sex
male	7	11	7	7	15
female	5	2	2	0	1
Newly reported AIDS cases by exposure category
MSM	0	3	0	3	12
IDU	6	5	2	1	1
MSM/IDU	0	1	0	0	0
Heterosexual contact	3	4	5	3	1
Blood Products	1	0	0	0	1
Endemic	1	0	2	0	1
NIR	1	0	0	0	0
Newly reported AIDS cases by age
0-19	0	0	0	0	0
20-39	8	8	4	2	14
40-49	3	4	3	3	0
50+	1	1	2	2	2
AIDS-related deaths	3	5	6	7	13
HIV Infection
Total number of newly reported HIV cases	111	70	65	57	51
Newly reported HIV cases by exposure category
MSM	12	10	10	13	15
MSM/IDU	4	0	1	1	4
IDU	19	22	23	16	14
Heterosexual contact	31	21	19	21	13
HIV/AIDS-endemic countries	22	11	5	4	4
NIR	22	4	5	2	1
Recipient B/B products	1	2	2	0	0
Newly reported HIV cases by sex
Men	71	41	39	38	42
Women	40	29	26	19	9
Newly reported HIV cases by ethnicity
Aboriginal people	31	27	27	23	N/A
Asian	4	5	1	2	N/A
African	25	10	8	4	N/A
Caucasian	21	19	18	21	N/A
Other	3	1	0	1	N/A
Unknown/Missing	27	8	11	6	N/A
Newly reported HIV cases by age
<15	4	1	0	0	0
15-19	0	3	0	2	1
20-29	27	14	13	19	21
30-39	48	30	30	20	21
40-49	25	12	9	10	6
50+	7	10	13	6	2

Organization

In 1996, the Government of Manitoba adopted a Provincial AIDS Strategy incorporating a population health philosophy and committing to "services that are readily accessible closer to home."⁵⁶ Communities were to be responsible for assessing need and determining who would provide what services while the provincial government would be responsible for integrating services, setting standards, developing policy and for monitoring outcomes. The Strategy's goals were:

• to reduce the spread of HIV infection;
• to provide a continuum of compassionate prevention, care, treatment and support programs for persons at risk of and infected/affected by HIV/AIDS; and
• to facilitate the planning, delivery and evaluation of all programs and efforts to ensure that they are guided by a population health philosophy.⁵⁷

The Strategy also included a statement of principles that emphasized targeted efforts, reasonable accessibility, a continuum of services, coordination and integration, client centred services and confidentiality, human rights, community development and health promotion, and consistency with the Canadian Strategy on HIV/AIDS. Importantly it also recognized the special needs of Aboriginal people and prepared, in 2001, a harm reduction discussion paper to broaden the discussion around the epidemic.

Manitoba also has a Sexually Transmitted Diseases Control Strategy that can have "important implications for HIV prevention"⁵⁸ particularly since the province has some of the highest rates in the country for certain sexually transmitted infections. The chlamydia rate, for example, is 275 (/100,000) compared to a national average of 130 while for gonorrhoea it is 54.2 compared to 16.7. Manitoba intends to integrate its HIV/AIDS-related efforts with those relating to hepatitis C and other sexually transmitted infections. Some believe this approach will assist in bringing attention to this epidemic.

It has been suggested that the AIDS strategy has been limited in that there are not dollars specifically attached to it. Manitoba Health funds the eleven regional health authorities to provide direct service to their residents. The availability and accessibility of HIV/AIDS-related services varies greatly throughout the province with the majority of services available only in Winnipeg. Manitoba Health has a limited budget for special projects related to HIV/AIDS, STIs and hepatitis C.

Service delivery and planning for services is the responsibility of the regional health authorities. The Winnipeg Regional Health Authority has been most active, a reflection of the fact that over 80% of those living with HIV/AIDS live in that region. It has also been suggested that public awareness, interest and commitment - particularly outside of Winnipeg - has diminished over the years due to the relatively low number of HIV cases and competing priorities.

Coordination and Cooperation

In 2002, the Manitoba government acknowledged that to be effective, its HIV/AIDS-related efforts and issues have to become a "key component of not only health programming but also [of] the programs and policies of justice, education and social service organizations across the province."⁵⁹ In November 2003, Manitoba Health became co-chair of the Manitoba Harm Reduction Network (MHRN). The MHRN is supported by both provincial and federal funding sources.

The MHRN is a diverse network of people involved in reducing the incidence of sexually transmitted infections and blood borne pathogens while its focus is to improve access to services for individuals and communities at elevated risk of infection. The MHRN has created specific task groups on Policy, Support and Basic Needs, Education and Outreach. It intends to meet annually to set priorities for action and to evaluate past initiatives.

Manitoba Health works closely with both the national and the regional offices of PHAC and Health Canada. PHAC, for example, funds a Field Surveillance Officer who works alongside provincial staff to enhance, compile and analyze surveillance and epidemiological data. Other cooperative initiatives include:

• the Manitoba Corrections Knowledge Attitude and Behaviour Study that is currently in the developmental stage; and
• a partnership between Manitoba Health and Manitoba Corrections to implement a Public Health Nurse Pilot Project in five of the province's correctional institutions.

At the community level, the Manitoba AIDS Cooperative brings together 15 AIDS Service Organizations to advocate for funding and for consistency across health regions.

Testing, Prevention, Care and Treatment

Between 1996 and 2002, almost 170,000 HIV tests were conducted in the province, ranging from 17,300 in 1996 to over 29,000 in 2002. The majority of both men and women being tested were between 20 and 39 years of age. Manitoba provides prenatal testing using an opt-out model. A working group is currently in the process of expanding testing options to include nominal and anonymous HIV testing.

The Regional Health Authorities and community-based organizations have undertaken a variety of prevention and harm reduction initiatives. One study, however, suggested that 30% of IDU respondents have difficulty obtaining needles at least some of the time because of their cost, the refusal of some pharmacies to sell them or the inaccessible location of needle exchange programs.⁶⁰

There is also a broad range of services available to those living with HIV/AIDS, particularly in Winnipeg. These include a 12-unit housing complex, a series of educational workshops for social services and housing staff, a faith-based hospice targeted to those using injection drugs, various supports for street involved persons and a good network of services for street youth. The Nine Circles Community Health Centre, for example, may be unique in Canada in terms of the comprehensive array of clinical, advocacy and support, transportation, child care and other services it provides for those living with HIV/AIDS. Kali Shiva AIDS Services, the Ma Mawi Wi Chi Itata Centre, the Manitoba AIDS Hospice, the Northern AIDS Initiative and the Rainbow Resource Centre, among others, also provide an array of supports including non-medical home care, a women's program, a "kids club" and various activities for youth.⁶¹

Many HIV/AIDS-related drugs are covered by the provincial drug program although the deductible may be problematic for the working poor. Some respondents indicate that the process for placing new drugs on the formulary is very slow.

Knowledge

It has been suggested that the academic research and epidemiological data being analyzed in Manitoba are useful for community purposes although very often they do "not drill down far enough" and are not available in a timely manner. Community agencies often witness trends a year or two before they are represented in the data and research. Key informants suggest that cohort and other such studies are needed to explore behavioural issues, and that community groups should be more fully engaged in the research process.

Strengthening the Effort

A variety of key informants have suggested that the following could strengthen the province's effort to address the epidemic:

• adopt a harm reduction philosophy to address the needs of those unable to abstain from injection drug use, and enhance the availability of injecting equipment.
• enhance the availability of additional treatment and support services.
• provide additional funding and resources to pursue the policies outlined in the provincial Strategy; include mechanisms to encourage cooperation and an accountability system that is not unduly onerous.
• place more emphasis on primary prevention including better links between education and health, and greater emphasis on marginalized populations everywhere in the province including Winnipeg.
• develop better accountability tools to ensure that funds are being used in the most effective manner possible.
• enhance public awareness and encourage political commitment.

3.6 Ontario

Surveillance Highlights

• over 22,000 persons were living with HIV/AIDS in Ontario in 2003. HIV prevalence has increased by 6% annually through the past five years.
• the number of newly diagnosed HIV-positive cases increased in 2002 and 2003 from an average of 1000 new diagnoses per year (1997-2001) to 1233 (2002) and 1217 (2003).
• 29% of new HIV diagnoses in 2003 were among women, a dramatic increase from the 2% observed after HIV testing began in 1985 and the 20% in the late 1990s. Men who have sex with men, however, remain the largest proportion of new diagnoses for which the exposure category has been identified, at 51%.
• since 1997, HIV prevalence rate has increased by 90% among persons from HIV-endemic countries.
• it is estimated that only 64% of the 22,100 HIV-infected persons in Ontario have been diagnosed, leaving about 7,950 who do not know they are infected.⁶²
• it is suggested that some HIV/AIDS-related deaths are being attributed to other causes and hence not being identified in the epidemiological data.

Ontario⁶³

Indicator	Year
	2003	2002	2001	2000	1995
Prevalence Estimate64	> 22,100	22,100	21,700	20,600	15,800
AIDS Cases
Number of AIDS cases reported by year	119	123	157	132	608
Cumulative number of AIDS cases reported	7,514	7,395	7,272	7,115	5,930
Newly reported AIDS cases by sex
male	91	98	129	115	562
female	28	25	28	17	46
Newly reported AIDS cases by exposure category
MSM	44	45	66	60	406
MSM/IDU	0	3	4	4	31
IDU	10	13	12	16	32
Heterosexual contact	26	29	23	22	65
HIV Endemic	31	31	30	18	27
Clotting Factor/Transfusion	1	0	3	3	20
NIR/occupational	6	8	12	5	20
Perinatal	1	3	1	3	7
Total number of AIDS cases by age	1981-2003	2002
<15	77	2
15-24	257	2
25-44	5,467	76
45-59	1,457	26
60+	254	3
Unknown	2	0
AIDS-related deaths		21	46	50
HIV Infection
Number of newly reported HIV cases	1,217	1,233	1,017	938	1,360
Newly reported HIV cases by exposure category
MSM	266	316	222	251	359
MSM/IDU	5	4	8	13	19
IDU	36	39	36	42	75
Recipients of Blood	3	3	4	9	10
Recipient of clotting factor	2	0	2	2	10
HR/LR Heterosexual	131	135	121	95	108
HIV/AIDS-endemic countries	46	47	36	30	19
NIR/Other	700	655	558	466	736
Perinatal	28	34	30	30	25
Newly reported HIV cases by sex
Men	852	878	733	686	1,080
Women	346	325	253	203	221
Unknown	19	30	31	49	59
Newly reported HIV cases by Age	1985-2003
<1 year	544	79	52
1-14 years	191	9	7
15-24 years	2,090	113	84
25-39 year	13,357	625	517
40-59 years	5,767	352	275
60+	462	29	37
Unknown	2,323	31	41

Organization

The first Ontario HIV/AIDS Strategy was developed in 1994-1995 and was intended to serve until 2001. It proved useful as a touchstone for decision-making within government and for providing direction to community agencies.

In June 2002, the Ontario Advisory Committee on HIV/AIDS (OACHA) proposed a new strategy for the province covering the period to 2008. This strategy was an attempt to respond to the changes in "our ability to treat HIV, the course of the disease, the public and media attention given to HIV, and the spread of the virus."⁶⁵ It proposed two goals - namely, to prevent the spread of HIV and to improve the health and well-being of people living with HIV and their communities - as well as four policy directions:

• adopt a determinants of health approach and address social justice issues;
  
• focus on long-term, integrated, sustainable, targeted responses;
  
• develop a flexible provincial response to HIV that takes into account local/population needs; and
  
• improve Ontario's capacity to respond effectively through improved monitoring and accountability.⁶⁶

The proposed Strategy also incorporates five elements. The first involves enhanced knowledge while the second emphasizes fostering leadership that will pursue an integrated approach to HIV prevention, support, care and treatment based on the determinants of health. A third endeavours to ensure access to prevention, support, care and treatment services. The remaining elements emphasize adequate resources and accountability.

In 2001-2002, the Ontario government spent approximately $50 million to support HIV-related services, not including physician costs, drug programs, in-patient hospital services, home care services and palliative care services. Many community-based AIDS organizations receive funding not only from the Ministry of Health and Long-Term Care but also from municipalities, the federal government and private sources.⁶⁷

The province's AIDS Bureau is responsible for co-ordinating the Ministry's response to HIV. In many ways, it is the entry point to the Ministry and provides central coordination through its efforts to work bilaterally with the branches responsible for laboratories, public health, addictions and Aboriginal health. It also serves as the OACHA secretariat, provides funding for community groups and for research activities, monitors anonymous HIV testing, and helps to develop policy. There is not an interdepartmental committee on HIV/AIDS although ad hoc groups are established as required to address specific issues.

In addition to the AIDS Bureau, the Ministry's Public Health Branch, Central Public Health Laboratories Branch, OHIP, drug programs and others have some responsibility for funding HIV/AIDS-related services. OACHA suggests that while this approach promotes integration and the mainstreaming of HIV/AIDS-related services, it also means that:

• decisions about the funding and management of certain HIV programs are made by those for whom HIV may not be a priority.⁶⁸

The OACHA report provides a useful assessment of the Ontario efforts to date. This assessment is presented in Table 3.

Table 3, OACHA Summary of Perceived Strengths and Weaknesses

Type of Service	Strengths	Weakness
Prevention	diversity, variety and comprehensiveness of prevention programs	fragmentation of services, lack of co-ordination among HIV/AIDS programs and between HIV programs and other services
	availability of anonymous testing	lack of sustained, high-profile information campaign, lack of focus on the determinants of health, lack of services in rural areas, and lack of education for youth
	community expertise
Care and Treatment	comprehensive care provided by HIV clinics; effective collaboration among clinics	lack of services in rural areas and for marginalized populations
	Trillium and ODB willingness to cover new drugs	impact of hospital restructuring
		restrictions on CCAC services
	clinical care infrastructure	lack of rehabilitation services
		lack of co-ordination across services
		timeliness within the Trillium Drug Program
		lack of addiction/methadone services and mental health services, and of services for people in prisons
Support	availability of comprehensive programs in urban centres	lack of services in rural areas, of affordable housing and focus on social determinants
	strong social safety net	lack of outreach services,workplace support, mental health services and other social services
	support provided by the AIDS Bureau
Research	strong research infrastructure	lack of collaboration among researchers
	high calibre of research/teams	lack of research in key areas
	the public health laboratory system	lack of a global research strategy

The OACHA work is complemented by an Ontario Aboriginal HIV/AIDS Strategy covering the period from 2001 to 2006.

Public health services in Ontario are delivered through 37 local public health units that are overseen centrally. Monitoring allows for a degree of consistency in terms of services provided while still permitting the flexibility that is required to respond to local health needs.

Coordination and Cooperation

Ontario works closely with PHAC and Health Canada on HIV/AIDS-related efforts, at both the regional and national levels. The relationship is particularly close and effective at the regional level where the intergovernmental culture emphasizes that they are partners in a common effort. The two governments, for example, will make common visits to funded agencies, share information both formally and informally, and periodically fund projects jointly. They are currently working on a common reporting mechanism designed to reduce the administrative workload of community agencies while maintaining accountability requirements.

There is a sexual health component in the public school system but this is very much the responsibility of the Ministry of Education and local school boards, and was developed and is delivered without any significant involvement by the Ministry of Health and Long-Term Care.

Although the intra-governmental links with public health and the different public health units around the province are not strong, the latter play an important role through public education and contact tracing. Their obligations in this regard are outlined in a Mandatory Health Programs and Service Guidelines that includes goals and standards. It also links STIs with HIV/AIDS.⁶⁹ The level of cooperation between community agencies and local health authorities can differ dramatically from location to location.

Testing, Prevention, Care and Treatment

Prenatal testing for HIV, using an opt-in model, is an important component of the provincial effort and the Ontario experience with this testing speaks to the importance and impact of careful follow-up with physicians. Ontario introduced prenatal testing in January 1999 and saw testing uptake increase from 41% to 48% in the first six months. This was followed by gradual improvement in the subsequent two years, to 60% in the second quarter of 2001. In September 2001, the HIV Laboratory began sending a memo with each prenatal test result for which an HIV test had not been ordered reminding the physician that an HIV test is recommended. This appears to have had a substantial impact, increasing HIV test uptake to 89% by the end of 2003. Other Ontario initiatives in this regard include the real-time monitoring of test uptake in pregnancy with updates to Medical Officers of Health and communication campaigns targeted to physicians and women. This prenatal testing has enabled Ontario to identify 186 HIV-infected pregnant women of whom 139 had not been previously diagnosed.⁷⁰

Generally, there are public health and community-based HIV/AIDS services in most of the province's regions. At the same time, however, there is a lack of clinical services for people living with HIV/AIDS in the Northwest as well as in the Guelph/Kitchener/Waterloo and Peel regions. There is also a significant physician shortage in the province, and great concern that with retirements looming over the next five years, there may be a crisis in physician care for people living with HIV/AIDS.

Nevertheless, a number of significant services have been developed through the past five to seven years, including:

• the Trillium Drug Program, an income-based program that provides drug coverage for people with disproportionately high drug costs;
  
• 25-30 needle exchange programs, some with mobile vans;
  
• 33 anonymous testing sites, prenatal testing for HIV and an infant formula program;
  
• both on and off-reserve agencies are funded to address HIV/AIDS issues within the Aboriginal community; and
  
• supportive housing and McEwan House.⁷¹

Ontario has had some success through the development of strategies for each of its high risk populations. These are as follows:

1. African and Caribbean Council on HIV/AIDS
   
   The African and Caribbean Council on HIV/AIDS in Ontario (ACCHO) is in the final preparation stages before launching the Strategy to Address Issues Related to HIV Faced by People in Ontario From Countries Where HIV is Endemic. The ACCHO Strategy is a framework to coordinate and guide action to address issues related to HIV faced by people in Ontario from countries where HIV is endemic. It will result in coordination of agencies, institutions and policy makers working with these populations; community development initiatives to strengthen the capacity of these communities to address HIV/AIDS issues; and the identification of research priorities and opportunities.
   
   
2. Ontario Aboriginal HIV/AIDS Strategy
   
   The Ontario Aboriginal HIV/AIDS Strategy (OAHAS) was developed in 1995 to direct HIV prevention, care, treatment and support work with off-reserve Aboriginal people in Ontario. The OAHAS was updated in 2000 as a strategic plan for the years 2001 to 2006. The OAHAS provides funding for a provincial coordinator and 7.5 HIV/AIDS workers located in strategic locations in the province. A reference group, composed of ministry and off-reserve Aboriginal representatives, oversees the implementation of recommendations contained within the OAHAS. The Strategy, controlled and implemented by Aboriginal people, has been successful at responding to the unique needs of Aboriginal people in a culturally appropriate way and raising the profile of HIV/AIDS in Aboriginal communities..
   
   
3. Injection Drug User Outreach Program
   
   In 1996/1997, Ontario enhanced existing outreach to injection drug users by introducing 15 new IDU outreach workers throughout the province. This enhancement contributed to a significant reduction in new HIV infections in this population, with the rates never returning to the levels seen prior to the enhanced outreach program. In general, the IDU HIV epidemic in Ontario has been stabilized and is decreasing, a trend that began after the introduction of enhanced IDU HIV prevention strategies.
   
   
4. Gay Men's HIV Prevention Summit and Working Group
   
   In March 2003, Ontario hosted the Ontario Gay Men's Prevention Summit, which brought together over 100 HIV stakeholders from across the province. The Summit resulted in a consensus of the need to move forward with a more cooperative, province-wide, centrally coordinated response to the HIV prevention needs of gay and bisexual men. A provincial working group was struck to formulate a new HIV prevention strategy for gay and bisexual men. At the same time, Ontario contributed to a federal campaign to reduce the spread of HIV amongst gay and bisexual men entitled, "How do you know what you know?" The campaign was coordinated by the AIDS Committee of Toronto and implemented throughout Ontario, resulting in the distribution of prevention materials and messages throughout the province and establishing a precedent in the province for the utility of a single campaign of relevance to men across an extremely diverse province.
   
   
   
   The ability of the broad array of community organizations to meet community needs has been compromised by the lack of funding increases from the province. Community organizations are operating with the same base funding they have had for 10-12 years in spite of many organizations seeing their caseloads double over the past five years.

Knowledge

The province has made significant investments in HIV research through the HIV Ontario Observational Database (HOOD), the AIDS Program Committee, the Ontario HIV Treatment Network (OHTN) and the AIDS Bureau funding for university-based research. The OHTN, for example, is a not-for-profit agency funded by the Ontario Ministry of Health and Long-Term Care. Its mission is "to optimize the quality of life of people living with HIV in Ontario and to promote excellence and innovation in treatment, research, education and prevention through a collaborative network of excellence representing consumers, providers, researchers and other stakeholders."⁷² It is a collaborative network bringing together people living with HIV/AIDS, health care providers, consumers, researchers, community-based organizations and government.

In addition to advising government, the OHTN allocates $8 million annually for research and a provincial HIV Information Infrastructure Project (HIIP) that endeavours "to improve treatment and care for people living with HIV in Ontario, and increase the security and enhance the management of personal health information through the use of information technology."⁷³ Importantly, HIIP is also a valuable research database with the potential to dramatically improve research linked to patient care.

The province, OACHA and community organizations all understand the relationship between health for those living with HIV/AIDS and social determinants such as poverty and inadequate housing. It is suggested that governments are not adequately addressing these health determinants.

Strengthening the Effort

Key informants and other sources suggested that the following would strengthen the provincial effort to address HIV/AIDS:

• commit additional attention and target efforts more fully to particularly vulnerable groups including Aboriginal people and people from countries in which HIV is endemic.
  
• address the complacency associated with HIV/AIDS that may be contributing to increasing HIV incidence. Enhance public awareness of and political commitment to HIV/AIDS particularly at the local level where efforts to address the epidemic must compete for local health funds.
  
• better integrate HIV/AIDS-related and other services while devoting greater attention to the social determinants and their contribution to HIV vulnerability.
  
• importantly, provide additional funding that will enable AIDS service organizations to catch up to increasing costs, to meet ever increasing need, to retain and adequately compensate their employees, and to achieve some measure of organizational stability.

Importantly key informants in Ontario suggested that the province should "strengthen what we are already doing."

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⁴⁶ 12 Saskatchewan, 2002:21; 19 Canada, 2003(c):19.

⁴⁷ 12 Saskatchewan, 2002:21.

⁴⁸ Saskatchewan, 2002:2.

⁴⁹ Saskatchewan, 2002:31.

⁵⁰ Saskatchewan Health, 2000:4. See also Saskatchewan Health, 1998.

⁵¹ Saskatchewan Health, 2000:5-6.

⁵² Saskatchewan Health, 1998:3.

⁵³ Saskatchewan, 2002:3.

⁵⁴ Elliott, 1999:iii.

⁵⁵ Key source is Manitoba Health, 2003. Data provided by Manitoba Health, AIDS Case and HIV Case databases. Data extracted, July 9, 2004. AIDS cases are reported by date of diagnosis.

⁵⁶ Manitoba Health 1995:8.

⁵⁷ Manitoba Health, 1995:13.

⁵⁸ Manitoba Health, 2001(a):3.

⁵⁹ Manitoba Health, 2002:2.

⁶⁰ Elliott, 1999:iv.

⁶⁶¹ See the Manitoba AIDS Cooperative at http://www.mts.net/~aidscoop/MAC_members.html.

⁶² Ontario Advisory Committee on HIV/AIDS (OACHA), 2002:6.

⁶³ Main sources are data provided by the Ontario HIV Epidemiologic Monitoring Unit, and Remis et al., Report on HIV/AIDS in Ontario, 2002, 2003.

⁶⁴ Estimates from Remis, 1998-2003.

⁶⁵ Ontario Advisory Committee on HIV/AIDS (OACHA), 2002:Preface.

⁶⁶ OACHA, 2002:9-10.

⁶⁷ OACHA, 2002:61.

⁶⁸ OACHA, 2002:61.

⁶⁹ See Ontario, 1997.

⁷⁰ Correspondence with the Ontario office of the Chief Medical Officer of Health.

⁷¹ OACHA, 2002:59.

⁷² See http://www.ohtn.on.ca/.

⁷³ See http://www.ohtn.on.ca.

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