The Actions:
What We Will Do Between Now and 2010

3. Step Up Prevention Programs

Rationale

HIV is first and foremost a preventable disease. Communities most vulnerable to HIV need targeted programs that use culture/gender-sensitive and age-appropriate prevention strategies. They also need access to new prevention tools that will significantly enhance their ability to protect themselves, such as preventive vaccines and microbicides. Stepping up prevention is directly linked with strengthening diagnosis, care, treatment and support. Those currently unaware of their infection will be able to access the services they need and participate in reducing further infections.

Gay men

MSM (including gay and bisexual men) continue to be the group most affected by HIV/AIDS. In 2002, they accounted for 58% of the 56,000 people living with HIV infection and 40% of all new infections (an increase from 38% of new infections in 1999). Over the last few years, there has also been an increase in the number of MSM diagnosed with other STIs, such as syphilis. These trends indicate that gay men are engaging in riskier sexual behaviours.

Findings from two recent studies examining sexual behaviours and attitudes among gay and bisexual men reinforce the need to step up prevention efforts: 53 , 54

• A significant proportion of gay men underestimate their risk/are unaware of their HIV status: 27% of men who identified themselves as HIV-negative or who had never been tested were infected (based on saliva testing)
• More men (25% in one study) are having unprotected sex with casual male partners, and the proportion of gay men engaging in unprotected anal sex, a high-risk activity, has almost doubled in the last decade.
• Many men "trade off" safer sex for a desirable partner, to feel desirable themselves, or when their judgment is clouded by alcohol or drugs.
• Depression makes men more vulnerable to unsafe sex.
• 45% of gay men in one survey reported that they never disclose their HIV status (positive or negative) to casual partners.
• Gay men are making assumptions about their sexual partners' HIV status that could put them at risk. For example, many HIV-negative men assume that a partner who does not initiate condom use is also HIV-negative, while many HIV-positive men assume that partners who are willing to have unprotected sex are positive.
• While most men are practising safer sex and using condoms, a significant proportion report problems with condoms, including erectile difficulties, slippage and breakage.
• Gay men are generally well informed, and effective prevention initiatives should acknowledge and build on this knowledge base.

How Do You Know What You Know? A Prevention Campaign Targeting Gay Men Community-based AIDS organizations in Vancouver, Calgary, Winnipeg, Toronto, Montréal and Halifax are participating in a prevention campaign that targets gay and bisexual men. Funded by Health Canada and provincial governments, the goal of the campaign is to reduce the incidence of unprotected anal sex in situations where gay men do not know the HIV status of their sexual partner. The campaign challenges gay men to review the strategies they use to assess risk and question the assumptions they make about their sexual partners. The campaign, originally developed in San Francisco and adapted for use in Canada, is an example of building on other initiatives and pan-Canadian collaboration.

Among gay and bisexual men, certain groups appear to be at higher risk, including young gay men who tend to assume that HIV is a problem for older gay men or who are vulnerable because of poverty, homelessness or a power differential in their relationships; gay men who are just coming out and may not be as knowledgeable about HIV; men from cultures where there is severe discrimination against gay men; and older gay men who, given the gay-identified culture's focus on physical attractiveness, are willing to take more risks in order to have sexual relationships.55 According to older gay men who participated in a focus group to develop Leading Together, the increasing use of Viagra and increasing sexual expectations are also a factor in unsafe sex.56

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People who use injection drugs

Between 75,000 and 125,000 people in Canada inject drugs such as heroin, cocaine or amphetamines.57 While the majority of people who use injection drugs live in large urban centres, such as Toronto, Vancouver and Montréal, IDU has also been reported in many smaller towns and cities and in rural communities. People who inject drugs are at high risk of health problems associated with their drug use, including overdoses and infections. When they share needles to inject, they are at extremely high risk of acquiring HIV and hepatitis C. The proportion of people using injection drugs who report sharing needles varies considerably but is exceedingly high in many communities: 76% in Montréal (Bruneau et al. 1997), 69% in Vancouver (Strathdee et al. 1997), 64% in a semi-rural Nova Scotia community (Stratton et al. 1997), 54% in Québec City (Bélanger et al. 1996) and Calgary (Elnitsky and Abernathy 1993), 46% in Toronto (Myers et al. 1995) and 37% in Hamilton-Wentworth (DeVillaer and Smyth 1994).58

People who inject drugs account for about 20% of people in Canada infected with HIV and for 30% of new infections in 2002. In 2002, between 800 and 1,600 people who inject drugs were newly infected with HIV. This population remains highly vulnerable.

Prevention programs that strive to reduce the harm associated with injecting drugs -- such as needle- and syringe-exchange programs, methadone maintenance and other substitution therapy, and safe injection sites -- are highly effective in reducing the risk of both HIV and hepatitis C among people who use injection drugs.59 These harm reduction initiatives are even more effective when they are combined with increased, meaningful involvement of people who use injection drugs, including through support of organizations of people who use injection drugs60, 61, 62 and other services that meet broader complex health and social needs, such as outreach programs, easy access to non-judgmental primary care, access to stable housing and food, addiction treatment programs and collaboration with the law enforcement and justice system.63 Given the growing evidence of the link between depression and addiction, better access to mental health services and treatment for depression may also help reduce the risk of HIV, hepatitis C and other harms associated with drug use.64

While some jurisdictions in Canada have been leaders in harm reduction programs for people who use injection drugs, the services currently available do not meet the needs. For example, we do not have enough needle- and syringe-exchange programs, and many of the existing programs are too limited in terms of hours of operation and number of needles distributed to meet needs.65 Access to methadone maintenance also continues to be limited in many parts of the country. Canada only has one safe injection site, and the rules imposed by the regulator are more stringent than in other countries with safe injection sites, thus limiting access to the site. For example, the rules do not allow one person to inject another, which limits access to this service for, among other people, many women who use injection drugs and rely on their partners to inject them.

Effective prevention programs for people who inject drugs must address the risk of transmission not only through needle sharing but also through sexual transmission. The sexual partners of people who inject drugs are at high risk, even if they do not inject. For example, women and youth who inject drugs may be at increased risk because they may be financially dependent and therefore less able to control the conditions that make them vulnerable to infection.

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Aboriginal people

In 2002, it was estimated that approximately 3,000 to 4,000 Aboriginal persons were living with HIV in Canada, representing 5% to 8% of all prevalent HIV infections, compared to the 1999 estimate of about 6% of the total. Note that Aboriginal people make up only about 3% of the country's population.66 Documented rates of HIV infection are particularly high in western Canada. For example, between 1995 and 1997, Aboriginal people in British Columbia accounted for between 15% and 18% of newly diagnosed infections.67 Between 1993 and 1998, 26% of Alberta's newly diagnosed HIV cases were in Aboriginal people.68

Aboriginal Canadians have also expressed concern about the fact that most jurisdictions do not collect information on the ethnicity of people diagnosed with HIV. In these jurisdictions, therefore, available data are based primarily on information collected among First Nations groups on reserve and do not include Métis, Inuit or Aboriginal people living off-reserve.

Given the lack of consistent data, it is difficult to know the exact extent of the epidemic in this population; high rates of poverty, alcohol and substance use, the long-term impact of discrimination, loss of culture, the legacy of abuse from residential schools, the mobility of this population (on and off reserve) and high rates of incarceration make Aboriginal people highly vulnerable. Of the 250 to 450 Aboriginal people newly infected with HIV in 2002, the main risk factors for infection were IDU (63%), heterosexual transmission (18%), men having sex with men (12%) and IDU/men having sex with men (7%).69

While HIV is a growing issue in many Aboriginal communities, it is only one of a number of health and social problems. Because of this, the focus of the five Aboriginal strategies developed in Canada (Strengthening Ties -- Strengthening Communities: An Aboriginal Strategy on HIV/AIDS in Canada, along with strategies for Aboriginal people in British Columbia, Quebec, Alberta and Ontario) is on HIV as part of the larger challenge of building healthy communities. Within Aboriginal communities, HIV prevention initiatives must target women and two-spirit men as well as the underlying issues of poverty, lack of employment, stigma within the Aboriginal community, substance use and low self-esteem.

Effective approaches will be led by Aboriginal people and grounded in Aboriginal culture, healing and the intertwining of body, mind and spirit. They will also be integrated with other urgent Aboriginal health issues, such as diabetes and the use of tobacco and alcohol, and encourage people to value and take care of themselves.70 Leadership, innovation and a long-term commitment will be vital. As one of Canada's Aboriginal strategies says, "Tear the ideas apart and identify what doesn't work as well. But don't give up trying ... try again or try something else. HIV has taught us ... that we cannot achieve everything we need alone -- we need each other to support and guide, be coaches, listeners and activists, for encouragement, pushing, and pulling as needed."71

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People from countries where HIV is endemic

In much of Africa and many countries in the Caribbean, HIV is endemic. But HIV is not just a crisis for people living there -- it is also a crisis for people from Africa and the Caribbean who settle in other parts of the world. Over the past 40 years, a growing number of people have immigrated to Canada from Africa and the Caribbean. Most (over 90%) have settled in Ontario and Quebec.

• According to Public Health Agency of Canada data, in 2002, there were 3,700 to 5,700 prevalent HIV infections among people born in a country where HIV is endemic, which represents 7% to 10% of prevalent infections in Canada.72
• Between 1999 and 2004, the proportion of positive HIV test reports attributed to people from a country where HIV is endemic increased from 4.2% to 7.6%.73
• The African and Caribbean communities in Ontario account for 2,071 out of 21,453 HIV diagnoses in Ontario. They represented only 6.7% of diagnoses from 1985 to 1998 but 22% of diagnoses in 2001 and 2002. HIV prevalence rates in people from countries where HIV is endemic in Ontario are 50 times higher than in other heterosexual, non-injecting populations in Ontario.74

Modeled HIV Prevalence Among Persons Born in Sub-Saharan Africa or the Caribbean. Ontario 1981-2002 75

• The risk is not limited to new immigrants. In Ontario, 30% to 45% of new infections in African and Caribbean Canadians occur in Canada.
• In this population, the virus is mainly spread through heterosexual contact. Because women are biologically more vulnerable to HIV infection through heterosexual sex than men,76 African and Caribbean women are at high risk. The majority of HIV-infected babies in Ontario are born to women from countries where HIV is endemic.
• The rapid and growing spread of HIV in African and Caribbean communities in Canada is being fuelled by the stigma associated with HIV, the challenges faced by recent immigrants (e.g., settlement issues, poverty, financial dependence, racism, stigma), cultural attitudes, lack of support from the broader community and lack of comprehensive, coordinated and targeted prevention efforts. We must act now to address the underlying factors and provide services for this community.

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People in correctional facilities

"By entering prisons, prisoners are condemned to imprisonment for their crimes; they should not be condemned to HIV and AIDS. There is no doubt that governments have a moral and legal responsibility to prevent the spread of HIV among prisoners and prison staff and to care for those infected. They also have a responsibility to prevent the spread of HIV among communities. Prisoners are the community. They come from the community, they return to it. Protection of prisoners is protection of our communities."77

The proportion of people in Canada's federal correctional facilities who are known to be living with HIV (2.01%) is significantly higher than in the Canadian population as a whole (0.16%).78 In 1989, 14 prisoners in Canadian federal prisons were known to have HIV; by 2002, the number was 251 (based on preliminary data).79 Given that many prisoners may not know they are infected or may not have disclosed their status, the actual number of prisoners infected may actually be much higher. Studies undertaken in provincial prisons have also all shown that HIV seroprevalence rates in prisons are at least 10 times higher than in the general population, ranging from 1 to 8.8%.80

Rates of hepatitis C in prison populations are even higher than rates of HIV: in 2002, 3,173 federal prisoners were known to be infected with hepatitis C: 25.2% of male and 33.7% of female prisoners.81

The high rates of both HIV and hepatitis C in correctional facilities put prisoners who engaged in IDU, unprotected sex and/or tattooing at high risk of infection.

Most prison systems in Canada have taken some steps to protect prisoners (and ultimately the public) by providing education, access to condoms, dental dams and lubricants and by making methadone maintenance treatment available to opioid-dependent prisoners. However, the extent to which these and other prevention measures are available and accessible varies, and generally Canadian systems lag behind some other countries that have implemented comprehensive harm reduction programs, including needle- and syringe-distribution programs.

Comprehensive prevention programs in correctional facilities will reduce the risk to prisoners and, as most prisoners will leave prison and integrate back into society, will also reduce the risk to Canadian society as a whole.

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Women and heterosexual transmission

Over one quarter of the diagnosed and reported HIV infections in 2004 were among women. This is a notable change from the years prior to 1995 when they represented less than 10%. The largest rise in this proportion is seen among the 15-29 year age group, where females represented 13.2% of reports in 1985-1994 and 42.2% in 200482. Many of the women are Aboriginal, from a country where HIV is endemic, users of injection drugs or are at risk from sex with a partner who injects drugs or who has had sex with men.

Growing rates of HIV infection in women reflect the fact that women are biologically, economically, socially and culturally more vulnerable to HIV infection than men.83 Poverty often leads to situations where women trade sex for survival, and economic dependence limits women's ability to leave dangerous relationships or negotiate safer sex with their partners. Domestic violence, sexual violence, abuse and coercion affect women's ability to protect themselves. Women who are in violent relationships or who fear violence cannot negotiate safer sex with their partners.84 The women who are most at risk may not have the knowledge, resources or power within their relationships to protect themselves from infection. Because women's ability to ensure that their partners use condoms or practise safer sex is often limited, every effort must be made to develop prevention tools that women themselves can control and use to protect their health, such as microbicides and preventive vaccines. Canada must invest adequately in developing prevention strategies for women.

Because women are highly vulnerable to HIV through heterosexual sex, every effort must be made to monitor infections and ensure that prevention and awareness programs are reaching women at risk. Ontario is now working with the Public Health Agency of Canada on a study of the risk factors for all new heterosexual infections in women. The results will be used to guide prevention programs for women and to ensure that initiatives aimed at vulnerable populations (e.g., Aboriginal people, people from countries where HIV is endemic, people who use injection drugs) provide gender-sensitive programs for women.

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At-risk youth

A number of youth in Canada are at high risk of HIV infection, including street-involved youth, transient youth, youth who inject drugs, gay youth and Aboriginal youth. To prevent the spread of HIV among young people, all prevention programs targeting communities at risk should include age-appropriate information and youth-led initiatives for youth. In addition, organizations and agencies serving marginalized or transient youth should be directly involved in delivering HIV prevention/harm reduction messages and skills as part of larger health and social support programs for youth.

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Babies born to women with HIV

Canada has made progress in reducing the number of babies born with HIV. While the number of babies born to women living with HIV has increased from 87 in 1993 to 163 in 2004, during the same time period the percentage of infants confirmed to be HIV-positive born to women living with HIV has decreased from 47% to 2%.85, 86 The change is primarily due to the development of effective strategies to prevent mother-to-child transmission, including the use of antiretroviral therapy during pregnancy and Caesarean sections. The ability to use these strategies depends on knowing the mother's HIV status. Offering pregnant women HIV testing has proven to be effective in identifying women who are infected and providing appropriate treatment.

Prenatal HIV testing programs are now in place in all provinces and territories in Canada. With infections rising among Aboriginal women, women from countries where HIV is endemic and women who inject drugs, special efforts are required to ensure that these women are provided with access to culturally appropriate information on the benefits of HIV testing during pregnancy and access to voluntary testing and counselling programs. As with all HIV testing, providers are ethically and legally required to ensure that pregnant women give informed consent to be tested. This is best done by asking women whether they want to opt in to testing after providing them with all the relevant information during counselling, rather than by asking them to opt out of testing.87 More information is required on the long-term impact on children of treatment with antiretroviral therapy.

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People living with HIV

The successful use of HAART means that many people with HIV are living longer in good health, yet little has been done to help people with HIV manage the challenges of living many years with an infectious disease. There have been few PHA-based or PHA-led strategies designed to help people with HIV enjoy full lives while reducing the risk of HIV transmission. To remedy this, more people living with HIV are taking a lead role in prevention programs (e.g., Positive Prevention initiatives in the United Kingdom and the "HIV stops with me" program in San Francisco).

Positive prevention initiatives, which are based on the principles of health promotion, start by actively promoting the physical, mental and sexual health of people living with HIV. By ensuring that PHAs receive appropriate treatment, support in dealing with complex psychosocial issues (e.g., depression, denial, rejection, isolation, grief and loss), and other services that enhance health (e.g., adequate nutrition and housing), these initiatives empower people living with HIV to be actively involved in prevention.

The trend to focus more on positive prevention is driven by:

• the desire of people living with HIV to prevent transmission and protect themselves from re-infection
• the importance of protecting people with HIV from other STIs that could threaten their health
• legal developments indicating that people with HIV may be legally responsible for virus transmission if they have not disclosed their HIV status to their partner

Peer-led prevention programs provide support for people living with HIV in their efforts to practise safer sex and drug use and to protect their own, as well as other people's, health. They can also help people living with HIV develop strategies to disclose their HIV status where appropriate or, if disclosure is likely to put them at risk of physical harm or discrimination, to protect themselves and their partners without disclosure. PHAs also need strategies to deal with discrimination and stigma following disclosure.

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Desired outcomes

• Members of communities most vulnerable to HIV disease have the knowledge, skills, supportive environments to protect themselves from HIV and other STIs.
• A substantial decrease in new HIV infections in Canada.
• All communities at risk have access to targeted, evidence-based, sustained prevention programs.
• Prisoners have access to the same prevention measures available to people in the general community.
• People at risk have access to a wider range of prevention tools, including microbicides and preventive vaccines.
• New HIV infections in newborns are further reduced.
• People with HIV are leading positive prevention programs.
• A comprehensive HIV surveillance system provides timely information and reports that provinces and communities can use to anticipate new trends and guide targeted prevention programs.

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Targets

By 2010:

• The number of new HIV infections each year in Canada drops by 40%
• The number of new HIV infections each year among gay men drops by 40%.
• The number of new HIV infections through IDU drops by 40%.
• The number of new infections among people from countries where HIV is endemic drops by 40%.
• The number of new infections among Aboriginal people drops by 40%.
• The number of new infections in women drops by 40%.
• The number of new HIV infections among youth drops by 40%.
• Rates of other sexually transmitted diseases in communities at risk will remain stable or decrease.
• One hundred percent of pregnant women in Canada are offered voluntary prenatal HIV testing with quality pre- and post-test counselling and respect for the principle of informed consent.
• The proportion of people living with HIV who report that they always practise safer sex increases significantly.
• The proportion of people who use injection drugs who never share needles increases significantly.
• Access to drug treatment, including methadone maintenance treatment, and to harm reduction measures such as needle exchange programs and safe injection sites increases significantly in all jurisdictions in Canada.
• Prisoners in all prison systems have access to the same prevention measures available to people in the general population.
• Canada increases its contribution to global efforts to develop microbicides and preventive HIV vaccines and implements comprehensive HIV vaccine and microbicide plans.

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Actions

3.1	Step up targeted, peer-led, age/gender/culture-appropriate prevention initiatives for people living with HIV.
3.2	Implement comprehensive prevention programs for gay and bisexual men that: are peer-planned and led acknowledge the strong HIV knowledge base within the gay community address the assumptions, risk assessments and trade-offs that affect men's decisions to practise safer sex address external and internal homophobia address the barriers/problems gay and bisexual men face in using condoms provide the education and support that highly vulnerable groups in the gay community (i.e., young gay men, men just coming out, older gay men, immigrant MSM, sex workers) need to protect themselves address the role that depression and substance use play in decisions to practise safer sex build support for people living with HIV within the gay community.
3.3	Implement comprehensive prevention/harm reduction programs that will address the social determinants of health of people who use injection drugs, people infected through IDU and their needle-sharing and sexual partners and that: meaningfully involve people who use injection drugs in planning and implementation provide effective peer-led outreach to people who use injection drugs expand access to existing harm reduction measures (e.g., needle exchanges, methadone programs) expand access to new/innovative harm reduction measures (e.g., safe injection sites, prescribed heroin, other drug substitution programs) ensure that people who use injection drugs receive appropriate pain management expand access to a full range of health and social services, including primary care, housing, food, income security, mental health services and long-term (i.e., 12-month) residential addiction treatment programs provide prevention programs specifically targeted to women who use injection drugs and to Aboriginal people who inject drugs.
3.4	Implement comprehensive, peer-led, culturally appropriate prevention/harm reduction programs that reflect the diversity in Aboriginal communities, address the complex health and social needs of Aboriginal people and communities and that: enlist the active support of Aboriginal leaders integrate HIV prevention into broader health and wellness programs, including employment and anti-violence programs address the high rates of substance use and depression and the lack of self-esteem in Aboriginal communities reinforce the Aboriginal view of the interrelationships among body, mind and spirit focus on the unique needs of women and two-spirited men increase the number of Aboriginal health care providers and educators, and provide the necessary training reduce HIV stigma within the Aboriginal community, and build support for people who are infected.
3.5	Implement comprehensive, peer-led, culturally appropriate prevention/harm reduction programs that will address the complex health and social needs of people from countries where HIV is endemic and that: provide culturally appropriate prevention guidelines and information address the issues that contribute to the spread of HIV, including long-term discordant heterosexual partnerships; reproduction, testing, disclosure and partner notification issues; immigration issues; the impact of racism and other discrimination on this population's response to HIV/AIDS; their ability to access HIV information/services; and lack of employment and housing target women in these communities and their complex issues (e.g., gender inequality, violence, isolation, the physiological differences in HIV treatment) reduce HIV stigma in the community, which isolates people who are infected, and build support for those living with HIV.
3.6	Implement policies and programs designed to reduce the risk of HIV transmission in all correctional facilities in Canada, and give prisoners access to age-, gender- and culture-appropriate prevention, harm reduction and treatment tools and services, including: information and ongoing education peer education, counselling and support programs condoms, dental dams and water-based lubricants bleach for cleaning syringes clean needles and syringes tattooing equipment voluntary HIV testing methadone maintenance therapy, for both those on methadone when they enter the facility and those who want to begin treatment while incarcerated detoxification and addiction treatment services targeted programs for women and Aboriginal people.
3.7	Implement prevention initiatives that meet the needs of women and support other initiatives designed to enhance women's ability to reduce their risk (e.g., the development of microbicides, anti-violence programs, women's shelters, drug treatment programs for women).
3.8	Implement prevention initiatives targeted to sex workers.
3.9	Implement peer-led, age-appropriate prevention initiatives to meet the needs of at-risk youth.
3.10	Provide and promote voluntary HIV prenatal testing to women and their physicians/midwives, developing special programs to reach Aboriginal women, women from countries where HIV is endemic, and women who use injection drugs.
3.11	Implement PHA-led positive prevention programs designed to help people living with HIV manage the challenges of living with an infectious disease.
3.12	Develop plans to support the development of new prevention technologies, including vaccines and microbicides, and to make them available once they are developed.

Surveillance/research/monitoring

3.13	Identify standard, consistent data to be collected on HIV in all jurisdictions, and enhance the capacity of the existing HIV surveillance system to analyze data and provide timely information and reports to guide prevention programs.
3.14	Conduct targeted epidemiological surveillance studies designed to enhance understanding of the factors that contribute to the spread of HIV in affected communities.
3.15	Conduct research on effective prevention strategies for communities vulnerable to HIV, and use the findings to inform prevention programs.
3.16	Monitor the impact of antiretroviral therapy on children born to women with HIV.
3.17	Develop new prevention technologies beyond vaccines and microbicides.

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