Government of Canada Report to the Secretary General of the United Nations on the United Nations General Assembly Special Session on HIV/AIDS Declaration of Commitment on HIV/AIDS January 2003 - December 2005

Previous | Table of Contents | Next

Annex 2: Part B
National Composite Policy Index

I. Human rights

I. 1 Canada has laws and regulations that protect people living with HIV and AIDS against discrimination (such as general non-discrimination provisions or those that specifically mention HIV, that focus on schooling, housing, employment, etc.).

While Canada has enacted human rights legislation, and interpreted it in a way that it includes people living with HIV/AIDS under the umbrella of physical disability, enforcement of this legislation remains inadequate. In most cases, it is up to the individual who experiences discrimination to 1) know their rights, 2) recognize that they have been discriminated against, 3) have knowledge of the complaints mechanisms available for redress, and 4) be willing/able to lodge a complaint. These mechanisms for enforcement present many barriers for people living with HIV/AIDS and vulnerable populations. In order to access their basic rights, people must first have access to basic human rights information, rights-based education, and knowledgeable service providers to advocate and support self-advocacy. Given the nature of HIV/AIDS related stigma and the corresponding need for confidentiality, national and community-based AIDS service organizations have a key role to play in eliminating discrimination by bridging the enforcement gap through supporting such education and advocacy. The role of education and advocacy is not just the promotion of human rights, but also an integral part of ensuring the adequate enforcement of human rights legislation (particularly for vulnerable populations who might not otherwise have access to the information and resources they need).

Despite human rights protections being available in Canada, there remain significant challenges. Provided an individual has the fortitude to go forward with one of the redress mechanisms available to them, the process is often a daunting task, which requires resources that may not always be worth the effort. In some cases, a positive outcome in a formal remedial action may not necessarily result in positive change, and are at times compromised by various jurisdictional issues, as in the case of Aboriginal people who fall within both federal jurisdiction and provincial/territorial jurisdictions.

I. 2 Canada has non-discrimination laws or regulations which specify protections for certain groups of people identified as being especially vulnerable to HIV and AIDS discrimination (i.e., groups such as people who inject drugs, gay and other men who have sex with men, sex workers, youth, mobile populations, and prison inmates).

Section 15(1) of the Canadian Charter of Rights and Freedoms, which applies to all laws and other actions by governments in Canada, states:

Every individual is equal before and under the law and has the right to the equal protection and equal benefit of the law without discrimination and, in particular, without discrimination based on race, national or ethnic origin, colour, religion, sex, age or mental or physical disability.

Under the Canadian Human Rights Act¹, people living with HIV are protected from HIV-based discrimination in all jurisdictions because HIV is considered a disability in the context of anti-discrimination law with respect to any employment, goods, services, facilities or accommodation or access thereto or occupancy of any commercial premises or residential accommodation². These protections apply to both the private and public sector. The Canadian Human Rights Commission Policy on HIV/AIDS states:

Everyone has the right to equality and to be treated with dignity and without discrimination, regardless of HIV/AIDS status.

The Canadian Human Rights Act ³ prohibits discrimination on the basis of disability. Individuals with HIV/AIDS may therefore seek protection under the Canadian Human Rights Act. People who are not HIV positive may also be subject to discrimination by virtue of their real or perceived membership in a risk group or their association with a person or people with HIV/AIDS. These individuals may also seek protection under the Canadian Human Rights Act on the basis of perceived disability. The Commission will expedite the investigation of complaints alleging HIV/AIDS related discrimination. There are problems associated with relying on the concept of disability for framing human rights obligations and prohibition of discrimination. Discrimination on the basis of HIV status alone, as well as discrimination against those who are vulnerable, should be prohibited in all circumstances, including those outside of issues of disability.

Discrimination on the basis of sexual orientation is also prohibited in all jurisdictions of Canada. G ender-based discrimination is prohibited, as with HIV status or sexual orientation. However, only one jurisdiction in Canada (the Northwest Territories) has explicit protection on the basis of gender identity. Discrimination on the basis of r ace or ethnicity is prohibited. Discrimination on the basis of age is prohibited for those between the ages of 18 and 65 (youth and the elderly are not generally covered). Discrimination on the basis of injecting drug use is not prohibited under anti-discrimination legislation in any jurisdiction. However, in the employment context, some courts and tribunals have considered drug addiction/dependence to constitute a disability (or "handicap", depending on the wording of the applicable statute) under law and therefore there is a duty to accommodate that disability, short of "undue hardship."

There is also no protection for sex workers against discrimination based on their involvement in sex work. If an individual is convicted of using a place for prostitution, the owner or landlord of that space must be notified and can face criminal charges and conviction if they do not take steps such as evicting the sex worker from his or her apartment which thereby persecutes the sex worker.

Anti-discrimination legislation needs improvement in terms of protecting youth, transgendered people, drug users and sex trade workers. According to an environmental scan conducted by the AIDS Calgary Equality Project, there is a dearth of information on HIV-related discrimination in Canada. It is unknown how frequently HIV-based discrimination occurs, in what contexts, the responses to HIV-based discrimination, and how individuals seek effective redress⁴. Human Rights Commissions are charged with providing redress for discrimination, and some have a fast-track process or special guidelines for HIV-based complaints. However, there are concerns about delays and hurdles in getting Commissions to adequately respond to HIV-related complaints, largely due to resource constraints.

Canada needs some additional research to gain a more thorough assessment of the extent of discrimination - in employment, housing, harassment, health care settings - on the basis of HIV status. Human Rights Commissions would be able to provide information about the number of complaints filed, which is generally believed to be a small proportion of actual incidents of discrimination.

The complexities of jurisdictional issues for the three Aboriginal groups in Canada (First Nations, Inuit and Métis) can result in lack of consistency in service delivery. There are parallel systems in Canada due to Treaty and Aboriginal rights which result in unique status for Aboriginal people. In many cases, Aboriginal people fall through the cracks, and they often face discrimination based on ethnicity, HIV status, and in some cases, discrimination based on risk behavior(s) such as injection drug use.

I. 3 Canada has some laws and regulations that present obstacles to effective HIV prevention and care for most-at-risk populations.

All HIV prevention tools (e.g., male and female condoms, lubricants, clean needles, methadone substitution therapy) are, in principle, available and accessible in communities across Canada. With respect to prisons, there is uneven access across correctional jurisdictions, which, in Canada, are divided into provincial/territorial (for those serving sentences of less than two years) and federal (for those serving sentences of two years or more). No correctional jurisdiction currently makes clean needles accessible.

A 2002 report⁵ noted that in the provincial/territorial jurisdictions of New Brunswick, Nunavut, Prince Edward Island, and some institutions in the Northwest Territories, condoms, dental dams and water-based lubricant were still not available to prisoners. The province of Québec provided condoms, but not dental dams or water-based lubricant. As well, based on the same 2002 findings, some of the provincial/territorial jurisdictions that provided safer sex materials in prisons did so primarily (or solely) through the medical units. This meant that prisoners who sought access to condoms had to make a request to staff, a clear barrier to prisoners who wanted to practice safer sex. In the case of provincial institutions in Ontario, provincial correctional policy specifically prohibited prisoners from accessing more than one condom at a time or having more than two in their possession. Correctional Service Canada (CSC), responsible for federal penitentiaries, has a national policy to make condoms, dental dams, bleach, lubricant and methadone continuation and initiation available to prisoners. It should also be noted that CSC has sought scientific and technical advice from the Public Health Agency of Canada on the risks and benefits of prison needle exchange programs.

The Canadian HIV/AIDS Legal Network has recommended that in order to remove barriers to the use of prevention tools in prisons, condoms, dental dams, bleach and water-based lubricant needed to be made more easily and discreetly accessible to inmates in all prisons, in different locations throughout the institutions, and without inmates having to ask for them.

In practice, even within community settings, most vulnerable populations (e.g., youth, Aboriginal communities, small rural communities, refugees, trafficked women and sex trade workers) have very spotty access to these prevention tools. For over a decade, it has been recommended that Canadian prison systems move ahead with implementing needle exchange programs in prisons.

Provision of these prevention tools and programs varies according to province/territory and between health regions, especially for female condoms, needles, methadone and bleach. For some small communities, even where these prevention tools are accessible, individuals may be reluctant to access them from health centres or stores due to lack of privacy. Refugees, immigrants and trafficked women may not be able to get prevention tools and programs due to language barriers or lack of availability. Vancouver ( British Columbia) is piloting Canada's first official safe injection facility and a thorough evaluation is being conducted in order to assess the impacts of the program on drug use, overdose, infection, and crime rates.

I. 4 The promotion and protection of human rights is explicitly mentioned, in varying degrees and with varying depth, in HIV and AIDS strategies.

Leading Together: Canada Takes Action on HIV/AIDS (2005-2010) is a pan-Canadian multi-stakeholder, multi-sectoral Action Plan, providing an opportunity for all parts of the country and all organizations involved in HIV/AIDS to come together as part of a larger, nation-wide effort. Leading Together explicitly bases its approach and recommended actions on the principles of human rights. Human rights is stated as one of the core values of Leading Together: " All people, regardless of their sexual orientation, race, culture, gender or risk behaviour, are important, and their human rights - including their economic, social, cultural, civil and political rights - should be recognized, respected and promoted. Not one life is expendable. We recognize the dignity and worth of each person."

Human rights is also mentioned in the description of the " Current State of the Epidemic: Why We Need to Step up Our Efforts" as Reason #4: "Stigma and discrimination continue to threaten people with HIV and communities at risk. Stigma can lead to violations of the human rights of people living with HIV, including unlawful discrimination in housing, employment and health and social services."

Under the Blueprint, "Commitment to Social Justice and Human Rights," Leading Together states that a n effective response to HIV: "recognizes and addresses the broad determinants of health that make people vulnerable to HIV and to disease progression; understands those determinants in ethical terms and is committed to addressing the injustices that contribute to them; and is based on human rights and recognizes that protecting people's human rights - including the right to the highest attainable standard of health - is a means of achieving social justice and the goals of this document." Leading Together also states "Advocacy is an essential part of a commitment to social justice and to human rights. When the voices of a disadvantaged group are not heard or listened to, others must speak for them and advocate for their civil and political rights (e.g., freedom of expression and association, freedom from torture) and their economic, social and cultural rights (e.g., the right to shelter, food, a safe working environment). All those involved in HIV must champion the rights of people living with HIV and of communities at risk. The determinants of health will be addressed when social justice is achieved, and social justice is achieved when the human rights of every person are fully realized."

Under "The Actions: What we will do between now and 2010", Action #2 is to Address the Social Factors/Inequities Driving the Epidemic, with the rationale: "While the majority of Canadians are aware of how HIV is transmitted, fewer realize the impact of social determinants of health on risk or understand the need for a social justice and human rights approach to HIV." Seventeen specific actions are recommended under Action #2. Human rights are also mentioned under Action #5, Under Action #5: Provide Leadership in Global Efforts, and specifically, the document instructs Canada to i ntegrate human rights, including the right to the highest attainable standard of physical and mental health and the human rights of women, into Canada's international relationships through a variety of methods and partnerships.

The Federal Initiative to Address HIV/AIDS in Canada: Strengthening Federal Action in the Canadian Response to HIV/AIDS replaces the Canadian Strategy on HIV/AIDS and is meant to contribute to a comprehensive and integrated Government of Canada response towards realizing Leading Together. However, the Federal Initiative is weak in its grounding in a human rights framework. Human rights are only mentioned briefly under Knowledge Development, stating that " Support will be provided for research on and analysis of the legal, ethical and human rights dimensions of Canada's response to HIV/AIDS." Under Global Engagement, the Federal Initiative states: "In collaboration with CIDA, Foreign Affairs Canada and others, technical support and policy guidance will be provided on global issues, such as gender risk factors, human rights, microbicides, vaccines and harm reduction. CIDA, Foreign Affairs Canada and Federal Initiative partners will cooperatively represent Canada in international HIV/AIDS and health fora."

While the Federal Initiative states that the federal government will make a larger and more effective contribution to addressing the complex social, human rights, biological and community barriers that continue to fuel the epidemic, it does not commit to domestically address human rights issues faced by those living with or vulnerable to HIV/AIDS beyond providing support for research on human rights issues. The Government of Canada should be taking much more active steps to reduce human rights barriers within all five of its Areas of Action and human rights should be core principles and explicit activities within program and policy interventions, communications and social marketing; and coordination, planning, evaluation and reporting (as well as in knowledge development and global engagement).

I. 5 The Canadian Government, through political and financial support, has involved vulnerable populations in governmental HIV-policy design and program implementation.

Leading Together: An HIV/AIDS Action Plan for All Canada was developed by a broad cross-section of organizations and individuals involved in the Canadian response, including organizations representing vulnerable populations and people living with HIV. Starting in 2000, civil society was involved in a series of consultations and committees to develop the Action Plan. Key experts assisted in identifying strategic directions and specific objectives to answer the question: "What do we need to do to optimize the Canadian Response to HIV/AIDS over the next five years?" The results were used to begin drafting the Strategic Plan. The draft strategic plan then underwent a wide consultation in the Fall of 2003. Two consultation processes were developed. The first was a broad consultation of Canadian participants in the HIV/AIDS response from as many sectors as possible. The second process aimed to consult directly with PHAs and vulnerable populations. The consultation of PHAs and vulnerable populations required particularly innovative mechanisms to allow for the strongest possible voice and input. To assist in guiding the development of that consultation, an advisory group of PHAs, vulnerable Canadians and others was assembled and provided advice and parameters to frame those particular consultations. All of this work culminated in the finalization of a Strategic Plan, announced and launched on World AIDS Day of 2003.

The Federal Initiative to Address HIV/AIDS in Canada facilitates increased engagement by, and improved collaboration among, all levels of government, communities, non-governmental organizations, professional groups, institutions and the private sector. Most of the following national organizations are supported by funding through the Federal Initiative:

• Canadian Aboriginal AIDS Network
• Canadian AIDS Society
• Canadian AIDS Treatment Information Exchange
• Canadian Association for HIV Research
• Canadian Foundation for AIDS Research
• Canadian HIV/AIDS Information Centre
• Canadian HIV/AIDS Legal Network
• Canadian HIV Trials Network
• Canadian Treatment Action Council
• Canadian Working Group on HIV and Rehabilitation
• Interagency Coalition on AIDS and Development
• International Council of AIDS Service Organizations

The AIDS Community Action Program (ACAP) is one component of the Federal Initiative to Address HIV/AIDS in Canada. ACAP is a federal funding program that supports local, regional, and provincial/territorial community-based organizations addressing HIV/AIDS issues across the seven regions of Canada: Atlantic provinces, Quebec, Ontario, Manitoba/Saskatchewan, Alberta, British Columbia, and the Northern Secretariat ( Northwest Territories, Nunavut Territory and Yukon Territory).

ACAP programming reflects the principles of community development; health promotion; partnerships and collaboration; population health; and planning and evaluation. These principles are in alignment with the policy direction of t he Federal Initiative: partnership and engagement; integration and accountability. ACAP funding supports programming in the following areas:

• Prevention Initiatives to prevent HIV in populations known to be vulnerable to HIV.
• Health Promotion for People Living with HIV/AIDS to increase the capacity of people living with HIV to manage their condition (services, treatment, support, work, learning), and support for people affected by HIV.
• Creating Supportive Environments to reduce social barriers that prevent people living with HIV, those at risk, and those affected from accessing health care and social services. Targeted environments include (but are not limited to): prisons, addiction treatment, professional groups (nurses, educators, pharmacists, physicians, etc.), workplaces, other non-profits, general public.
• Strengthening Community Based Organizations to increase the skills and abilities of the people who work at all levels of the community-based HIV movement: board, staff and volunteers.

ACAP resources are available for operational funding (available to AIDS Service Organizations) and for time limited project funding (available to community organizations that deal with HIV/AIDS as part of their wider programming). ACAP plays a key role in influencing the development and implementation of provincial and territorial programs designed to support community-based HIV/AIDS work. Previous evaluation reports of the National AIDS Strategy clearly indicate that continued federal support for ACAP is integral to any success the federal government hopes to have in preventing the spread of HIV and in creating supportive social environments for people living with HIV/AIDS⁶. ACAP is also an invaluable funding program in furthering multi-sectoral participation in the population health framework⁷.

It is important to note that inclusion and involvement of community-based organizations does not necessarily mean that there is meaningful involvement of vulnerable populations. Sex trade workers are not even named as a vulnerable population in the Federal Initiative, and prisoners and people who inject drugs traditionally have not been well-represented by community-based HIV/AIDS organizations or national NGOs.

I. 6 Canada does not have a specific policy to ensure equal access, between men and women, to prevention and care.

Health care is a provincial jurisdiction in Canada but the Canada Health Act mandates that all Canadians have the right to access essential health care services. Although there is officially universal access to health care in Canada, people living with HIV or vulnerable to HIV still experience barriers to accessing health care services and realizing the right to health. Canada does not have specific policies for men and women with respect to HIV prevention and care, but there is a legal framework that governs equal access to care in general.

Recently, the Public Health Agency of Canada has been working with the coalition called " Blueprint for Action on Women and HIV/AIDS" in order to discuss the draft Framework on Population Specific Approaches for the Federal Initiative and to identify priority actions/issues for consideration for women in each of the priority vulnerable populations listed in the Federal Initiative. Blueprint for Action on Women and HIV in Canada: Towards 2006 (referred to as The Coalition) was created by civil society to bring together individuals and organizations addressing the needs of women living with, and affected by, HIV/AIDS in Canada to act as a united voice on policy issues. The coalition seeks to advocate on these issues and influence national, provincial and municipal governments to provide services and funding programs aimed specifically at services for women living with HIV/AIDS and women affected and vulnerable to HIV/AIDS.

The aim of the coalition is to develop a set of demands addressed to governments, the pharmaceutical industry and other stakeholders addressing all aspects of HIV/AIDS including prevention, care, treatment and support, research and policy initiatives that would stop the alarming infection rate and lack of gender-based treatment information and research. The Blueprint has defined a group of demands with one overarching demand: All demands must have adequate and sustained resources, including financial and human resources; must be culturally and linguistically appropriate and must include women with HIV as an integral part of the solution making and decision making process.

With respect to HIV prevention and education, the coalition calls for a comprehensive approach to sexual and reproductive health and prevention programming, including enhanced support and adequate resources for the research and development of microbicides and creation of a microbicide implementation plan that will ensure affordable, free and unlimited access. Also, the coalition calls for sustainable and culturally and linguistically sensitive services for women who experience violence and their families, and for culturally and linguistically appropriate prevention and education strategies and programs for First Nations, Métis and Inuit, developed by Aboriginal peoples with resources provided by all levels of governments.

Further work needs to be done by appropriate stakeholders, including governments, healthcare institutions, healthcare providers and HIV-positive women, to develop responsive models for health care and support delivery that acknowledge and affirm the multiple roles that women play and the importance of including these in care and support plans. With respect to w omen's care, treatment and support issues, the Blueprint Coalition makes the following recommendations:⁸

• Ensure that informed choice and option of treatments (e.g., complementary and alternative medicine) be available and specific to women.
• Ensure that there is a systemic post-approval surveillance system on drugs for women (and their treatment). This does not currently exist.
• Investigate and research how stigma and discrimination are barriers for getting and receiving support and care. The collected data should be segregated by sex and age.
• Gather and provide gender specific treatment information to: (a) ensure that treatment options are just as good for women as men, and that women are treated as women (not just mothers), and (b) provide health care professions with gender-specific information.
• Across the country, establish standards of care, improve access to treatment (add treatment to formularies quickly).
• Coordination of treatment information across Canada.

Women tend to receive HIV-positive test results later in the course of the disease (often finding out during pregnancy) because many doctors and women still believe women are at low risk of contracting HIV. Women therefore are discouraged from receiving early detection and treatment, receiving both can maintain health over a longer period of time⁹ .

Diagnosis is one important part of the continuum of services to address HIV/AIDS, along with prevention, care, treatment and support. There is a need for more anonymous testing sites and population-specific testing sites, particularly for women. Physicians need better training on how to recognize and respond to signs and symptoms that women are in abusive relationships. Partner notification and disclosure in the context of violence against women is not well addressed in Canada.

Discrimination against women and failure by the medical community to understand the disease in women also prevent women from receiving effective treatment. Many HIV-positive women feel intimidated by doctors and may not ask as many questions as their HIV-positive male counterparts.

Pharmaceutical companies and the medical community must remove barriers preventing women from joining drug studies. Governments must remove the social and economic barriers preventing women from gaining access to treatment. Women need greater social and economic support if they are to receive effective treatment.

Poverty is another barrier to treatment because anti-HIV drugs are very expensive, and although the majority of costs are often covered by provincial plans, deductibles, co-payments and dispensing fees may prove prohibitive for people on low-income. Women earn less than men; many women work part time, and are often excluded from health plans; many mothers place the financial needs of their children and families above their own. Complementary and alternative therapies are typically not covered by provincial health plans, placing such therapies out of reach for many women.

Clinical Trials : despite increasing rates of HIV among women, they are woefully under-represented in clinical trials, which require a substantial time commitment, and may result in unpaid time away from work. Pharmaceutical companies and hospitals do not provide child-care services or compensatory money, making it difficult for women to participate in studies. Taking time off work may raise disclosure issues, as some women may not want to disclose their HIV status to employers. Women are often excluded from drug trials because of their biological potential for pregnancy. Many women lack support in the home, which can hinder their ability to participate in studies.

Barriers to drug adherence : as with barriers to treatment, social and economic factors prevent HIV-positive women from keeping to a drug regimen. However, women are faced with an additional burden: as traditional family caregivers, they give much of their time and energy to the care of others. Skipping medications, or taking drugs later than recommended, can reduce the overall level of health in HIV-positive women. Women need a family-centred approach to care and treatment.

It should be noted that there is very little attention given to the role of men and boys and there is no gender-focused policy on men and boys (e.g., to mitigate the epidemic amongst heterosexual men). There is also no analysis in the Federal Initiative of the differential impact of the HIV/AIDS epidemic on men, women, girls and boys.

I. 7 Canada does not have an explicit policy to ensure equal access to prevention and care for most-at-risk populations.

The Federal Initiative states that n ew programs will be developed along the prevention-care continuum with and for people living with HIV/AIDS, gay men, people who inject drugs, Aboriginal people, federal inmates, youth and women at risk for HIV and people coming from countries where HIV is endemic. The Federal Initiative does not, however, directly address measure to ensure equal access and care for most at-risk populations. With respect to prisons, there is uneven access across correctional jurisdictions, which, in Canada, are divided into provincial/territorial (for those serving sentences of less than two years), and federal (for those serving sentences of two years or more). No correctional jurisdiction currently makes clean needles accessible.

A 2002 report¹⁰ noted that in the provincial/territorial jurisdictions of New Brunswick, Nunavut, Prince Edward Island, and some institutions in the Northwest Territories, condoms, dental dams and water-based lubricant were still not available to prisoners. The province of Québec provided condoms, but not dental dams or water-based lubricant. As well, based on the same 2002 findings, some of the provincial/territorial jurisdictions that provided safer sex materials in prisons did so primarily (or solely) through the medical units. This meant that prisoners who sought access to condoms had to make a request to staff, a clear barrier to prisoners who wanted to practice safer sex. In the case of provincial institutions in Ontario, provincial correctional policy specifically prohibited prisoners from accessing more than one condom at a time or having more than two in their possession. Correctional Service Canada (CSC), responsible for federal penitentiaries, has a national policy to make condoms, dental dams, bleach, lubricant and methadone continuation and initiation available to prisoners. It should also be noted that CSC has sought scientific and technical advice from the Public Health Agency of Canada on the risks and benefits of prison needle exchange programs.

The Canadian HIV/AIDS Legal Network has recommended that in order to remove barriers to the use of prevention tools in prisons, condoms, dental dams, bleach and water-based lubricant needed to be made more easily and discreetly accessible to inmates in all prisons, in different locations throughout the institutions, and without inmates having to ask for them.

In practice, even within community settings, most vulnerable populations (e.g., youth, Aboriginal communities, small rural communities, refugees, trafficked women and sex trade workers) have very spotty access to these prevention tools. For over a decade, it has been recommended that Canadian prison systems move ahead with implementing needle exchange programs in prisons.

Provision of these prevention tools and programs varies according to province and between health regions, especially for female condoms, needles, methadone and bleach. For some small communities, even where these prevention tools are accessible, individuals may be reluctant to access them from health centres or stores due to lack of privacy. Refugees, immigrants and trafficked women may not be able to get prevention tools and programs due to language barriers or lack of availability. Vancouver ( British Columbia) is piloting Canada's first official safe injection facility and a thorough evaluation is being conducted in order to assess the impacts of the program on drug use, overdose, infection, and crime rates.

There are a limited number of First Nations, Métis and Inuit prevention messages and programs being offered to Aboriginal youth¹¹. Of the messages that are available, a pan-Aboriginal approach is sometimes being taken that is often ineffective. In particular, Inuit youth are being lost in this approach. Aboriginal youth under the age of 15 and people who inject drugs are the groups most in need of HIV prevention messages but they are among the least likely to be receiving them. Prevention education must begin before youth become sexually active, and it must address injection drug use.

There are now efforts underway by the African and Caribbean Council on HIV/AIDS in Ontario to develop a National HIV/AIDS Strategy for Black Canadian, African and Caribbean Communities. Generally speaking, targeted prevention programs are well designed and well-targeted but grossly under-resourced (due to one-time project funding). Prevention initiatives are largely led by community organizations working directly with the vulnerable populations. Most prevention messages in Canada have targeted MSM and gay men, people who inject drugs, and youth. Limited messages have been targeted to women, migrants and mobile populations; as well, very few prevention initiatives have been implemented for prisoners, t ransgendered people, and sex workers.

I. 8 Canada has policies prohibiting HIV screening for general employment purposes (appointment, promotion, training, benefits).

The Canadian Human Rights Commission (CHRC) originally issued a policy statement on AIDS in 1988. In June 1996, the Commission released a revised version of the statement, based on current medical, scientific and legal information. The CHRC's policies are mirrored in numerous other Canadian legislation and policies ¹².

Commission will not accept being free from HIV/AIDS as a bona fide occupational requirement (BFOR) or a bona fide justification (BFJ) unless it can be proven that such a requirement is essential to the safe, efficient and reliable performance of the essential functions of a job or is a justified requirement for receiving programs or services.

HIV positive persons pose virtually no risk to those with whom they interact in the workplace. The Commission, therefore, does not support pre- or post-employment testing for HIV. Such testing could result in unjustified discrimination against people who are HIV positive.

As a result of new drugs and forms of intervention, people with HIV infection are now able to continue productive lives for many years. If individuals with the requisite workplace accommodation are able to continue to work, they should be allowed to do so. Any decision made by an organization relying on health and safety considerations to exclude a person must be based on an individual assessment supported by authoritative and up-to-date medical and scientific information.

Regarding health care workers, the Canadian Medical Association Policy on HIV/AIDS states that:

The routine testing of health care workers for the HIV antibody is not justified. The CMA supports the application of universal precautions that enhance the protection of health care workers against potential infection from patients and vice versa.

The Canadian Human Rights Commission supports this view.

The Public Service Staff Relations Act, which applies to all federal government departments and other portions of the Public Service, states that employees are not required to undergo mandatory tests for HIV infection. Human rights regulations in Canada recognize that in most work environments in the public and private sector, employees with HIV infection or AIDS do not pose a health risk to others. As with other serious illnesses and disabilities, these employees are encouraged to remain productive as long as they are able. They must not be subject to discriminatory practices. The Public Service Staff Relations Act also states that d epartments must ensure that: the rights and benefits of employees with HIV infection or AIDS are respected; the occupational safety and health of employees with a potential risk of exposure to HIV is protected; employees are informed of existing information, education, counseling and evaluation services in the Public Service with respect to HIV infection and AIDS.

However, other issues relating to workforce participation for people living with HIV require further policy development in Canada. As the nature and impact of HIV/AIDS have shifted in recent years, many people living with HIV in Canada are living longer but also with impairments, activity limitations and participation restrictions. Many community-based AIDS organizations in Canada are initiating work to address workplace issues for people living with HIV, such as the Canadian AIDS Society, the Canadian Aboriginal AIDS Network, COCQ-sida, British Columbia Persons with AIDS Society, AIDS Committee of Toronto, the British Columbia Coalition of People With Disabilities, the Interagency Coalition on AIDS and Development (ICAD), AIDS Calgary, and the Canadian Working Group on HIV and Rehabilitation (CWGHR). People living with HIV face numerous barriers with respect to remaining in employment or returning to employment after taking disability or sick leave. There are many issues faced by people living with episodic disabilities, such as HIV, in Canada. Two priority issues identified by the participants of the Episodic Disabilities Network are income security and labour force participation. The unpredictability of living with HIV, as with other episodic disabilities, can have a significant impact on income support.

ICAD is working to apply a rights-based approach to policy development and the practical considerations for implementing employee rights and employer obligations in the workplace. ICAD is developing training materials and workshops for both employers and employees regarding human rights and employment related legislation in Canada and how this relates specifically to HIV/AIDS as well as other life threatening, chronic and/or episodic disabilities. CWGHR is leading the "Labour Force Participation and Social Inclusion for People Living with HIV and Other Episodic Disabilities" project. This project is building on a network of episodic disability groups to identify and analyse policies, programs and practices of public and private disability income support and workplace issues to determine strengths, gaps and barriers. This knowledge will then be transferred to policymakers, employers, human resource professionals, labour representatives, insurance providers and other relevant stakeholders. Finally, the project will facilitate labour force participation by testing and evaluating new models for flexible employment and income support to accommodate people with episodic disabilities.

One area for improvement in Canada is for the private sector (particularly Canadian corporations working internationally) to adopt the International Labour Organization's Code of Practice on HIV/AIDS. Currently, the government of Canada does not institute any incentives for Canadian firms working internationally to abide by the ILO Code of Practice on HIV/AIDS, nor penalties for those who do not.

I. 9 Canada has policies to ensure that HIV and AIDS research protocols involving human subjects are reviewed and approved by a national/local ethical review committee.

Organizations that can apply for HIV/AIDS research funding to bodies such as the Canadian Institutes of Health Research (CIHR), the Canadian Foundation for AIDS Research, or provincial health research funding bodies (e.g., Ontario HIV Treatment Network), must be able to administer a process for ethical review that is consistent with the Tri-Council Policy Statement on Ethical Conduct for Research Involving Humans, which articulates national standards for Canadian researchers ¹³. The general principles articulated in the Canadian Tri-Council Policy Statement include: respect for human dignity; respect for free and informed consent; respect for vulnerable persons; respect for justice and inclusiveness; balancing harms and benefits; minimizing harm; and maximizing benefit.

Although research ethics committees are common features of academic and clinical research institutions, they usually provide services only to their own members, so non-affiliated community-based researchers are usually ineligible. Most community-based HIV/AIDS organizations, however, don't have mechanisms for research ethics review. Only a few community-based research ethics review boards exist in Canada: Aboriginal Ethics Review Boards, the Community-Based Research Centre, the Community Research Ethics Board of Alberta , the University of Toronto's HIV/AIDS Research Ethics Board. Canada generally lacks HIV/AIDS-focused research ethics boards that communities or clinical/academic researchers across Canada can access.

Consequently, community-based researchers experience difficulties to access ethical review which diminishes opportunities to access the annual allocation of community-based research (CBR) funding for HIV/AIDS. To overcome this barrier, the current strategy of community-based researchers is to rely on partnerships with academic researchers.

Ultimately, this has implications for the completion of important research projects and the ethical soundness of community-based research projects. In such academic-community partnerships, however, the process of applying for ethical review is left to the dominion of the academic's institutional guidelines. These institutional guidelines and the members of academic ethics committees are not necessarily sensitive to ethical issues arising from CBR methodologies, do not necessarily include civil society representatives or people living with HIV, nor do they provide a forum for ethical guidance and consultation for community-based researchers. Additionally, researchers submitting protocols to academic ethics committees experience lengthy delays in the review process, have concerns about legal liability superseding ethical responsibility, and dominant scientific-research values are imposed on community-based researchers¹⁴. In AIDS prevention research, there is often a very close relationship between the affected communities and behavioural researchers. These complex relationships present challenges for institutional guidelines, which often do not understand or recognize collaborative research relationships. For that matter, members of institutional ethics committees are likely to come from research backgrounds that have placed them in control of the research process, because of scientific and funding criteria. In the context of CBR, an ethics committee needs to be aware of the distribution of power between community-based researchers and the organizations in which they work.

Access to ethical review continues to be a programmatic concern for CBR. Community-based organizations and investigators recognize and respect the need for ethical conduct in research. However, obtaining ethical review for CBR projects from traditional institutional committees requires partnerships that they feel are not necessarily helpful to, or understanding of, community research goals. One way to resolve the existing systemic barrier to ethical review for CBR would be through the establishment of competent and impartial community ethics committees. They should be understanding of the sensitive issues that often accompany HIV/AIDS projects as well as the multidisciplinary nature of CBR. The development of a community-based research ethics infrastructure would also promote increased independence for non-academic researchers and improve their awareness of ethical issues. Other potential benefits of CBR ethics committees would be:

• Community ownership of the ethics review process would promote independence in CBR. It would also help develop expertise essential to more balanced relationships with academic partners in research.
• Expedited ethics review at the community level would facilitate timely completion of research.
• Community-based ethics committees would provide direct guidance and consultation to community-based researchers and research populations.
• Community members would become more receptive to CBR as a result of increased peer involvement in the ethics review process.
• The autonomy of community-based ethics review would promote understanding of less traditional research methodologies. The ethics review process undertaken by community ethics committees can be expected to be less rigid and formulaic, and would prioritize different ethical aspects than academic or clinically based ethics committees.

Community-based researchers have been asking for a CBR ethics committee at least since 1999 to remove the systemic barrier facing community-based researchers. The committee should be recognized as having the authority to review, approve, or reject research proposals as well as perform a positive function by providing ethical guidance to researchers and organizations. The CBR ethics committee would promote principles of fairness and access, so that any CBR project in Canada could benefit from ethical review and guidance. Finally, the existence of any CBR ethics committee should be made known to researchers and community-based organizations. This could be achieved by including contact information in the CIHR's CBR grant applications.

I. 10 Does your country have the following monitoring and enforcement mechanisms?

Collection of information on human rights and HIV and AIDS issues and use of this information in policy and program development reform. There are no formal and standardized mechanisms for provincial, regional, or national-level monitoring of human rights issues relating to HIV/AIDS.	Yes	No
Existence of independent national institutions for the promotion and protection of human rights, including human rights commissions, law reform commissions and ombudspersons which consider HIV- and AIDS-related issues within their work	Yes	No
Establishment of focal points within governmental health and other departments to monitor HIV-related human rights abuses	Yes	No
Development of performance indicators or benchmarks for compliance with human rights standards in the context of HIV and AIDS efforts	Yes	No

I. 11 Members of the judiciary have not been trained/sensitized to HIV and AIDS and human rights issues that may come up in the context of their work.

The National Judicial Institute is an independent, non-profit organization that serves the Canadian judiciary, by planning, coordinating and delivering judicial education dealing with the law, the craft of judging and social context. The NJI also partners with and promotes the education offered by many other organizations, both Canadian and international. According to the National Judicial Institute, there are no courses offered to judges to provide them with sensitivity training in issues of HIV/AIDS as it relates to human rights or other legal issues.

I. 12 Are the following legal support services available in your country?

Legal aid systems for HIV and AIDS casework There are only a few legal aid organizations targeted to HIV/AIDS casework (the HIV & AIDS Legal Clinic of Ontario, University of Ottawa Community Legal Clinic , Comité des personnes atteintes du VIH du Québec ), but otherwise there are only general legal aid systems which do not specialize in HIV/AIDS.	Yes	No
State support to private sector laws firms or university based centers to provide free pro bono legal services to people living with HIV and AIDS in areas such as discrimination	Yes	No
Programs to educate, raise awareness among people living with HIV and AIDS concerning their rights Many community-based AIDS organizations in Canada provide services for people living with HIV to understand their rights (e.g., Canadian HIV/AIDS Legal Network, Canadian Aboriginal AIDS Network, Canadian AIDS Society, COCQ-sida, British Columbia Persons with AIDS Society, AIDS Committee of Toronto, the Interagency Coalition on AIDS and Development, AIDS Calgary, and the Canadian Working Group on HIV and Rehabilitation).	Yes	No

I. 13 There are programs led by the Government of Canada which are designed to change societal attitudes of discrimination and stigmatization associated with HIV and AIDS to understanding and acceptance.

Most information, education or communication initiatives aiming to change societal attitudes of discrimination and stigmatization are local or regional, sporadic, and time-constrained (mostly around AIDS Awareness Week, Aboriginal AIDS Awareness Week, and World AIDS Day). The Canadian HIV/AIDS Information Centre (a program of the Canadian Public Health Association) has produced resources for their "Change the World" social marketing campaign that focuses on reducing the stigma and discrimination faced by those infected or affected by HIV/AIDS, funded by the Public Health Agency of Canada. This campaign was developed for Canadian HIV/AIDS Awareness Week and World AIDS Day (2005). The Canadian Aboriginal AIDS Network is also implementing an Aboriginal HIV/AIDS Anti-Discrimination project, also supported by the Public Health Agency of Canada. The HIV/AIDS Division has also been working for the past year with stakeholders on the development of a PHAC-led national social marketing strategy to address HIV/AIDS related stigma and discrimination, as identified in the Federal Initiative.

II. Civil society participation

II. 1 Civil society has made a significant contribution to strengthening the political commitment of top leaders and national policy formulation.

Leading Together: An HIV/AIDS Action Plan for All Canad a was developed by a broad cross-section of organizations and individuals involved in the Canadian response, including organizations representing vulnerable populations and people living with HIV. Starting in 2000, civil society was involved in a series of consultations and committees to develop the Action Plan. Key experts assisted in identifying strategic directions and specific objectives to answer the question: "What do we need to do to optimize the Canadian Response to HIV/AIDS over the next five years?" The results were used to begin drafting the Strategic Plan. The draft strategic plan then underwent a wide consultation in the fall of 2003. Two consultation processes were developed. The first was a broad consultation of Canadian participants in the HIV/AIDS response from as many sectors as possible. The second process aimed to consult directly with PHAs and vulnerable populations. The consultation of PHAs and vulnerable populations required particularly innovative mechanisms to allow for the strongest possible voice and input. To assist in guiding the development of that consultation, an advisory group of PHAs, vulnerable Canadians and others was assembled and provided advice and parameters to frame those particular consultations. All of this work culminated in the finalization of a Strategic Plan, announced and launched on World AIDS Day of 2003.

Civil society - led primarily by national HIV/AIDS non-governmental organizations, community-based AIDS service organizations, and regional coalitions - is very active in analyzing and influencing Canadian policies relating to, and affecting, those vulnerable to or living with HIV/AIDS. Many civil society organizations are very active in policy analysis, education, advocacy, and community mobilization. Civil society organizations use a variety of advocacy strategies (such as letter-writing campaigns, petitions, demonstrations, lobbying and in person-meetings) to challenge politicians, government and other decision makers to address critical issues relating to HIV/AIDS, increasingly from a rights-based approach. Canadian civil society consistently insists on its inclusion in government policy formulation processes, either formally as members of advisory committees and steering groups, or through consultation with civil society stakeholders.

II. 2 Civil society representatives have had very limited involvement in the planning and budgeting process for the National Strategic Plan on HIV and AIDS and for the current activity plan.

Civil society organizations working in the area of HIV/AIDS have very little input into the allocation of Federal Initiative funding between and within the areas of 1) program and policy interventions; 2) knowledge development; 3) communications and social marketing; 4) coordination, planning, evaluation and reporting; and 5) global engagement. There has generally been less than optimal transparency about how funding is allocated within these areas of federal action; NGOs have very little information, for example, on the full plan for requests for proposals and their respective focus areas. There has also been tension between the government and NGOs with respect to the slow pace at which the Federal Initiative funding has been released to organizations and not enough of the funding is reaching vulnerable populations. The doubling of the Federal Initiative funding levels between 2003-04 and 2008-09 so far has not been reflected in the funding programs being offered to civil society.

One of the criticisms from the civil society HIV/AIDS sector is that a significant proportion of the new Federal Initiative funding for HIV/AIDS will be allocated to the overhead and administration costs of the Public Health Agency of Canada and the other government departments administering the Federal Initiative. A request has been sent to the Government of Canada for the exact amounts of Operations and Management funds allocated within the government departments so that civil society can ensure that the amounts are reasonable in relation the funds allocated to actual Grants and Contributions for non-governmental HIV/AIDS programming and research. Civil society is concerned that the increases in Federal Initiative funding for HIV/AIDS will not proportionally benefit national NGOs, community-based organizations, and the vulnerable communities that the serve, due to high administration costs associated with the newly established Public Health Agency of Canada, as well as the increasing complexity of the HIV epidemic in Canada.

II. 3 The complimentary services provided by civil society to areas of prevention and care are well recognized in both the National Strategic plans and reports.

The Federal Initiativeto Address HIV/AIDS in Canada facilitates increased engagement by, and improved collaboration among, all levels of government, communities, non-governmental organizations, professional groups, institutions and the private sector. Community development is the cornerstone of an effective response to HIV/AIDS. Much of the progress made so far in reducing the spread of HIV, and in caring for and supporting infected individuals, has been accomplished by non-profit, voluntary organizations and community groups. Federal support has been essential in helping to build and maintain this nation-wide community-based network.

Funding enables new and innovative programs that further engage the volunteer, health care and research communities in programs to prevent HIV infection and to care, treat and support people living with HIV/AIDS. These programs result in decreased infections, scientific advances in new treatment therapies, reliable diagnostic testing, effective health care practices, a strong community support system and a national knowledge base on how the epidemic is moving and changing.

Most of the following national organizations are supported by funding through the Federal Initiative:

• Canadian Aboriginal AIDS Network
• Canadian AIDS Society
• Canadian AIDS Treatment Information Exchange
• Canadian Association for HIV Research
• Canadian Foundation for AIDS Research
• Canadian HIV/AIDS Information Centre
• Canadian HIV/AIDS Legal Network
• Canadian HIV Trials Network
• Canadian Treatment Action Council
• Canadian Working Group on HIV and Rehabilitation
• Interagency Coalition on AIDS and Development
• International Council of AIDS Service Organizations

The AIDS Community Action Program (ACAP) is one component of the Federal Initiative to Address HIV/AIDS in Canada. ACAP is a federal funding program that supports local, regional, and provincial/territorial community-based organizations addressing HIV/AIDS issues across the seven regions of Canada: Atlantic provinces, Quebec, Ontario, Manitoba/Saskatchewan, Alberta, British Columbia, and the Northern Secretariat ( Northwest Territories, Nunavut and Yukon).

ACAP programming reflects the principles of community development; health promotion; partnerships and collaboration; population health; and planning and evaluation. These principles are in alignment with the policy direction of t he Federal Initiative: partnership and engagement; integration and accountability. ACAP funding supports programming in the following areas:

• Prevention Initiatives to prevent HIV in populations known to be vulnerable to HIV
• Health Promotion for People Living with HIV/AIDS to increase the capacity of people living with HIV to manage their condition (services, treatment, support, work, learning), and support for people affected by HIV
• Creating Supportive Environments to reduce social barriers that prevent people living with HIV, those at risk, and those affected from accessing health care and social services. Targeted environments include (but are not limited to): prisons, addiction treatment, professional groups (nurses, educators, pharmacists, physicians, etc.), workplaces, other non-profits, general public
• Strengthening Community Based Organizations to increase the skills and abilities of the people who work at all levels of the community-based HIV movement: board, staff and volunteers.

ACAP resources are available for operational funding (available to AIDS Service Organizations) and for time limited project funding (available to community organizations that deal with HIV/AIDS as part of their wider programming). ACAP plays a key role in influencing the development and implementation of provincial and territorial programs designed to support community-based HIV/AIDS work. Previous evaluation reports of the National AIDS Strategy clearly indicate that continued federal support for ACAP is integral to any success the federal government hopes to have in preventing the spread of HIV and in creating supportive social environments for people living with HIV/AIDS¹⁵. ACAP is also an invaluable funding program in furthering multi-sectoral participation in the population health framework ¹⁶.

II. 4 Civil society expects to be prominently involved in a National Periodic review of the Strategic Plan.

Each organization that receives funding from the Federal Initiative must submit funding proposals and progress reports to the government department administering the funding. Additionally, there are departmental workplans within each government department, with funded evaluation components in each department, and regular reports are provided to the Ministerial Council regarding the status of Federal Initiative spending.

A monitoring plan has not yet been established for Canada's Action Plan. The Federal Initiative states that c oordination, planning, evaluation and reporting will be enhanced to optimize both the federal and pan-Canadian responses to the epidemic and the use of resources. The focus will be on supporting the implementation of Leading Together and the development of issue-specific plans (for example, vaccines, population-specific approaches) and an evaluation strategy for the Federal Initiative. Integral to this will be mechanisms that enhance the engagement of people living with and vulnerable to HIV/AIDS. The following activities were outlined for coordination, planning, evaluation and monitoring of the Federal Initiative:

• A body will be established to coordinate and align the work of departments and agencies participating in the Federal Initiative.
• A multi-jurisdictional and multi-sectoral model will be developed to support the implementation of Leading Together .
• National and regional plans consistent with Leading Together will be developed and implemented.
• A performance measurement and evaluation strategy will be developed and implemented. Progress toward the goals of the Federal Initiative will be monitored on an ongoing basis.
• An annual report will be published each year on World AIDS Day as a key component of the performance measurement strategy.

The success of Leading Together depends on a voluntary nation-wide partnership, the responsibility for steering and monitoring it is to be shared among all the partners. The process for monitoring will likely involve five stages:

1. Commitment. Identifying the partners who should be part of the collective plan, and receiving from them a commitment to participate.
2. Roles and Responsibilities. Encouraging each partner to define its roles and responsibilities in implementing the Action Plan, based on its mission, skills and resources (i.e., what can each organization bring to our collective effort?)
3. Operational Plans. Asking each partner to identify the steps it will take over the next five years to implement the Action Plan, and reviewing all the operational plans against the Action Plan to identify any gaps (i.e., are there any outcomes or actions in the Action Plan that are not addressed by at least one partner?).
4. Monitoring Progress. Identifying the measures we will use to assess our progress and the information that partners will provide to support monitoring.
5. Steering the Plan. Using the monitoring information to develop progress reports, share effective strategies, and identify the need for new outcomes or actions, or to make changes in the Action Plan to respond to changing needs and knowledge.

II. 5 To what extent your country have a policy to ensure that HIV and AIDS research protocols involving human subjects are reviewed and approved by an independent national/local ethical review committee in which people living with HIV and caregivers participate?

Individuals representing community perspective, including AIDS service organization representatives, care providers, and PHAs make up 50% of the membership of the Canadian Institute for Health Research review committee for Community-Based Research. However, community representatives are not necessarily members of other research review committees (e.g., for basic or clinical HIV/AIDS research). Civil society strongly recommends that inclusion of community representatives be instituted on other research review committees.

III. Prevention

(Check all programs that are implemented beyond the pilot stage to a significant portion of both the urban and rural populations).	2005
a. A program to promote accurate HIV and AIDS reporting by the media.	NO
b. A social-marketing program for condoms With the exception of World AIDS Day campaigns led by the Global AIDS Campaign, there are no standardized prevention (or condom promotion) messages in Canada. Any information, education or communication initiatives on prevention are local or regional, sporadic, and time-constrained (mostly around AIDS Awareness Week and World AIDS Day - e.g., the Assumptions Campaign, Gay Men Play Safe, and Condom Country Campaign). Communities generally develop and deliver their own targeted messages, due to restraints from school boards and the need to deliver population-specific messages. Most community-based prevention messages are based on sex-positive and harm reduction approaches, as opposed to abstinence-based models, recognizing that most people are sexually active and/or use drugs, while also providing them with information and prevention messages that will assist them to protect their health.	YES/ NO
c. School-based AIDS education for youth The curriculum in schools varies by province and school board with respect to condoms and needle use messages. There is currently no standardized curriculum across Canada mandating HIV/AIDS education in all jurisdictions.	YES/ NO
d. Behaviour-change communications (see b above)	YES/ NO
e. Voluntary counseling and testing Canadians choosing to be tested for the presence of HIV infection have three different testing options, depending on the province or territory in which testing takes place: Nominal, Non-Nominal, or Anonymous. To varying degrees, depending on provincial or territorial health regulations, w omen are routinely tested during their prenatal care. However, in practice of prenatal HIV testing, specific informed consent is still inconsistently obtained.	YES
f. Programs for sex workers Prevention programs for sex workers vary between communities, with very few organizations specializing in HIV/AIDS prevention for this population. Sex workers are not listed as a vulnerable population in the Federal Initiative.	YES/ NO
g. Programs for men who have sex with men Prevention programs for gay men and other men who have sex with men vary between communities, although they are listed as one of the vulnerable populations in the Federal Initiative.	YES
h. Programs for people who inject drugs, if applicable Prevention programs for people who inject drugs varies between communities, although they are listed as one of the vulnerable populations in the Federal Initiative. In theory, needle exchange programs are available across Canada, except in prisons where institutional policies prohibit access to clean needles. For over a decade, it has been recommended that Canadian prison systems move ahead with implementing needle exchange programs in prisons17. Correctional Service Canada has sought scientific and technical advice from the Public Health Agency of Canada on the risks and benefits of prison needle exchange programs. Vancouver ( British Columbia) is piloting Canada's first official safe injection facility and thorough evaluation is being conducted in order to assess the impacts of the program on drug use, overdose, infection, and crime rates.	YES
i. Programs for other most-at-risk populations 12 In theory, all HIV prevention tools (e.g., male and female condoms, lubricants, clean needles, methadone substitution therapy) are available and accessible across Canada. In practice, even outside of prisons, most vulnerable populations (e.g., youth, Aboriginal communities, small rural communities, refugees, trafficked women and sex trade workers) have very spotty access to these prevention tools. Provision of these prevention tools and programs varies according to province and between health regions, especially for female condoms, needles, methadone and bleach. For some small communities, even where these prevention tools are accessible, individuals may be reluctant to access them from health centres or stores due to lack of privacy. Refugees, immigrants and trafficked women may not be able to get prevention tools and programs due to language barriers or lack of availability.	YES/ NO
j. Blood safety Canadian Blood Services carefully screens all prospective donors to minimize the potential for transmission of infectious diseases. Donated blood undergoes extensive testing for infectious diseases, and blood groups and compatibility.	YES
k. Programs to prevent mother-to-child transmission of HIV	YES
l. Programs to ensure safe injections in health care settings	YES

IV. Care and support

IV. 1 Which of the following activities have been implemented under the care and treatment of HIV and AIDS programs?

(Check all programs that are implemented beyond the pilot stage to a significant portion of both the urban and rural populations).	2005
a. HIV screening of blood transfusion Canadian Blood Services carefully screens all prospective donors to minimize the potential for transmission of infectious diseases. Donated blood undergoes extensive testing for infectious diseases, and blood groups and compatibility.	YES
b. Universal precautions	YES
c. Treatment of opportunistic infections (OI)	YES
d. Antiretroviral therapy (ART) The current standard of HIV treatment includes the use of a combination of at least 3 different anti-HIV medications from at least two different classes. Currently there are two major classes of anti-HIV medications available in Canada: reverse transcriptase inhibitors or RT inhibitors (RTIs) protease inhibitors (PIs) Drug coverage formularies through public drug reimbursement plans vary by province as health care is a provincial jurisdiction. There are also 19 federal drug formularies that operate outside of provincial health formularies (e.g., for Veterans, on-reserve Aboriginals or refugees). Generally, while admitted to a hospital, patients will receive drugs free of charge as they are considered medically necessary. While Canada has the right principles in place to provide access to treatment, the difficulty is putting those principles into practice. There are significant inconsistencies in access to treatment based on geography and sub-populations through marginalization of certain vulnerable groups. The Canada Health Act only requires that public health insurance plans in the provinces/territories cover medically necessary hospital and physician services; this includes those prescription drugs that are supplied to patients while in hospital or sometimes upon discharge from hospital if they are sent home with a supply of medication. Other than that, there is no universal requirement to include coverage for medications in the public health insurance plans. Provinces provide drug coverage for (a) the elderly, and (b) social assistance recipients (including people with disabilities); but even though the province pays the cost, individuals often have to pay the pharmacist's dispensing fee or some small "co-payment". Only some provinces (e.g., British Columbia, Québec) provide a more extensive pharma-care program that isn't just limited to the elderly or recipients of social assistance, but is available to all residents. Finally, there are "catastrophic drug plans" for people (who are not elderly nor on social assistance) who face catastrophically high drug costs. These programs (e.g., Ontario's Trillium Drug Program) are income-based - that is, there is a deductible based on the person's annual income; the person pays out of pocket for their medications up to that deductible amount, and the catastrophic drug program covers the remainder of the costs. Generally, ARVs are covered by provincial health formularies. Some ARV medications are restricted by limited use or can be accessed through exceptions to drug formulary rules, however it requires a lot of paper work and cost for physicians to prove that their patients meet the exceptions. For example, in Ontario with Tenofovir, doctors were asked to provide a genotype test and a full medical history of the patient's file; many doctors find this very daunting and expensive. There are also inconsistencies in the formularies between provincial health jurisdictions; each province re-evaluates their formularies based on recommendations from the national Common Drug Review. In some cases, they disregard the recommendations (e.g., Atavanavir is not on the Manitoba formulary and not on Aboriginal on-reserve formulary). There are also inequities in access to treatment for specific populations. In urban settings, the ability to access treatment in a confidential way is much greater than in a rural setting. The First Nations and Inuit Health Branch (FNIHB) has its own drug formulary system for on-reserve Aboriginals; however, there is no jurisdictional responsibility for ensuring access to treatment for off-reserve Aboriginal people. Canadian NGOs report that women, immigrants/refugees and people who use illicit drugs have less access to ARV therapies. There are also rural-urban differences in access to treatment. Rural settings don't get access to as many clinical trials, and women are not enrolled in trials to an equitable degree to their male counterparts.	YES
e. Nutritional care There are no formal nutritional care programs for people living with HIV within the health care system. Food supports are provided by some community-based HIV/AIDS organizations or through food banks.	NO
f. Sexually transmitted infection care	YES
g. Family planning services	YES
h. Psychosocial support for people living with HIV and their families People living with HIV and their families primarily receive psychosocial support through local community-based HIV/AIDS organizations.	YES
i. Home-based care Home-based care is a provincial health jurisdiction and varies by health authority within provinces. Generally, there are inadequate home-care services across all disease and health conditions and HIV/AIDS care is no exception.	YES/ NO
j. Palliative care and treatment of common HIV-related infections: pneumonia, oral thrush, vaginal candidiasis and pulmonary TB (DOTS)	YES
k. Cotrimoxazole prophylaxis among HIV-infected people A wide variety of antibiotic and antiprotozoal treatments for Pneumocystis carinii pneumonia, urinary tract infections, bronchitis, middle ear infection, and diarrhea are available through the various provincial/territorial health jurisdictions. In Canada, Cotrimoxazole is available through all of the provincial/territorial public health drug formularies through one or more of the following brand names: Apo-Sulfatrim, Bactrim, Coptin, Novo-Trimel, Nu-Cotrimox, Roubac and Septra. Cotrimoxazole has been available in Canada for over 20 years.	YES
l. Post exposure prophylaxis (e.g., occupational exposures to HIV, rape) Standards for PEP vary by health jurisdiction.	YES
m. Rehabilitation services for people with HIV/AIDS In Canada, the profile of HIV disease is changing, with new drugs delaying disease progression and helping people to live longer. People living with HIV disease, their families, caregivers and those involved in treatment, education and policy face many challenges. Living longer with HIV often means dealing with problems in body functions or structures, activity limitations, and participation restrictions that range from moderate and inconvenient to severe and debilitating. Impairment refers to loss of physiological or psychological functions, such as weakness or impaired cognition. Activity limitation refers to lack of ability to perform activities such as walking or bathing. Participation restriction refers to a disadvantage that limits fulfillment of a role that is considered normal for a person, such as the inability to return to work. These challenges are manifest in physical, psychological, and social forms. They require a series of concerted and collaborative efforts for rehabilitation. Rehabilitation services such as physiotherapy, occupational therapy, and speech-language support are not widely available for people living with HIV/AIDS, nor are the costs for these services covered by many provincial health plans on out-patient basis. Awareness, access and quality of knowledge/service vary by jurisdiction and amongst both service providers and people living with HIV/AIDS.	NO

---

1. Canadian Human Rights Act: http://www.efc.ca/pages/law/canada/canada.H-6.head.html
2. R. Elliott & J. Gold. Protection against discrimination based on HIV/AIDS status in Canada: the legal framework. HIV/AIDS Policy & Law Review 2005; 10(1): 20-31.
3. Canadian Human Rights Commission pamphlet: HIV/AIDS Discrimination: It's Against the Law
4. Canadian HIV/AIDS Legal Network (1998). HIV/AIDS and Discrimination: A Discussion Paper
5. Canadian HIV/AIDS Legal Network: Action on HIV/AIDS in Prisons: Too Little, Too Late (2002).
6. Health Canada. ACAP Allocations for Regional HIV/AIDS Programming - A discussion paper. September 1999.
7. Susan Dann & Associates. The PPHB Regional Office Role in HIV/AIDS. May 2003.
8. Blueprint for Action on Women and HIV/AIDS in Canada: Towards 2006 , April 1-2 2005 Meeting, Minutes
9. Canadian AIDS Society. www.cdnaids.ca
10. Canadian HIV/AIDS Legal Network: Action on HIV/AIDS in Prisons: Too Little, Too Late (2002).
11. Canadian Aboriginal AIDS Network: HIV Prevention Messages for Canadian Aboriginal Youth, March 2004. http://www.caan.ca/english/grfx/resources/publications/youth_prevent.pdf
12. Canada Labour Code, Part II; Canadian Human Rights Act; Constitution Act , 1982 (Canadian Charter of Rights and Freedoms); Government Employees Compensation Act; Privacy Act; Public Service Employment Act; Public Service Staff Relations Act
13. Medical Research Council, Natural Sciences and Engineering Research Council, and Social Sciences and Humanities Research Council, August 1998. The full text is available at <http://ncehr.medical.org/english/mstr_frm.html>.
14. HIV/AIDS Policy and Law Newsletter. Ethical Review in Community-Based HIV/AIDS Research. Volume 5, Number 1, Fall/Winter 1999
15. Health Canada. ACAP Allocations for Regional HIV/AIDS Programming - A discussion paper. September 1999.
16. Susan Dann & Associates. The PPHB Regional Office Role in HIV/AIDS. May 2003.
17. Canadian HIV/AIDS Legal Network: Prison Needle Exchange: Lessons from a Comprehensive Review of International Evidence and Experience (2004).

Previous | Table of Contents | Next