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

A National Portrait

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Executive Summary

Introduction

Approximately 56,000 Canadians were living with HIV/AIDS at the end of 2002. The epidemic has been largely concentrated in four jurisdictions, with British Columbia, Alberta, Ontario and Quebec having 95% of all HIV positive test reports but only 85% of the Canadian population. Nevertheless, every jurisdiction has reported some cases and five jurisdictions reported more cases in 2003 than in 1995.

Overview by Jurisdiction**
Jurisdiction	Number of HIV+ Test Reports, 1985-2003	Number of HIV+ Test Reports, 2003	Number of HIV+ Reports/100,000 Population, 2003
Canada	55,180	2,482	8.27
British Columbia	11,552	436	11.16
Alberta	3,961	145	4.87
Saskatchewan	460	36	3.68
Manitoba	1,097	111	9.91
Ontario	24,408	1,104	9.68
Quebec	12,464	621	8.58
New Brunswick	313	9	1.23
Nova Scotia & PEI	626	4	0.38
Newfoundland & Labrador	221	19	3.70
Yukon, Nunavut and the NWT	78	6	6.47

Governments across Canada - federal, provincial and territorial - are responding to the epidemic in a manner appropriate to their circumstances. In January 2004, the Federal/Provincial/Territorial Advisory Committee on AIDS (FPT AIDS) initiated this project in order:

• to summarize the different jurisdictions' responses to the epidemic;
• to analyze issues of common concern; and
• to identify means for strengthening the Canadian response to the epidemic.

Research for the project included a review of both surveillance data and of government publications relating to the epidemic, as well as interviews with approximately 50 key informants, including both non-governmental organizations and government officials involved in the response to HIV/AIDS.

A Sound Foundation

The HIV/AIDS epidemic remains a serious problem for all jurisdictions in Canada, if not at present then most certainly in the future. In some jurisdictions with few new reports of HIV infection, for example, the incidence of sexually transmitted infections speaks to unsafe sexual practices that place people at risk of HIV infection. It is by no means assured that the decade of declining incidence will continue into the future.

Nevertheless all jurisdictions have a sound foundation in place for addressing the current epidemic. Most have articulated a comprehensive, sound and well-considered strategy that provides direction to stakeholders. Some non-government HIV/AIDS stakeholders have identified lack of dedicated funding and measurable objectives or accountability requirements as challenges.

Invariably, jurisdictions are monitoring the epidemic and attempting to improve their surveillance and reporting systems. Public health delivery systems endeavour to ensure partner notification and are promoting awareness of HIV/AIDS and of sexual health in their schools and among their vulnerable populations. Jurisdictions include HIV testing as part of their prenatal screening programs - using either an opt-in or opt-out model - and may have nominal, non-nominal and sometimes anonymous testing available.

Additionally, all jurisdictions have some projects and organizations in place - some with federal rather than provincial or territorial funds - to reduce vulnerability and harm, and to provide care and support. In some jurisdictions, the different government and community stakeholders are working together to define priorities and allocate resources. In some jurisdictions also, stakeholders are endeavouring to find ways to transcend the boundaries that currently compromise efforts to bring a seamless array of services and supports to Aboriginal people.

Treatment is available everywhere in Canada and mechanisms are in place to ensure that physicians have access to the advice and support they need in order to provide quality care. The goal is to ensure that people - marginalized or mainstream - receive good care regardless of who they are and where they live. The key problems that have not been resolved anywhere are:

• the reluctance of many small communities to acknowledge there is a problem and to introduce measures to educate and prevent; and
• the challenge of reaching certain marginalized populations and effecting behavioural change.

Furthermore, after two decades of experience, there is a good understanding of what is needed to effectively address the epidemic, for example particular treatment regimens, community partnerships, culturally appropriate services, targeted prevention efforts sustained through the long term, a variety of harm reduction initiatives, a focus on vulnerable populations and efforts to overcome the stigma associated with HIV infection.

Most jurisdictions also understand the importance of a population health model and a human rights framework for effectively preventing HIV infection through the long term. This is not to say, however, that this model or framework is in place everywhere in Canada or that all jurisdictions are acting on the knowledge they have. Key informants highlighted the need for heightened public awareness, increased resources and re-energized leadership to address the epidemic.

Themes

A number of important themes emerge from the provincial and territorial pictures. The provincial and territorial pictures speak to the importance of each jurisdiction having the latitude to respond to the epidemic in a manner that reflects the local situation and local trends. These pictures illustrate that there is not one epidemic in Canada but rather several epidemics. First, there is one epidemic in the four largest provinces where a very significant number of people are living with HIV/AIDS. Here, governments have committed significant resources to support a broad range of prevention, harm reduction, care, treatment and support services, although key informants indicated that these were not adequate in all jurisdictions. In the other jurisdictions, the commitment of resources is much smaller and the range of services more limited.

Furthermore, the national portrait shows how the epidemic's character differs across jurisdictions. Men who have sex with men (MSM) remains the largest exposure category while the injection drug use (IDU) exposure category continues to be significant. Infections among people from HIV-endemic countries are more common in some jurisdictions than in others. The proportion of men to women who were diagnosed as HIV positive in 2003 differs from jurisdiction to jurisdiction. In one jurisdiction, for example, the ratio is 2:1 while in certain others it is 7:1.

Importantly, even within a single jurisdiction, there are distinct differences in the epidemic across regions. In Quebec and Manitoba, for example, the epidemic is largely concentrated in Montreal and Winnipeg respectively. In Alberta, the epidemic in Edmonton is largely in the IDU exposure category and involves Aboriginal people while in Calgary it is largely in the MSM category and involves non-Aboriginal people.

The regional differences in the epidemic speak to the role of regional or local health authorities that have the responsibility for planning the response to the epidemic and for providing services in most jurisdictions. These organizations are well positioned to identify and respond to local needs. There is, however, a perception that the epidemic may not be a priority for some health authorities, and that there is a need for strengthened accountability, enhanced coordination and integration at the regional level.

The provincial and territorial pictures also illustrate the importance of working in partnership, across departments, across governments and across government and community sectors. In some jurisdictions, there is a strong relationship and even a partnership between the provincial/territorial government, the regional offices of the Public Health Agency of Canada and Health Canada, and their community partners. There are similarly strong relationships between the Public Health Agency and provincial/territorial offices responsible for gathering and analyzing epidemiological data.

There appears to be a less strong relationship, however, among those agencies responsible for correctional services and those more directly responsible for health and HIV/AIDS, or among those agencies having responsibility for the health of Aboriginal people on and off reserve. Key informants also raised the issue of community partners needing additional resources to respond to an increasing number of people living with HIV/AIDS and to their enlarged realm of responsibility.

A recurring theme across the country was that there is a need to build public awareness of and to renew and further enhance political commitment to HIV/AIDS. In essence, HIV/AIDS risks falling off the policy map as a result of the declining number of new infections, the small number of people living with HIV/AIDS in certain jurisdictions, the misconception that HIV/AIDS is now curable, and the emergence of new priorities. These factors have been compounded by the epidemic affecting primarily marginalized populations and inner city neighbourhoods, neither of which elicit a great deal of public attention and public concern.

Strengthening the Canadian Effort

The provincial and territorial pictures, taken together, suggest means for building on the existing, sound foundation in order to strengthen the Canadian effort to address the HIV/AIDS epidemic.

First and foremost, efforts are needed to promote public awareness and concern, and "to put HIV/AIDS back on the public radar." Such efforts might include national awareness and education campaigns and the broader and more timely dissemination of surveillance and epidemiological information. They could also involve efforts to integrate HIV/AIDS with campaigns directed at other blood-borne pathogens and sexually transmitted infections. Integration may serve to place HIV/AIDS within a broader public health and perhaps population health context.

Second, it is important to continue to enhance political commitment as well as leadership that will champion efforts to address the epidemic in a vigorous and comprehensive manner. Political commitment and leadership are vital for:

• promoting public awareness, providing clear direction, dispelling stigma and preventing discrimination;
• providing the resources needed to build, disseminate and apply new knowledge, to effectively prevent the epidemic's spread, and to provide appropriate care, treatment and support; and
• ensuring that prevention, treatment, care and support efforts are available to all people everywhere in Canada.

Third, there is a need in Canada to shift public awareness and government spending from the treatment of disease to population health, and from short-term palliatives to long-term solutions. Efforts to promote population health - for example, by better protecting children from violence or through adequate housing - are the key to preventing HIV infection in the future. Controlling the epidemic requires efforts to address the very roots of HIV vulnerability.

Fourth, effectively managing the epidemic will require efforts to build greater cooperation and more effective partnerships across governments and across sectors, for the purpose of planning, delivering and funding programs. Inherent in this are efforts to strengthen and stabilize the community organizations that, at present, are struggling to cope with ever increasing needs and numbers, and with an increasingly broad range of issues and responsibilities. Inherent in this also are efforts to address the stigma still evident in small communities and to overcome the conservatism surrounding sexual health education and harm reduction.

HIV/AIDS is a complex disease and an ever-changing epidemic. Through the past decades, governments in Canada have built a strong foundation for addressing both the disease and the epidemic. But commitment to doing so has faded over time as other priorities emerged. A renewed commitment to action through cooperative partnerships is now needed, everywhere in Canada, if Canadians are to effectively address the epidemic.

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**Data for the Number of HIV+ Test Reports 1985-2003 and the Number of HIV+ Test Reports 2003 are from Health Canada, Surveillance Report to December 31, 2003:23. Due to reporting delays and other factors, these data may differ from those provided by the provinces and territories in the jurisdiction-specific sections.

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