Canada's Report on HIV/AIDS 2005

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Focussing On Populations

The Federal Initiative to Address HIV/AIDS in Canada commits the federal government to develop discrete approaches to addressing the epidemic for eight specific target populations: people living with HIV/AIDS, gay men, injection drug users, Aboriginal people, prison inmates, youth, women and people from countries where HIV is endemic. Leading Together also calls for additional focus on HIV/AIDS prevention among these population groups, many of which continue to face stigma and discrimination in Canada. This section of the report provides epidemiological data for each of the eight target populations as well as examples of work that is under way. It also includes an explanation of the shift to population-specific initiatives and a breakdown of year-one funding under the Federal Initiative.

Why Population-Specific Approaches?

The shift in emphasis to population-specific approaches reflects a number of lessons learned over the past two decades:

• the factors that make people vulnerable to HIV/AIDS are different for each population
• HIV is principally transmitted among specific populations and under specific conditions
• the epidemic is regionally and culturally diverse
• responses tend to work best when they are close to and meaningfully involve the people most affected, including people living with HIV/AIDS
• prevention messages targeted to specific populations work best and are most effective when delivered in settings where these populations gather
• each population has specific needs in relation to prevention, diagnosis, care, treatment, support and rehabilitation
• multiple issues that impact vulnerability should be addressed in an integrated manner

The population-specific approach results in evidence-based, culturally appropriate responses that are better able to address the realities that contribute to infection and poor health outcomes for the target groups. Population-specific approaches also allow people at risk of infection and those living with HIV/AIDS to directly shape policies and programs that affect them.

Working in consultation with key stakeholders, PHAC has undertaken to develop a framework to guide the development and implementation of population-specific initiatives and plans. The framework will support priority setting, provide linkages to front-line initiatives, encourage collaboration and partnership, and provide opportunities for the sharing of knowledge about specific populations.

Year-One Funding Under the Federal Initiative

The first $5 million of additional funding under the Federal Initiative was provided in 2004-2005 and was targeted specifically to support populations most at risk of infection and those already living with the disease.

Half of the additional funding ($2.5 million) was administered by the AIDS Community Action Program (ACAP), which provided a total of $10.64 million to support the operations and projects of more than 100 community-based organizations across Canada. This funding was administered through PHAC's regional offices. (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.)

Additional funding was also provided to community-based organizations through PHAC's Non-Reserve First Nations, Inuit and Métis Communities HIV/AIDS Project Fund, which supports 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. With increased funding of $250,000 under the Federal Initiative, total investments by the Non-Reserve First Nations, Inuit and Métis Communities HIV/AIDS Project Fund were $1.478 million in 2004-2005.

PHAC also provided $150,000, in addition to existing resource allocations, to key NGOs supported under the Federal Initiative (see list of Key Partners on page 48). This incremental funding supported both individual organizational strategic planning and broader voluntary sector strategic planning to ensure a coordinated and collaborative response to HIV/AIDS in Canada.

Also in 2004-2005, PHAC contributed an additional $100,000 to the development of Leading Together: Canada Takes Action on HIV/AIDS . This brought PHAC's total contribution to $2.15 million in the first year of the Federal Initiative.

Health Canada's First Nations and Inuit Health Branch (FNIHB) received an additional $250,000 in year one of the Federal Initiative, bringing its total allocation to $1.35 million. FNIHB also invested $2.59 million from its own budget to provide HIV/AIDS education, prevention and care and support networks to on-reserve First Nations people and Northern Labrador Inuit communities. IAD received additional funding of $250,000 as Phase I of Health Canada's contribution to AIDS 2006.

CSC received incremental funding of $500,000, for a total allocation of $1.1 million in 2004-2005. CSC also invests $13.5 million annually from its own budget in infectious disease management, including HIV/AIDS care, treatment and support, in the correctional environment.

The $1 million in incremental funding provided to CIHR in year one of the Federal Initiative was used to support the work of the Canadian HIV Trials Network (CTN).

People Living with HIV/AIDS

As previously noted, an estimated 56 000 people in Canada were living with HIV infection (including AIDS) at the end of 2002. This represents a 12 per cent increase from the estimate of 49 800 at the end of 1999. There were an estimated 2 800 to 5 200 new HIV infections in Canada in 2002, approximately the same as in 1999. An estimated 17 000 (30 per cent) of HIV-infected people in Canada are not aware of their infection.

ACAP supports numerous projects aimed at meeting the needs of people living with HIV/AIDS. In the Ontario Region, for example, ACAP is supporting a project by the Toronto People with AIDS Foundation to increase the number and capacity of volunteers (most of whom are living with HIV/AIDS) providing programs, services and support to the agency's approximately 5 000 clients. To this end, the Foundation is implementing strategies for volunteer recruitment, training and retention; publishing a monthly volunteer newsletter; updating its volunteer manual; providing social opportunities for volunteers and staff; and implementing volunteer acknowledgment programs. Partnering with the Foundation in this project are the AIDS Committee of Toronto, the AIDS Bereavement Project of Ontario, Canada World Youth, the Community-Linked Evaluation AIDS Resource Unit, the 519 Church Street Community Centre and Kikkawa College.

AIDS Programs South Saskatchewan (APSS) and All Nations Hope continues to respond to the needs of those living with HIV/AIDS by providing the necessary information to make informed choices and to improve the knowledge level of the public on issues such as HIV and other STIs.

The Community-Based Research Program, which was transferred from PHAC to CIHR on April 1, 2004, supports collaborative projects that engage communities and professional researchers in health research on HIV/AIDS. Among the projects approved as a result of the first round of requests for applications under the new program, researchers at Fife House in Toronto received funding for a study to explore the impact of housing support and homelessness on the health outcomes of people living with HIV/AIDS in Ontario.

With funding from CIHR, the CTN - a partnership of researchers, people living with HIV/AIDS, industry and others that facilitates clinical trials for the development of treatments, vaccines and a cure for HIV/AIDS - supported 16 HIV clinical trials involving more than 853 Canadians living with HIV/AIDS in 2004-2005. The CTN also approved and implemented two new trial protocols: CTN 198 will examine whether a psycho-educational intervention helps people living with HIV improve their adherence to HIV drugs, and CTN 203 is an early-stage therapeutic HIV vaccine study that is being conducted at one site in Canada and two sites in the United Kingdom.

CTN researchers completed a major study of structured treatment interruption in 2004-2005, the results of which were presented at several conferences. CTN 164 found that people taking antiretroviral drugs did not benefit from a 12-week structured treatment interruption before switching to a salvage highly active antiretroviral treatment regimen (compared to those who immediately switched to a salvage regimen).

The CTN has also begun to collaborate more extensively with researchers in other disease areas of relevance to HIV/AIDS and in other countries. In Canada, for example, the CTN is exploring ways to help build capacity for clinical trials on hepatitis C. Abroad, it continued to support a range of HIV trials at sites in Europe, the United States and South America and established its first international affiliate satellite at a hospital in Uganda.

The Canadian AIDS Treatment Information Exchange (CATIE) continued to respond to the needs of people living with HIV/AIDS by providing free, current, confidential and bilingual information on HIV/AIDS treatment and related health care issues. CATIE received 2 049 treatment information requests in 2004-2005, almost 90 per cent of which were made through its toll-free telephone service. As well, CATIE's Web site received more than 650 000 visits during the year, a 50 per cent increase over 2003-2004. In response to these Web site visits and requests for information, CATIE distributed 64 013 print publications (an increase of 31 per cent over 2003-2004), 29 486 bulletins through e-mail (an increase of 46 per cent), and 2.5 million Web pages (an increase of 84 per cent). An additional 80 books, 912 articles and 85 Web resources were added to CATIE's collection.

CATIE News and TreatmentUpdate continued to provide breaking news on HIV treatments, complications, side effects, co-infections, nutrition and other research. In response to inquiries from readers, the entire issue of Treatment Update 146 was devoted to developments in the management of lipodystrophy. TreatmentUpdate reached an important milestone in June/July 2005, with the publication of the 150^th issue. CATIE also continued to publish The Positive Side, Canada's national magazine for people living with HIV, which covered stories ranging from treatment adherence to the struggles of managing long-term side effects.

CATIE presented a total of 78 workshops to 7 040 participants across Canada in 2004-2005, including new workshops on HIV and the heart, anal cancer, tips for HIV-positive travellers, and HIV and depression. Throughout the year, CATIE was supported by 280 volunteers who contributed more than 19 000 hours of service answering treatment calls, translating documents, desktop publishing articles, testing the usability of CATIE's Web site, indexing magazines, attending clinical rounds at a local hospital, and conducting Internet research.

CAS launched a project to examine access and regulation issues faced by people living with HIV/AIDS who choose to use cannabis as part of their therapy (for some people, the use of cannabis alleviates symptoms associated with the disease and with HIV/AIDS medication). Focus groups have been conducted in Vancouver, Victoria, Toronto, Montréal and Ottawa to document the experiences of people living with HIV/AIDS who use cannabis as therapy. Lawyers, physicians, pharmacists, compassion clubs, cannabis growers, regulators and law enforcement officials will also be interviewed. Based on the feedback received, information materials will be developed for organizations and individuals on how to access Health Canada's medical marijuana program, how to speak to a physician about medical marijuana, legal considerations, suggestions on how to use cannabis as therapy, and other topics. The project, which is being funded by PHAC's Legal, Ethical and Human Rights Fund, will also develop an action plan to address the issues identified.

The Canadian Working Group on HIV and Rehabilitation (CWGHR) has developed a network of 25 disability groups across Canada to link HIV and other episodic disabilities (e.g., multiple sclerosis, arthritis, diabetes, lupus, mental health problems, some forms of cancer and hepatitis C) and to work on issues of common concern. The cross-disability network is undertaking policy research and education on disability income support, labour force participation and social inclusion for people living with HIV and other episodic disabilities. In partnership with this network, CWGHR is also working with public and private disability insurance programs, unions, employers and human resource professionals to research models of disability income support and labour force participation, with the goal of developing and testing new models to accommodate the challenges related to living with alternating periods of disability and wellness.

PHAC's National HIV/AIDS Capacity-Building Fund is supporting a number of projects to update the knowledge and skills of organizations and individuals who work with people living with HIV/AIDS, including the following:

• The Canadian Treatment Action Council (CTAC) has initiated a major project to develop, promote, deliver and evaluate up to 15 standalone training modules on HIV/AIDS treatment access in Canada. Entitled «Tools for Action: HIV/AIDS Treatment Access Advocacy Series,» the training modules will increase the HIV/AIDS treatment and access- to-treatment knowledge and skills of staff and volunteers working in areas related to HIV/AIDS in Canada, as well as their capacity to influence relevant treatment policy and practices. The training will be delivered both in person and through interactive technologies such as tele-workshops. CTAC's partners in this initiative include the Canadian Aboriginal AIDS Network (CAAN), the British Columbia Persons With AIDS Society, the HIV/AIDS Legal Network, Voices of Positive Women, le Comité des Personnes Atteintes du VIH du Québec, the Prisoners with HIV/AIDS Support Action Network (PASAN), the Wellesley Central Health Corporation, Planned Parenthood Federation of Canada, Arthritis Consumer Experts, CATIE, CAS, the Canadian Hemophilia Society and the Canadian Harm Reduction Network.
• CATIE has launched a two-year capacity-building project involving seven AIDS service organizations: Positive Living North (Prince George, British Columbia), HIV Edmonton, AIDS Programs South Saskatchewan (Regina), Bruce House (Ottawa), MIELS-Québec (Québec City), the AIDS Coalition of Nova Scotia (Halifax), and one in Iqaluit, in partnership with Pauktuutit Inuit Women's Association. As a first step, the project will assess each organization's capacity to integrate HIV treatment information into the continuum of services it provides. CATIE will then work with each organization to develop specific strategies for expanding its HIV treatment information services.
• CWGHR is undertaking a multi-year project to support interprofessional learning about HIV for rehabilitation professionals. By integrating HIV issues into rehabilitation curricula, the project will increase the capacity of rehabilitation professionals to respond to the needs of people living with HIV. Project partners include several universities across Canada, as well as the Canadian Physiotherapy Association, the Canadian Association of Occupational Therapists, the Canadian Association of Speech-Language Pathologists and Audiologists and the College of Family Physicians of Canada.
• ICAD is providing training to its members and other organizations on HIV/AIDS as an episodic disability in the workplace. Pilot workshops were held in 2004-2005, leading to revisions to the content of the workshops and accompanying resource materials. A total of 20 workshops will be held across Canada in 2005-2006, some with organizations wishing to develop and implement relevant workplace policies and others directly with people living with HIV/AIDS.

A national coalition has been collaborating on issues of HIV and hepatitis C co-infection. The coalition consists of CATIE, CAS, the Canadian Hepatitis C Society, the Canadian Liver Foundation, the Hemophilia Society of Canada, and two programs of the CPHA - the Canadian HIV/AIDS Information Centre and the Canadian Hepatitis C Information Centre. CATIE and CTAC have also been participating in a broad coalition that challenges systemic barriers to health care access: the Best Medicines Coalition. Both coalitions include a range of stakeholders working in arthritis, cancer, multiple sclerosis and other illnesses.

During 2004-2005, CTAC and CATIE continued to partner with the Best Medicines Coalition and other disease/disability groups in coordinated meetings with federal officials on the federal drug review process (both pre- and post-approval). As part of this work, CTAC is participating in discussions and stakeholder consultations on issues regarding implementation of the Common Drug Review process, which went into effect in 2004-2005. Common Drug Review was created to provide a single process for evaluating new drugs and providing recommendations on formulary listings to participating provincial/territorial drug reimbursement plans across the country so that Canadians could have access to quality treatment and care in an acceptable length of time.

Gay Men

MSM (gay men and other homosexually active men) continue to be the group most affected by HIV/AIDS in Canada, accounting for an estimated 40 per cent of all new HIV infections in 2002 and 58 per cent of persons living with HIV/AIDS. The MSM/injection drug users exposure category accounted for a further 7 per cent of estimated new infections in 2002 and 4 per cent of persons living with HIV/AIDS. Recent data on risk behaviours suggest that MSM continue to be at considerable risk of HIV infection and other STIs through engaging in unsafe sex.

To better understand the epidemic in the gay community, PHAC is currently establishing M-Track, a second generation HIV surveillance system that aims to study trends in disease prevalence and risk behaviours among MSM in Canada.⁸ Phase I of this project was recently completed in Montréal, where more than 2 000 MSM completed questionnaires and provided dried blood specimens. Negotiations are under way to launch M-Track pilot studies in Toronto and Ottawa to assess the feasibility of the project's data collection procedures, and PHAC is examining the possibility of expanding the M-Track network to other sites. The M-Track studies completed to date have also provided a platform for undertaking new laboratory tests, such as detuned HIV assays on dried blood samples to assess the incidence of HIV.

As part of its ongoing health promotion work, PHAC is developing a range of national resources targeting gay men and encouraging them to seek out testing and screening for STIs, including HIV. Activities are also being developed to mitigate the threat of ulcerative STIs, such as lymphogranuloma venereum (LGV) and syphilis, which increase the risk of HIV infection. The aim is to increase awareness among gay and bisexual men of the risk of co-infection and find ways to use the Internet as a syphilis prevention and control tool. In partnership with provincial and territorial governments, PHAC has developed enhanced surveillance systems to better understand the prevalence of LGV and syphilis in Canada. Efforts are also under way to expand the capacity of PHAC's regional offices to integrate issues related to STI prevention and control and co-infection risks.

Working with a National Advisory Team composed of partner organizations from across Canada, AIDS Vancouver has developed «Gay Men Play Safe,» the second phase of a national social marketing campaign to reinvigorate HIV/AIDS prevention among Canadian gay men (see the feature article on page 17). Based on the evaluation of Phase 1 of the campaign («Assumptions - how do you know what you know?»), the new campaign has shifted from challenging gay men's assumptions about the serostatus of their partners to focussing on validating and supporting gay men's safer sex practices. To address the problem of unsafe sex, the AIDS Committee of London is receiving funding from ACAP for a project to increase knowledge of HIV, encourage risk-reduction behaviours, and improve the accessibility of HIV prevention services for the city's MSM population. Project activities include HIV presentations and workshops for MSM; the distribution of condoms, lubricants and other prevention materials; the provision of HIV-related information through chat lines and the AIDS Committee of London's Web page; and referrals to other HIV services in London. The committee is partnering in this initiative with the Middlesex-London Health Unit, the Options Clinic, Club 181 and Club London.

Planned Parenthood Edmonton is receiving funding from the Alberta Community HIV Fund (a joint community/provincial/federal funds disbursement model) for a project to enhance the programming of the Gay Men's Outreach Crew. The Outreach Crew is a peer-led initiative that aims to educate MSM about safer sex practices to reduce the spread of HIV and to increase positive attitudes and selfacceptance with respect to same sex relationships, experiences and encounters. Among other activities aimed at preventing HIV/AIDS in Edmonton's gay, bisexual and MSM populations, the project will develop outreach resources, maintain a sexual health discussion board and chat room on the Gay Men's Outreach Crew's Web site, and survey the target groups on issues of safer sex messaging, condom use and condom fatigue.

In Vancouver, the Community-Based Research Centre Society recently completed a project entitled Totally Outright: A Sexual Health Leaders Course for Young Gay Men. ACAP project funding enabled the Society to work in partnership with five youth-serving organizations to develop a gay health and HIV prevention education program for young gay men in the Greater Vancouver area. The curriculum is now being used extensively by partner organizations and has been disseminated across Canada in an effort to increase sexual health knowledge among young gay men. The project also served to strengthen cooperative relationships between often disparate community groups that work with young gay men in the Vancouver area.

Injection Drug Users

In 2002, injection drug users were estimated to account for 11 000 prevalent (known) HIV infections (20 per cent of the Canadian total) and 800 to 1 600 of the estimated new infections (30 per cent of the total) in that year. Although the proportion of new infections in this exposure category has decreased from previous estimates (down from 34 per cent in 1999), these numbers remain unacceptably high.

Injection drug users are at risk of acquiring HIV and other blood-borne infections, such as hepatitis C, through contaminated needles and unsafe sex practices. In collaboration with provincial, regional and local health authorities, community stakeholders and researchers, PHAC has established a surveillance system at sentinel sites across Canada to track HIV- and hepatitis C-associated risk behaviours (see the feature on page 46). The pilot phase of this surveillance system, known as I-Track, was undertaken during the fall of 2002.⁹ Phase I of the surveillance survey has now been completed in Victoria, Sudbury, Toronto, Winnipeg, Regina and Edmonton, and has been linked with a separate study (by the SurvUDI group) at sites in Ottawa and in the province of Quebec (a report on Phase I of the survey is currently being developed). Negotiations are ongoing to expand the I-Track survey to include additional sites. The specimens collected under I-Track have also enabled PHAC to study HIV prevalence and testing behaviour among IDUs, as well as hepatitis C genotypes circulating in Canada.

With funding from PHAC's Non-Reserve First Nations, Inuit and Métis Communities HIV/AIDS Project Fund, the Western Aboriginal Harm Reduction Society is endeavouring to increase knowledge and awareness of the risk of HIV and hepatitis C infection among Aboriginal people who use illicit drugs in Vancouver's Downtown Eastside. To that end, the Society is delivering HIV/AIDS prevention, peersupport and capacity-building workshops; networking with other Aboriginal HIV prevention and support organizations in Vancouver; and sponsoring presentations by other community organizations on HIV/AIDS, hepatitis C, harm reduction and related health topics. Partners in this project include the Vancouver Area Network of Drug Users, the PIVOT Legal Society, the BC Association of People on Methadone, the Portland Hotel Society, the B.C. Centre for Excellence in HIV/AIDS, the Life Is Not Enough Society and the Canadian HIV/AIDS Legal Network.

People who use injection drugs are also the focus of a harm reduction, prevention and support project by the Positive Living North West Society in Smithers, British Columbia. With funding from ACAP, this project is providing basic HIV and hepatitis C prevention and education programming and addressing a variety of support and care needs for people who use drugs and other at-risk groups throughout the Pacific Northwest.

The Alberta Community HIV Fund is supporting two projects aimed at reducing the risk of HIV infection by providing for safe disposal of injection drug needles:

• The Prostitute Awareness and Action Foundation of Edmonton is being funded to develop and distribute a toolkit of resources entitled Safe Needle Disposal: On the Streets Where We Live. The toolkit aims to build community capacity to address the issue of needle debris and the risk of needlestick injury in neighbourhoods across the city and will include information about HIV/AIDS and harm reduction.
• The Friends of Whitecourt Society has received funding for Sharp Smart, a project aimed at preventing injuries, including HIV infection, by raising awareness of and providing opportunities for the proper disposal of needles and other sharp objects in the communities of Whitecourt, Blue Ridge and Mayerthorpe. As part of this project, collection boxes have been installed at selected sites in the three communities for use by injection drug users and by farmers, ranchers and others who may need to dispose of sharp objects.

Also in Alberta, PHAC's Hepatitis C Prevention, Support and Research Program will provide funding for a project by the HIV Network of Edmonton Society, a member of the Alberta Non-Prescription Needle Use (NPNU) Public Awareness Task Group. The project will involve compiling, refining and marketing NPNU products to raise awareness among the general public and prison guards of the role of harm reduction in preventing hepatitis C and other blood-borne pathogens.

The Community-Based Research Program provided funding in 2004-2005 for a study to assess the need for a safer injecting facility in Ottawa. As part of this project, 250 street-recruited injection drug users were interviewed to determine their attitudes toward and expectations of safer injecting facilities (health care sites where injection drug users can inject pre-obtained drugs under medical supervision, access needle exchange services, and receive primary health care, emergency care for overdoses, health education and referrals). In addition, the survey yielded information on patterns of drug use and the demographic characteristics, drug treatment and overdose experience, and HIV and hepatitis C status of injection drug users in Ottawa. Focus groups will also be held with health professionals, policy makers, service organizations and law enforcement personnel to gauge community attitudes and concerns related to safer injecting facilities. Information gathered through this study will help to identify features that would optimize the use of a safer injecting facility, including location, hours of operation, supervision, provision of injection equipment, and referrals to drug treatment and social services. Results from the project will be presented through a series of community education fora in 2006.

Aboriginal Peoples

Aboriginal peoples are over-represented in the HIV/AIDS epidemic in Canada. In 2002, it was estimated that Aboriginal persons accounted for 5 to 8 per cent of all people living with HIV in Canada, even though Aboriginal peoples account for only 3.3 per cent of the total Canadian population.

Surveillance data available for this population have shown injection drug use to be a key risk factor.¹⁰ More than half (51.7 per cent) of diagnosed AIDS cases among Aboriginal peoples in 2003 were attributed to IDU. Females represent nearly half (45.0 per cent) of all positive HIV test reports among Aboriginal peoples, compared with 20.0 per cent among non-Aboriginal peoples. Aboriginal peoples are also being infected with HIV at a younger age than non-Aboriginal peoples. Almost a third (28.7 per cent) of positive HIV test reports for Aboriginal peoples in 2003 were among youth (under 30 years of age), compared to 21.3 per cent for non-Aboriginal peoples.

Since 2001, PHAC and FNIHB have jointly supported the National Aboriginal Council on HIV/AIDS (NACHA), which advises government and other stakeholders on HIV/AIDS and related issues among Aboriginal peoples (Inuit, Métis and First Nations) in Canada. NACHA is a forum where issues affecting Aboriginal peoples, both on- and off-reserve, are discussed and policy advice is developed based on the knowledge and reality of Aboriginal peoples. During 2004-2005, NACHA collaborated with PHAC in developing an HIV/AIDS Epi Note entitled Understanding the HIV/AIDS Epidemic among Aboriginal Peoples in Canada: The Community at a Glance. NACHA also developed a five-year strategic plan and contributed to the review of PHAC's Non-Reserve First Nations, Inuit and Métis Communities HIV/AIDS Project Fund.

ACAP funding is enabling the Vancouver Native Health Society to use music therapy to help HIVpositive Aboriginal residents of Vancouver's Downtown Eastside reconnect with their native culture. Music therapy is increasingly recognized as an effective catalyst for client motivation, stimulation and communication and can help improve an individual's mental, physical and emotional well-being. In addition to music therapy and storytelling workshops for HIV-positive clients, this innovative project is providing community outreach aimed at street-involved Aboriginal youth and elders and producing an audio CD that will convey a powerful prevention message and help to build skills in this highly marginalized population.

PHAC's Non-Reserve First Nations, Inuit and Métis Communities HIV/AIDS Project Fund is supporting a two-year project of the Battlefords Family Health Centre entitled Mobilizing Community Supports for the Prevention of HIV/AIDS. The aim of the project is to increase the knowledge of HIV/AIDS, hepatitis C and other STIs among Aboriginal youth and their health, social service and education providers in the Battlefords, Saskatchewan. Training is being provided to Aboriginal youth service providers, and a youth-friendly magazine that highlights harm reduction strategies for HIV/AIDS, hepatitis C and STIs is being published. The Battlefords Family Health Centre is also distributing awareness and education posters, sponsoring a public service announcement, and employing peer outreach strategies in areas frequented by Aboriginal youth in the Battlefords.

The four Eastern Métis settlements in northeastern Alberta were supported by the Alberta Community HIV Fund to send elders and youth who are employed by the communities during the summer to an HIV cultural camp, where they shared traditional practices and current attitudes on sexuality and HIV/AIDS and participated in train-the-trainer sessions. The Alberta Community HIV Fund also supported the Canadian Red Cross Society, Southern Alberta Region, in delivering Phase II of the Tipi of Courage project, a mobile Aboriginal community centre that offers a range of programs and services related to HIV/AIDS. Among other activities, focus groups were conducted with staff and clients from non-Aboriginal agencies who work with Aboriginal people to help the Red Cross Society meet their HIV prevention programming needs.

Eighty-two per cent of FNIHB's HIV/AIDS budget was transferred to its regional program in 2004-2005 to support First Nations communities in delivering a wide range of prevention, education and awareness projects. In addition, the regional program helps to support Aboriginal AIDS Service Organizations in British Columbia, Alberta, and Atlantic Canada. This year, FNIHB programming supported 200 contribution agreements, four through the national office and 196 in the regions. For example:

• In Atlantic Canada, FNIHB supported Healing Our Nations, a Nova Scotia-based Aboriginal AIDS service organization that provides prevention, education and awareness workshops to First Nations people in Nova Scotia, New Brunswick, Newfoundland and Labrador and Prince Edward Island. Of particular note, Healing Our Nations delivered HIV/AIDS workshops to the band council of the Indian Brook First Nation. This was the first time Healing Our Nations had been invited to make a presentation to Aboriginal leaders in this part of Nova Scotia and could lead to the community's future participation in Aboriginal AIDS Awareness Week activities.
• In Quebec, FNIHB co-funds the Cercle de l'Espoir to publish its biannual bulletin, develop a schoolbased HIV/AIDS prevention campaign for Aboriginal youth, and provide training on HIV/AIDS and hepatitis C for First Nations people living in urban areas.
• In British Columbia, FNIHB sponsored a leadership forum to respond to the outbreak of HIV and hepatitis C among Aboriginal youth in Prince George.

At the national level, FNIHB continued to support Pauktuutit Inuit Women's Association in delivering HIV/AIDS awareness sessions at Labrador's Winter Fair, as well as the policy work of the Assembly of First Nations. Also with funding support from FNIHB, the Canadian Aboriginal AIDS Network (CAAN) expanded its annual Aboriginal AIDS Awareness Day to a week-long event beginning on World AIDS Day (December 1). In 2004 - the first year for the week-long campaign - close to 14 646 people participated in HIV/AIDS workshops, rallies, press conferences and other activities in 133 communities across Canada. FNIHB's national program is also supporting the 2-Spirited People of the First Nations to develop and implement a one-day International Indigenous People's Conference, to be held in conjunction with the International AIDS Conference in Toronto in August 2006.

Under the Aboriginal Stream of CIHR's Community-Based Research Program, CAAN is being supported to conduct research on Aboriginal culturally competent care in the context of HIV/AIDS. In a community-based research project completed in 2004-2005, the group Positive Living North in Prince George, British Columbia, uncovered a complex and interrelated series of obstacles that either prevent or delay access to antiretroviral therapy for Aboriginal people living in urban areas. Integrating the results of this project into HIV/AIDS treatment practices could encourage early uptake of antiretroviral therapy by Aboriginal people, with significantly improved health outcomes.

In the summer of 2004, CAAN conducted a national survey of 195 Aboriginal people living with HIV/AIDS in Canada to document the extent to which their service needs are being met and to identify service deficiencies. While participants indicated that the services they access are meeting or exceeding their needs, the study concluded that barriers to care, treatment and support continue to exist for Aboriginal people living with HIV/AIDS. CAAN also recently published the results of a study of homophobia in relation to HIV/AIDS in Aboriginal communities. Most individuals who responded to the survey identified themselves as being gay male or two-spirited and indicated that they had experienced verbal forms of homophobic discrimination. Approximately one quarter of respondents had also experienced some form of physical violence. In a separate survey of Aboriginal service organizations, approximately half of the respondents reported incidents of homophobic discrimination within or involving their organization.

PHAC funded CAAN's Aboriginal HIV/AIDS Anti-Discrimination project, which created a policy development framework that can be used by Aboriginal organizations to produce anti-HIV/AIDS discrimination policies to support inclusion and the hiring of Aboriginal people living with HIV/AIDS and to strengthen their service delivery to Aboriginal people living with HIV/AIDS. The framework was developed in collaboration with the Canadian HIV/AIDS Legal Network, and was presented in a workshop format at the National Native Addiction Partnership Foundation's training conference in Ottawa. A guide to developing anti-discrimination policies was also developed and is available through CAAN.

CAAN has also undertaken a two-year project to examine HIV/AIDS privacy and confidentiality concerns in Aboriginal communities. This project includes a comprehensive legal analysis of Canadian and international privacy law as it impacts Aboriginal people living with HIV/AIDS, as well as analysis of Aboriginal customary laws, societal structures and self-government.

CAAN's Aboriginal People with HIV/AIDS Gathering was held in Toronto from February 14 - 16, 2005. Entitled «Gathering Wisdom,» the event was attended by about 80 Aboriginal youth, women, twospirited men and straight men from across Canada who are living with HIV/AIDS. Through focus groups and other activities, participants shared information, built support systems and explored how CAAN could better meet their needs. Gathering Wisdom was also supported by the Ontario Aboriginal HIV/AIDS Strategy and the 2-Spirited People of the First Nations.

Prison Inmates

The prevalence of HIV among federal and provincial inmates in Canada is estimated to be nearly 10 times higher than in the general population. Recent evidence indicates that HIV infection rates are higher among female inmates (3.44 per cent) than among male inmates (1.37 per cent).¹¹ Higher rates of infection among inmate populations are often the result of offenders' histories of participating in high-risk behaviours, such as injection drug use and unprotected sex, behaviours which some offenders continue to engage in while incarcerated.

CSC, a core partner in the Federal Initiative, undertakes a range of HIV/AIDS prevention and education activities in federal prisons in addition to providing care, treatment and support services to inmates. With the additional funding allocated under the Federal Initiative, CSC will focus on building knowledge through infectious disease surveillance, expanding infectious disease intervention, and implementing coordinated prevention responses with public health and federal, provincial and territorial partners.

During 2004-2005, CSC continued to implement the HIV/AIDS Peer Education and Counselling Program, which trains peer coordinators and volunteers to share information on HIV/AIDS and other infectious diseases and to provide peer support to fellow inmates. A parallel program is operated for Aboriginal inmates with the support of community Aboriginal AIDS service organizations.

For the third consecutive year, CSC provided funding through the Special Initiatives Program to enable inmates to organize activities and projects related to HIV/AIDS prevention. Nine projects were funded in 2004-2005. Examples include:

• Images painted by two inmates at the Atlantic Institution, with HIV prevention as the theme, were transformed into a calendar and distributed to all federal penitentiaries in the Atlantic Region, selected penitentiaries in other regions, and several HIV/AIDS service organizations.
• At Stony Mountain Institution in Manitoba, inmates held a «Chalk the Walk» contest in which HIV prevention images were drawn with chalk on the outside track. The winning design was printed on t-shirts, which were awarded as prizes to inmates during World AIDS Day activities.
• Inmates at the Grand Valley Institution for Women in Ontario produced drawings, poetry, paintings and sculpture to express how HIV/AIDS has affected their lives.
• In Quebec, inmates at the Federal Training Centre and Montée Saint-François Institution produced a publication, Virus en Pen, containing articles, drawings and poems with HIV prevention messages.

CSC funded 10 penitentiary nurses to attend the 2005 Canadian Association of Nurses in AIDS Care Conference in Banff. Two nurses who attended wrote about their experiences at the conference in the Summer 2005 issue of CSC's Focus on Infectious Diseases newsletter. CSC also delivered a presentation on infectious diseases in federal penitentiaries to the association's British Columbia chapter.

CSC has enhanced its surveillance forms for infectious disease screening and test requisition. The new forms guide nurses in assessing an inmate's risk behaviours and deciding whether to recommend testing for HIV and other infections. The forms also provide data that helps CSC develop effective health promotion and education programs and evaluate health interventions and harm reduction programs.

A pilot project related to safer tattooing practices was implemented by CSC in six penitentiaries. Several inmate tattooists have been trained in infection control, sterilization procedures and safer tattooing methods, and penitentiaries have been supplied with appropriate tattooing equipment. The project, which aims to further CSC's commitment to provide federal inmates with harm reduction measures, is being monitored on an ongoing basis and will be formally evaluated after one year.

Each year, inmates in CSC penitentiaries across Canada organize and participate in activities around World AIDS Day. For example, inmates at Mountain Institution in British Columbia hold a mini AIDS walk every year, collecting money from other inmates to donate to the British Columbia Persons With AIDS Society.

PHAC's Legal, Ethical and Human Rights Fund is currently funding a national joint project between PASAN and the Canadian HIV/AIDS Legal Network to assess the status of harm reduction programs and materials in federal and provincial prisons, identify gaps that need to be filled, and develop a best practice model for program and material delivery. PASAN and the Legal Network are collaborating on this project with the John Howard Society of Toronto, the Canadian Association of Elizabeth Fry Societies and the Canadian Harm Reduction Network. The project aims to ensure that all stakeholders are engaged in working toward increased access to harm reduction programs and materials in federal and provincial prisons.

The use of harm reduction measures while incarcerated is also being examined through a cross- Canada survey of federal inmates being funded jointly by PHAC's Hepatitis C Program and CSC. Other issues being addressed through the survey include participation in risk behaviours while incarcerated and knowledge of infectious disease transmission.

In the Quebec Region, ACAP is supporting the Centre Option Prévention Toxicomanie- Violence- Délinquance-Sida to undertake a pilot project to promote treatment adherence among incarcerated people living with HIV/AIDS. Phase I of the project involves conducting a needs assessment at the Archambault Institution to obtain information on the treatment adherence behaviour of inmates living with HIV/AIDS. This will lead to the development of an action plan tailored to the prison environment and the testing of various approaches to increasing treatment adherence. During Phase III of the project, the measures put in place will be evaluated, and information from the project will be shared with other CSC institutions.

CATIE and PASAN continued to work together in 2004-2005 on issues of HIV/AIDS and prisoners. For example, CATIE delivered workshops on HIV treatment information for PASAN staff, and PASAN in turn provided workshops on prison issues and HIV for CATIE staff and volunteers. PASAN also partnered with CATIE in its recent treatment information volunteer training program.

Youth

Although youth represents a small proportion of the total number of reported HIV and AIDS cases in Canada (individuals aged 10 to 24 account for 3.4 per cent of cumulative AIDS cases, and youth aged 15 to 19 account for 1.4 per cent of positive HIV test reports), risk behaviour data on young Canadians show significant potential for HIV transmission. A national study revealed that the use of condoms by sexually active youth decreases as their age increases.¹² The same study showed that approximately half of grade 9 students are not aware that there is no cure for HIV/AIDS, and some students think a vaccine is available to prevent HIV/AIDS. The extent of unprotected sexual activity among youth is captured in rates of chlamydia and gonorrhea among those aged 15 to 24 years. In 2002, the reported incidence of chlamydia in Canada was highest among females aged 20 to 24 years (1 377 cases per 100 000 women), and the reported incidence of gonorrhea was highest among 15 to 19 year old women (101.3 cases per 100 000).¹³

In Manitoba, the Sexuality Education Resource Centre, which promotes universal access to comprehensive, reliable information and services related to sexuality and reproductive health issues, undertook a project entitled Empowering Rural Youth Towards Healthy Sexuality. The objective of the project was to strengthen the involvement of rural Manitoba youth (grades 8 to 12) in education on sexuality issues for youth, including HIV/AIDS. With funding support from ACAP, the Resource Centre designed and delivered 74 workshops in schools, coordinated a youth conference, distributed promotional items such as condom key chains, and developed information tools containing harm reduction messages.

ACAP is providing ongoing funding to the AIDS Committee of Toronto for an outreach project aimed at HIV-positive youth. The committee sponsors the project on behalf of Positive Youth Outreach, a Toronto-based program that aims to empower, support and affirm the lives of young people infected with HIV/AIDS. Through workshops, drop-in groups, peer youth counselling and advertising, the project is increasing access to health promotion and HIV treatment information and support for HIV-positive youth, providing skills development opportunities, reducing social isolation and improving access to HIV-related psycho-social and medical services. In addition to the AIDS Committee of Toronto, the project involves the Toronto People with AIDS Foundation, Voices of Positive Women and CATIE.

The Alberta Community HIV Fund provided support for a number of projects aimed specifically at Aboriginal youth in 2004-2005. These include:

• the Grande Prairie Friendship Centre's Youth Wellness Program, which aims to ensure that youth aged 12 to 17, including at-risk street youth and incarcerated youth, are knowledgeable about HIV/AIDS, hepatitis C and how traditional teachings can help them make healthier lifestyle choices
• the Nechi Training, Research and Health Promotions Institute's Two Spirit Safe Communities Project, which is developing and delivering supportive outreach services to two-spirit youth aged 15 to 24 in the Edmonton area
• a project by the Canadian Red Cross Society, Southern Alberta Region, to recruit, train and supervise 200 Aboriginal youth (on- and off-reserve) to become «warriors» battling the spread of HIV in the Aboriginal population
• a project by the White Buffalo Dancers and Drummers Society in Edmonton to train urban Aboriginal youth to implement HIV/AIDS projects in their communities and to hold a retreat for Aboriginal youth
• an HIV/AIDS education and awareness workshop for pre-teen girls sponsored by the Métis Nation of Alberta.

PHAC continued to develop STI prevention and control materials, STI treatment guidelines, sexual health education guidelines, and materials to promote sexual health education among parents and teachers, using an approach based on common risk behaviours and shared modes of transmission.

Women

The HIV/AIDS epidemic is growing among women of all age groups in Canada. At the end of 2002, there were an estimated 7 700 women living with HIV in Canada, a 13 per cent increase over 1999 estimates. Women accounted for 23 per cent of estimated new infections in 2002. Surveillance data demonstrate that heterosexual contact and IDU are the two major risk factors for HIV infection in women.

At a meeting in the fall of 2004, CTAC, CAS, CATIE, Planned Parenthood Federation of Canada, the Positive Women's Network and Voices of Positive Women agreed to bring together other like-minded partners to develop a Blueprint for Action on Women and HIV/AIDS, launched on World AIDS Day this year. The national women's coalition formed by these groups now consists of more than 60 organizations from Canada and internationally, working to ensure that the impact of the epidemic on women around the world is addressed at the XVI International AIDS Conference in Toronto in August 2006.

Kali Shiva, a community-based organization that provides non-medical support services for people living with HIV/AIDS in Manitoba, is receiving funding from ACAP for a project entitled Positive Women Communicating for Change. The goal of the project is to build self-advocacy and life skills among HIV-positive women, thus enabling them to gain better access to employment, housing, social support systems and medical care. Among other activities, the project aims to establish an education and peer support group and a catering collective for HIV-positive women.

In Nova Scotia, the Antigonish Women's Resource Centre is being funded by ACAP for a two- year project to increase awareness among women of healthy sexuality, STIs and HIV/AIDS. Entitled Overcoming Resistance - From Awareness to Engagement, the project is involving community leaders and decision makers in increasing the availability of information that is both culturally and gender-relevant. Training sessions, workshops and presentations at community fairs are among the activities being used to raise awareness.

Voices of Positive Women held its fourth Dialogue Conference in Toronto in May 2005, providing an opportunity for HIV-positive women in Ontario and their health care providers to exchange knowledge, identify emerging issues and foster a cooperative environment for advocacy. Dialogue IV: Knowledge Exchange was held in conjunction with the LIGHT (Living In Good Health Together) Conference organized by PASAN to address issues for women living with HIV who had been incarcerated.

The British Columbia Persons with AIDS Society, in partnership with the Positive Women's Network, produced an interactive CD-ROM for HIV-positive women and health care providers. Entitled Retro Woman: Navigating Advanced Treatment Information for Women, the CD-ROM includes information that is specific to HIV-positive women on such topics as epidemiology, disease progression, gynecological health, drug side effects, STIs and antiretrovirals.

PHAC provided funding to enable Stella - an organization by and for sex workers - to plan and organize Forum XXX, the first ever international conference for sex workers and their allies. Held in Montréal in May 2005, the three-day conference attracted 250 street workers, escorts, strippers and x-rated film stars from countries around the world, including New Zealand, Thailand, India, Argentina, Sweden and Israel. HIV prevention was a major topic of discussion at the conference, which also featured workshops and presentations on legal and human rights for sex workers, job safety and the place of sex work in society.

CIHR's Community-Based Research Program awarded a grant to the British Columbia Centre for Excellence in HIV/AIDS to investigate HIV prevention and care strategies for women who depend on sex work for their survival.

People from Countries Where HIV is Endemic

In 2002 there were an estimated 3 700 to 5 700 prevalent HIV infections, and 250 to 450 incident (new) infections, among persons who were born in a country where HIV is endemic and who were infected through heterosexual contact. When these national incidence and prevalence estimates are compared to data from the 2001 Census, it is clear that persons from countries where HIV is endemic are overrepresented in Canada's HIV epidemic. In 2001, approximately 1.5 per cent of the Canadian population was born in a country where HIV is endemic, yet this group accounted for an estimated 7 to 10 per cent of prevalent HIV infections and 6 to 12 per cent of all new infections.

ACAP is providing funding support for a multi-faceted and multi-year project being undertaken by the Alliance for South Asian AIDS Prevention, a Toronto-based community organization working to prevent the spread of HIV and promote the health of South Asians infected with and affected by HIV/AIDS. The project aims to improve access to services for South Asian people living with HIV/AIDS and to increase their capacity to deal with psycho-social issues associated with the disease. As well, it will better enable these individuals to manage their own health, help build a supportive environment among service providers and the South Asian community, and strengthen volunteer involvement in the Alliance. Other partners in the project include CATIE, the Regent Park Community Health Centre and Asian Community AIDS Services.

In the Quebec Region, ACAP is supporting a compassion campaign led by GAP-VIES (Groupe d'action pour la prévention de la transmission du VIH et l'éradication du sida) to improve sensitivity among the Haitian community of Montréal about the needs, circumstances and experiences of Haitian people living with HIV/AIDS. The campaign aims to demystify HIV/AIDS, increase knowledge of the disease within the Haitian community, and improve understanding among service providers and others of the cultural aspects of HIV/AIDS and appropriate intervention models. Partners in the project include the Coalition des organismes québécois de lutte contre le sida, the Maison des jeunes l'Ouverture, the Centre d'alphabétisation NA Rive and McGill University's CKUT campus radio station.

The African Canadian Society of Alberta is being supported through the Alberta Community HIV Fund to develop and deliver an HIV/AIDS prevention project for new African immigrants in Edmonton. The project aims to develop sexual education awareness among this target group; to examine their attitudes, beliefs and values related to HIV transmission and prevention; and to encourage them to be tested for HIV infection. The project will also enable the African Canadian Society of Alberta to channel information about HIV and other STIs to African immigrants and to establish a referral system for HIV treatment.

PHAC's National HIV/AIDS Capacity Building Fund has approved funding for a national project that will strengthen the capacity of service providers and HIV/AIDS researchers to reduce the spread of HIV and improve the quality of life of African and Caribbean people living with HIV/AIDS. This joint initiative of the African and Caribbean Council on HIV/AIDS in Ontario (ACCHO) and the Women's Health in Women's Hands Community Health Centre will increase the availability and use of population-specific prevention resources, service providers' knowledge of HIV/AIDS-related issues that affect the African and Caribbean communities in Canada, and the cultural competency of service providers who work with these communities.

In a complementary initiative, ICAD, ACCHO and several other organizations have launched a process to develop a national strategy on HIV/AIDS for persons from countries where HIV/AIDS is endemic. Results of the work completed to date were presented during a satellite session at the 5th Canadian HIV/AIDS Skills Building Symposium in Montréal.

Through its languages @  catie.ca Web site, CATIE makes treatment information available in Swahili, Hausa, Tamil and several South Asian languages (more languages will be added in the future). CATIE staff are also involved in a study by ACCHO and the University of Toronto, with funding from the Ontario HIV Treatment Network, of HIV/AIDS stigma and discrimination in African and Caribbean communities.

Future Directions

The Federal Initiative to Address HIV/AIDS in Canada answers a call for more effective interventions and improved prevention and treatment initiatives for at-risk populations. As implementation of the Federal Initiative unfolds, programs will be established to improve front line capacity to deliver population-specific initiatives; increase access to care, treatment, support and rehabilitation; and provide for the meaningful involvement in the response of at-risk populations and people living with HIV/AIDS. The federal government will also continue to improve population-specific epidemiological, socio-behavioural, ethnographic and community-based research. As well, enhanced behavioural research is being undertaken among street youth, injection drug users, MSM, Aboriginal peoples and other at-risk populations to support the evidence-based HIV prevention and control strategies funded under the Federal Initiative.

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8. The term «second generation» is used to describe surveillance systems that aim to gather information on behaviour, as well as infection status.
9. A report on the findings of the pilot phase was published in February 2004. I-Track: Enhanced Surveillance of Risk Behaviours among Injecting Drug Users in Canada, Pilot Survey Report can be accessed online at /www.phac-aspc.gc.ca/i-track/psr-rep04/index-eng.php).
10. The degree to which the epidemic can be monitored among Aboriginal peoples is hindered by a lack of surveillance data. Ethnicity information is provided in only one-thirdone third of positive HIV test reports.
11. CSC Infectious Disease Surveillance System, preliminary unpublished data, 2005.
12. Canadian Youth, Sexual Health and HIV/AIDS Study: Factors influencing knowledge, attitudes and behaviours. The Council of Ministers of Education, Canada. 2003.
13. Community Acquired Infections Division, Centre for Infectious Disease Prevention and Control, Health Canada. 2003.