Canada's Report on HIV/AIDS 2004

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3e Strengthening Canada's Capacity to Address HIV/AIDS

Canada's capacity to respond to the HIV/AIDS epidemic has grown dramatically since the first AIDS case was diagnosed more than 20 years ago. However, changes in the epidemic and a broadening of the scope of HIV/AIDS-related issues require Canadian organizations and individuals working in this field, as well as those living with HIV/AIDS, to continually update their knowledge and skills.

HIV/AIDS Organizations Strengthen Their Capacity

CIDPC and the regional offices invested $14.8 million in 2003-2004 to help hundreds of organizations across Canada engage in the response to HIV/AIDS and contribute to the goals of the CSHA.

The largest portion of this funding was administered by the AIDS Community Action Program (ACAP), which provided $8 million to support the operations and projects of more than 100 community-based organizations across Canada. This funding was administered through regional offices (Atlantic Region, Quebec Region, Ontario and Nunavut Region, Manitoba and Saskatchewan Region, Alberta and Northwest Territories Region and British Columbia and Yukon Region). Organizations funded by ACAP may also receive financial support from other sources, including the private sector, municipal/provincial/territorial governments and/or regional health authorities.

During 2003-2004, further progress was made toward increasing the regional offices' capacity to measure specific outcomes from ACAP funding, which community-based organizations use to deliver prevention programming, create supportive environments, promote improved health for people living with HIV/AIDS, and strengthen their operations. ACAP staff in the Public Health Agency of Canada's regional offices are working closely with DPED to develop an evaluation framework that includes a logic model, indicators and a performance measurement strategy. The framework will be validated in the next fiscal year, and appropriate tools will be developed for collecting output and outcome data from across Canada. The evaluation framework will assist ACAP in presenting a concise, accurate and results-based description of the program logic for stakeholders and clients, and the collection of reliable data will lead to more responsive programming based on a solid evidence base.

National NGO partners in the CSHA received funding of $2 million in 2003-2004 to help ensure that HIV/AIDS issues were addressed in a strategic, multi-sectoral, collaborative way. This funding supported NGOs in the areas of program delivery, organizational development and relationship building between national, provincial and local organizations and governments.

FNIHB invested $1.1 million of CSHA funding and $2.5 million of non-CSHA funding to provide HIV/AIDS education, prevention and related health care services to on-reserve First Nations people and Inuit throughout Canada. CIDPC provided an additional $1.2 million to support HIV/AIDS programming in non-reserve Aboriginal communities, bringing the total federal investment in strengthening the capacity of Aboriginal communities to $4.8 million in 2003-2004.

DPED received $100,000 from the CSHA to provide expertise in evaluation and performance measurement. DPED continues to work with CIDPC and others to update and strengthen the CSHA's evaluation strategy. In 2003-2004, a synthesis evaluation was completed that examined 165 evaluations and similar studies undertaken in Canada between 1998 and 2003. The goal of the evaluation was to assess possible conclusions about the outcomes, impacts and cost-effectiveness of HIV/AIDS-related projects in Canada; to assess which methodologies might be most appropriate for evaluating HIV/AIDS-related projects; and to identify both potential improvements in the CSHA's evaluation strategy and further research needs. CIDPC is now integrating the findings of this report with other research to improve its HIV/AIDS programming.

CSHA Funding Streams Support Capacity Development

CIDPC administers a number of CSHA funding streams that contribute to capacity development.

The National HIV/AIDS Capacity-Building Fund supports projects that strengthen the capacity of staff and volunteers across Canada working in areas related to HIV/AIDS. A total of nine projects were funded in the 2002-2004 period. These included Canada's first multi-sectoral national forum on rehabilitation in the context of HIV, organized by the CWGHR in partnership with the Canadian Association of Occupational Therapists and the Canadian Physiotherapy Association. The forum, held from January 31 - February 1, 2004, brought together more than 80 stakeholders from across the country to exchange ideas, develop new knowledge and build their capacity to respond to the diverse rehabilitation needs of people living with HIV. The CWGHR subsequently published Breaking New Ground: Report on the National Forum on HIV and Rehabilitation, as well as a DVD of the forum proceedings, including presentations by key stakeholders and benchmarks for learning about rehabilitation developed at the forum. In a separate project, St. Michael's Hospital in Toronto received funding to increase the capacity of community-based organizations across Canada to identify people living with HIV/AIDS who are suffering from depression and to make appropriate interventions and referrals. This project was undertaken in collaboration with the Ontario Ministry of Health and Long-Term Care and the Ontario AIDS Network.

The Best Practice Models for the Integration of HIV Prevention, Care, Treatment and Support Fund continued to support the development of best practice models of initiatives that integrate HIV prevention and support for people living with HIV/AIDS. For example, CAAN received funding to develop a best practice model for HIV/AIDS prevention outreach to Aboriginal youth. Project outcomes included the publication of a report entitled HIV/AIDS Prevention Messages for Canadian Aboriginal Youth and a dialogue between national Aboriginal youth organizations and other key stakeholders. This project, the findings of which were disseminated through CAAN's web site and various Aboriginal organizations across Canada, has helped to minimize the adverse impact of HIV/AIDS on individuals and communities, as well as the impact of socio-economic factors that increase individual and collective risk. In another project supported by this fund, the University of Ottawa documented best practices used by the Ottawa Inner City Health Project to reduce the impact of HIV/AIDS on the homeless by helping HIV-positive clients access treatment and by supporting clients at risk of contracting HIV. Among other activities, a training module was developed for front-line shelter/housing staff to support HIV-positive clients in adhering to treatment regimes.

The Non-Reserve First Nations, Inuit and Métis Communities HIV/AIDS Project Fund provides funding for time-limited projects that enhance the capacity of non-reserve Aboriginal communities to address HIV/AIDS, promote sustainability and partnerships, and encourage Aboriginal agencies that do not currently offer services in this area to incorporate HIV/AIDS into their work. A total of 15 projects were funded in 2003-2004. Examples include a two-year initiative by the Labrador Friendship Centre in Happy Valley/Goose Bay to develop and deliver a culturally appropriate train-the-trainer HIV/AIDS prevention program and targeted prevention education workshops in Labrador. This project is building upon previous initiatives to heighten the awareness and willingness of Inuit and Innu communities in Labrador to address HIV/AIDS. As well, the Métis National Council in Ottawa received funding for "Following the Red Cart," a two-year project to develop and disseminate culturally appropriate HIV/AIDS prevention material British Columbia, Alberta, Saskatchewan, Manitoba and Ontario.

The Legal, Ethical and Human Rights Fund aims to support research, analysis, education and advocacy that focusses on the legal, ethical and human rights dimensions of Canada's response to HIV/AIDS. Projects funded in 2003-2004 included an initiative by the Canadian HIV/AIDS Legal Network to develop the capacity of the legal profession in Canada to respond to legal, ethical, and human rights issues related to HIV/AIDS. Activities included promoting the participation of law students and faculty in the Legal Network and other HIV/AIDS-related legal events; developing and distributing "HIV/AIDS and the Law" course modules for use in Canadian law faculties; and co-organizing and hosting an event to establish links between practising lawyers, law students, law faculty, community-based ASOs and people living with HIV/AIDS. As well, CAAN received funding for a project to reduce the vulnerability of Aboriginal people to HIV/AIDS. Among other initiatives, CAAN is developing a policy framework for Aboriginal communities to combat HIV/AIDS-related discrimination and sample antidiscrimination policies for implementation in Aboriginal organizations.

Building Individual and Community Capacity

Significant capacity-building work was done around the issue of disclosure of HIV status in 2003-2004, particularly in the aftermath of the Supreme Court of Canada's decision in the Williams case, the first criminal case dealing with exposure to HIV to reach the Supreme Court since the 1998 Cuerrier decision. In the Williams decision, the Supreme Court ruled that an HIV-positive individual who has unprotected sex without disclosing his/her status to a sexual partner who may already have been infected with the virus can be convicted only of "attempted aggravated assault," and not "aggravated assault." Immediately following the release of the decision in September 2003, the Canadian HIV/AIDS Legal Network and CAS prepared and disseminated an eight-page backgrounder on HIV Disclosure & the Criminal Law in Canada: Responding to the Media and the Public. The backgrounder provides community organizations with up-to-date, accurate information on HIV disclosure and Canadian criminal law, with the hope of fostering more balanced media coverage and public discussion of these issues.

CAS, in collaboration with the Legal Network and the AIDS Coalition of Nova Scotia, published a comprehensive guide entitled Disclosure of HIV Status After Cuerrier: Resources for Community-Based AIDS Organizations. The guide provides concise, accurate information and practical tools that help community-based AIDS organizations and people living with HIV/AIDS make informed and empowered choices about how to respond to the complex legal and ethical issues related to HIV disclosure. CAS held six workshops across Canada to present the guide, as well as a separate training session in Toronto to give participants from throughout the country the skills needed to conduct HIV-disclosure workshops in their own regions.

The Canadian HIV/AIDS Legal Network continued a three-year project to develop and implement an action plan to address HIV/AIDS-related stigma and discrimination in Canada. In October 2003, representatives of community-based ASOs, labour organizations and other social movements from across Canada met for a two-day workshop in Montréal to identify priorities for action. Drawing on input from the workshop, in November 2003 the Legal Network disseminated a draft Plan of Action for Canada to Reduce HIV/AIDS-related Stigma and Discrimination, seeking feedback and comments from its members, government officials and the general public. A revised Plan of Action will be released in the fall of 2004.

As a complement to this work, the Legal Network also undertook a one-year capacity-building project aimed at reducing stigma and discrimination at the local level. Participants from community groups across Canada exchanged information and experiences using an electronic discussion list and then attended a three-day workshop in Montréal in January 2004. The workshop provided participants with the opportunity to work through and share local action plans they had developed in relation to various models of community mobilization.

CATIE assisted its long-standing partner, Asian Community AIDS Services, with the delivery of peer treatment information training for staff and volunteers representing ethno-specific AIDS service agencies in Toronto. This partnership continues in 2004-2005.

The CWGHR delivered HIV rehabilitation workshops for physiotherapy and occupational therapy students, practising professionals, nurses and medical adjudicators for the Canada Pension Plan - Disability Program, and community-based organizations across Canada. CTAC also sponsored a number of skills-building events on topics such as cross-border Internet pharmacies (Toronto) and pharmacoeconomics (Vancouver).

FNIHB continued to support capacity building among on-reserve First Nations and Inuit people to ensure that they have the knowledge, skills and resources needed to prevent HIV transmission and to facilitate care for those infected with and affected by HIV/AIDS. For example, funding is provided to national Aboriginal organizations to explore best practice models, provide effective programming and develop culturally appropriate resources for First Nations and Inuit communities. At the community level, funding is provided through FNIHB's regional offices to support community-based prevention initiatives that build awareness and education, address the determinants of health and promote healthy lifestyles. CAAN also builds the capacity of individuals and organizations to respond to the HIV/AIDS epidemic in Aboriginal communities through its Skills Building Forum, which is held in conjunction with CAAN's annual general meeting.

Innovative capacity-building initiatives are also taking place at the regional level. For example, a wide range of partners, including the Public Health Agency of Canada's regional offices, FNIHB, Correctional Service Canada, Manitoba Health, Manitoba Corrections, the Winnipeg Regional Health Authority, the Nine Circles Community Health Centre and the private sector, pooled their resources and expertise to organize the "Partners in Caring" conference in Winnipeg in October 2004. The conference brought together participants from correctional institutions, the health care sector, social services, community-based organizations and First Nations communities to explore harm reduction needs and strategies in Manitoba.

IAD's organizational capacity is being enhanced through employee secondments. An IAD senior policy advisor is currently on secondment with UNAIDS, a senior member of CARE Canada has been seconded to IAD, and a senior manager from IAD has been seconded to the International Partnership for Microbicides. This is helping to bring about stronger linkages between Canada's domestic and international responses.

ICAD offered a workshop that gave ASOs, NGOs, labour unions, universities and private sector companies the opportunity to explore ways to increase their mutual cooperation in international HIV/AIDS work. As well, as part of its World AIDS Day 2003 activities, ICAD organized workshops on HIV/AIDS stigma and discrimination in Ottawa, Vancouver, Prince George, Saskatoon and Toronto. The workshops were funded by IAD and facilitated by a person living with HIV/AIDS from South Africa, who introduced and adapted the lessons learned from the sub-Saharan region to the Canadian context.

Growing Canada's HIV/AIDS Research Capacity

CIHR has established many mechanisms to develop the capacity of the Canadian health research community:

• The training of junior scientists increases the capacity of Canada's future research community. Training is enabled through the support of training awards or positions paid from research grants. In 2003-2004, CIHR approved 26 new HIV/AIDS training awards - more than in any previous fiscal year - bringing the total number of training awards to 46 (compared to 36 in 2002-2003).
• The capacity of Canada's current HIV/AIDS research community is increased through salary awards that allow individuals to dedicate more of their time to research projects. In 2003-2004, CIHR supported five new HIV/AIDS salary awards for a total of 15 awards.
• Similarly, the Canada Research Chair program increases research capacity in Canada by helping to retain and attract excellent researchers. As was the case in the previous fiscal year, CIHR supported nine HIV/AIDS researchers through this program in 2003-2004.
• In August 2003, a workshop entitled "A Coordinated Approach to HIV and Hepatitis C Research in Atlantic Canada: How do we get there?" was cosponsored by the CIHR Institute of Infection and Immunity, the Nova Scotia Health Research Foundation, the Atlantic Centre of Excellence for Women's Health, and Dalhousie University. The objectives of the workshop were to provide opportunities for networking, to discuss current gaps in HIV and hepatitis C research, and to promote a coordinated regional response to these research needs. The workshop led to commitments by participants to collaborate to enhance HIV and hepatitis C research in the Atlantic region. One of the specific activities resulting from the workshop was an application in response to a strategic requests for applications launched by the CIHR Institute of Infection and Immunity in June 2003, with the goal of providing funding to enhance interdisciplinary research capacity on social and behavioural issues in relation to HIV/AIDS and hepatitis C (a previously identified gap in Canadian research). The team hosting the workshop in August 2003 and three other interdisciplinary teams are now receiving funding through this strategic initiative to increase their collective research capacity and expertise.

Under the CSHA, the Community-Based Research Program awards scholarships of $18,000 annually to full-time master's and doctoral students who apply a community-based approach to HIV/AIDS research. To date, the program has supported students under the Community-Based Research General Stream and under the Aboriginal Community-Based Research Stream. An important element of the latter stream is the Summer Training Awards, which are administered by CAAN and support Aboriginal undergraduate arts and sciences students to participate in community-based research. Students received Summer Training Awards in 2003-2004 to work under the supervision of an academic advisor and an Aboriginal ASO. CAAN also administers the National Aboriginal Community-Based Research Capacity-Building Program, which supports Aboriginal community organizations and professional researchers to undertake Aboriginal community-based HIV/AIDS research.

The CSHA's Community-Based Research Program also provides funding for research technical assistants (RTAs), who play a key role in developing and enhancing research capacity among non-Aboriginal community organizations. RTAs work with organizations in their geographical area to identify, plan and deliver initiatives that build capacity for community-based research. CIHR is currently funding RTAs for four regional HIV/AIDS coalitions - COCQ-sida in Quebec, the Alberta Community Council on HIV, the Ontario AIDS Network and the British Columbia Persons with AIDS Society. CIHR also supports Aboriginal community organizations by providing funding to the National Aboriginal Community-Based Research Initiative. This project ensures that services similar to those of RTAs are available through a national Aboriginal coordinator.

Other CSHA partners are also supporting the strengthening of Canada's research capacity. For example, the CTN's Associateship Program provides financial support for up to half a dozen young scientists to work on HIV clinical trials each year. As well, CAHR's objectives include attracting and mentoring new HIV investigators and building research capacity within the community. In 2004, CAHR provided four New Investigator Awards to promising researchers and 18 scholarships to students and community members. CAHR also awarded its Red Ribbon Award for outstanding service to the cause of research in Canada that will lead to increased understanding of the treatment and prevention of HIV/AIDS while enhancing the quality of life of those living with HIV.

Canada Supports International Capacity Building

At the international level, ICAD and the Canadian Society for International Health continued to implement CIDA's Small Grants Fund (Phase 2), which provides support for 34 Canadian and overseas organizations to "twin" in implementing HIV/AIDS projects. For example, the Alberta Community Council on HIV/AIDS partnered with the Instituto Mexican De Investigacion Para La Familia y Poblacion, a non-profit Mexican organization, to train rural shopkeepers in Oaxaca State to be educators and distributors of HIV/AIDS prevention information. The partnership also strengthened the capacity of both organizations in the areas of cultural competency and organizational development. In another project, the AIDS Committee of Toronto twinned with the Associaçao Brasileira Interdisciplinar de AIDS in Rio de Janeiro on a project to reduce the risk of HIV infections among MSM. Through a two-way exchange of information and skills, both organizations increased their capacity to develop appropriate messaging and outreach for MSM and other marginalized groups. The Small Grants Fund was evaluated in 2004 by external evaluators who concluded that it was an innovative and cost-effective program and recommended continued funding under a new phase.

Canada is gaining international recognition as a location of choice for technology transfer and training in HIV testing methodologies. Over the past year, CIDPC's HIV/AIDS laboratories have provided training to scientists from Pakistan, Kosovo, Haiti, the Republic of the Ivory Coast, Ethiopia, South Africa, Mozambique, the Caribbean, China and Mexico. These international visitors typically stay for two to three weeks, depending on their background and the expected outcome of the training. CIDPC has also trained scientists from Russia on CD4 monitoring and assisted Russia in developing guidelines for CD4 monitoring technology. Through a partnership with Doctors Without Borders, CIDPC provided serology training to a scientist from Sudan.

CIDPC's International Quality Assurance Program continues to assist resource-poor countries in monitoring the effectiveness of antiretroviral treatments. Two to three times a year, panels of stabilized whole blood are sent to approximately 250 laboratories in 60 to 70 countries, where the specimens are analysed for CD4 lymphocyte enumeration, and results are sent back to Canada via the Internet. CIDPC assesses the accuracy of the results submitted by each country and provides feedback as required. The program helps to ensure that individuals on antiretroviral therapy in developing countries are receiving care and treatment comparable to the levels provided in developed countries.

With funding from CIDA, the Canadian HIV/AIDS Legal Network provided technical and financial support to professional legal associations in Kenya and Zambia. Local project management was provided by the Kenya AIDS NGOs Consortium and the Zambia office of the International HIV/AIDS Alliance. Based on an evaluation of the project undertaken between October and December 2003, a follow-up action plan was developed and will be implemented in the next fiscal year.

CIDPC also provides technical assistance to enhance the capacity of HIV/AIDS organizations and projects abroad. For example, technical support was provided to a project to design and implement a second generation HIV surveillance program in Pakistan. As well, CIDPC staff helped design a monitoring and evaluation system for the planned roll-out of HIV treatment in the Caribbean and participated in a UNAIDS mission to assess Guyana's need for technical support in the areas of HIV/AIDS surveillance and HIV treatment monitoring.

ICAD received funding from CIDA's Youth Employment Initiative to sponsor four interns who linked organizations in Canada and overseas by serving work terms with both organizations. A program officer worked at ICAD in Ottawa and with the ICROSS project in Kenya; an AIDS orphans project manager served work terms with the Canada-Africa Community Health Alliance in Ottawa and the MKUKI Project in Tanzania; an HIV/AIDS street youth worker was employed at CUSO in Ottawa and with the Kiota Women's Health and Development Organization in Tanzania; and an HIV/AIDS peer educator spent separate work terms with CARE/Ottawa and CARE/Cameroon.

With financial support from IAD, ICAD and CAS collaborated on two projects. The first involved maintaining a database launched in the previous fiscal year that allows Canadian ASOs, NGOs, educational institutions and others to promote their skills and expertise in the HIV/AIDS sector internationally. The second is a resource entitled Integrating International Perspectives in the Community-based AIDS Movement in Canada: The International Toolkit. The goal of the toolkit is to enhance the capacity of community-based HIV/AIDS organizations to integrate international perspectives in their work. Presentations on the toolkit were made at several meetings and conferences, including a full-day workshop in Montréal in November 2003 that was attended by 30 representatives of community-based AIDS organizations and development NGOs in Quebec.

Two Canadian experts - one from the Canadian HIV/AIDS Legal Network and one from the BC Centre for Excellence in HIV/AIDS - helped the Thai Drug Users' Network develop a proposal for a peer-driven HIV/AIDS prevention and care project. The project received a grant from the GFATM in October 2003, marking the first time the GFATM had provided funding directly to a user-run organization. The two Canadian experts later returned to Thailand, where more than 50 per cent of injection drug users are living with HIV, to provide additional training and discuss future collaboration in the evaluation and monitoring phases of this ground-breaking project.

Challenges and Opportunities

As in previous years, capacity building remains a significant challenge for organizations involved in the HIV/AIDS response. The problem is twofold: organizations are continuously required to create capacity in new areas due to the increasing complexity of the epidemic while at the same time struggling to maintain existing capacity in the face of high staff turnover and volunteer fatigue. Many CSHA partners have identified capacity development at the community level as a key priority for the additional strategy funding announced in May 2004. Internationally, the lack of human resource capacity to effectively deliver antiretroviral treatment is a significant constraint to the rapid scaling up of treatment and progress toward the "3 by 5" target.

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