Public Record of Meeting - December 17 - 19, 2006

The Ministerial Council on HIV/AIDS was created to advise the Minister of Health on aspects of HIV/AIDS that have a national scope. The Minister of Health meets with the Ministerial Council at least once a year to receive its advice and recommendations, and reports annually to Canadians on the progress of the Federal Initiative to Address AIDS in Canada. Additionally, the Ministerial Council provides ongoing advice and communications to the Minister throughout the year.

The Public Record of Meeting (PROM) that follows provides an overview of the issues, information and recommendations discussed at the December 17 - 19, 2006, meeting of the Ministerial Council on HIV/AIDS. Where appropriate, discussion points and action items are reported to the public within the PROM. For a detailed summary of activities, please refer to the annual report which the Ministerial Council publishes every June for the preceding year ending March 31. Annual reports are available for download from the Ministerial Council’s website:

http://www.phac-aspc.gc.ca/aids-sida/fi-if/minister-eng.php#min 

Present:

Ministerial Council: Louise Binder (Co-Chair); Richard Elliott, Deborah Foster, Jacqueline C. Gahagan, Marie Anésie Harérimana, Brian Huskins, Kenneth Monteith, Anita Rachlis, Sheena Sargeant. Ex-officio: Frank McGee.

Regrets: David M. Nelson, Frank Plummer.

Public Health Agency of Canada (PHAC): Grafton Spooner (December 17 and 18), Manager, Government and External Relations Section, and Neil Burke (December 19), Manager, Knowledge and Awareness Section, HIV/AIDS Policy, Coordination and Programs Division.

Secretariat: Andrew Howard, Guylaine Lavigne.

Recording and Facilitation Services: Wylie Thomas, Hajo Versteeg.

Presenters: Chris Archibald, Surveillance and Risk Assessment Division (SRAD), PHAC; Chris Armstrong, Canadian International Development Agency (CIDA); Frédéric Borgatta, Research Branch, Correctional Service Canada (CSC); Françoise Bouchard, Health Services Branch, CSC; James Brooks, National HIV Genetics Laboratory; Geneviève Dubois-Flynn, Canadian Institutes of Health Research (CIHR); Gayatri Jayaraman, SRAD, PHAC; Jennifer Gunning, CIHR; Marita Killen, International Affairs Division (IAD), Health Canada; Michael McCulloch, HIV/AIDS Division, PHAC; Val Percival, Human Rights, Gender Equality, Health and Population Division, Foreign Affairs and International Trade Canada (DFAIT); Rita Rouleau, CSC; Robb Travers, Ontario HIV Treatment Network (OHTN).

1 Welcome and Approval of Agenda

The Co-Chair of the Ministerial Council on HIV/AIDS opened the meeting with a few words of welcome. A roundtable of introductions was made. Grafton Spooner, Manager, External and Government Relations of the HIV/AIDS Policy, Coordination and Programs Division (HIV/AIDS Division) of the Public Health Agency of Canada (PHAC), introduced Andrew Howard and Guylaine Lavigne who would be providing Secretariat support to the Ministerial Council for this meeting. Hajo Versteeg, the meeting facilitator, reviewed the agenda, which was approved without modifications.

2 Approval of the June 2006 Record of Decision

The Ministerial Council on HIV/AIDS approved the Record of Decision from its meeting in Montreal on June 1 – 3, 2006, subject to specified changes.

3 Approval of the June 2006 Public Record of Meeting

The Ministerial Council on HIV/AIDS approved the Public Record of Meeting from its June meeting in Montreal, subject to specified changes.

4 Business Arising from the June 2006 Meeting of Council

The Ministerial Council on HIV/AIDS reviewed the status of action items arising from its meeting in Montreal on June 1 – 3, 2006, as well as correspondence to and from the Ministerial Council. It established a new procedure to assign priority to action items identified at meetings.

5 Update on the Minister of Health’s Review on the Federal Initiative

The Ministerial Council on HIV/AIDS received a debriefing from its representatives to the November 2 stakeholder review of the Federal Initiative, which the Minister of Health has called to ensure that the best results are achieved given current trends and evidence. The Minister of Health’s office emphasized that the review is not an evaluation and would not affect funding levels. A panel of experts will be set up to guide the review process. The Ministerial Council discussed its advice on the review and set up a small ad hoc working group to draft a letter to the Minister of Health outlining its advice. The following day, the Ministerial Council approved the draft prepared by the working group.

6 Committee Reports of the Ministerial Council on HIV/AIDS

6.1 Executive Committee

The Executive Committee provided its report to the Ministerial Council on HIV/AIDS. It reported that the Co-Chairs of the Ministerial Council had met with the Minister of Health’s Director of Policy to discuss matters pertaining to the Federal Initiative, including the review called for by the Minister of Health, and to the Ministerial Council.

6.2 Communications and Liaison Committee

The Communications and Liaison Committee provided its report to the Ministerial Council on HIV/AIDS. It tabled the Ministerial Council’s annual report for 2005, which the Ministerial Council approved. It directed the Secretariat to arrange for translation of the report into French and posting on the Ministerial Council website.

6.3 Research Committee

The Research Committee provided its report to the Ministerial Council on HIV/AIDS. The Ministerial Council’s representative to the CIHR HIV/AIDS Research Advisory Committee (CHARAC) gave a summary of CHARAC’s recent meeting, which included a report on the results from the Spring 2006 Priority Announcements for CIHR’s HIV/IADS Initiative, an Ethical Code of Conduct for research conducted overseas and CIHR’s priorities for HIV/AIDS research. The Ministerial Council asked for, and received, a status update from PHAC on plans to hold a stakeholder consultation on developing a pan-Canadian research strategy for HIV/AIDS. The Ministerial Council asked the Secretariat to forward to its members a copy of CIHR’s research priorities document.

6.4 Treatment Issues Sub-Committee

The Treatment Issues Sub-Committee provided its report to the Ministerial Council on HIV/AIDS. It described in detail the findings from the June 2006 National Pharmaceutical Strategy Progress Report, which lists recommendations in five areas: 1) Catastrophic Drug Coverage; 2) Expensive Drugs for Rare Diseases; 3) Real World Drug Safety and Effectiveness; 4) Common National Formulary; and, 5) Drug Pricing and Purchasing Strategies. In the discussion that followed, the Ministerial Council asked the committee to consider writing a letter in response to the report and report back with its recommendations.

6.5 International Affairs Committee

The International Affairs Committee provided its report to the Ministerial Council on HIV/AIDS. It highlighted: the work of the Global Treatment Access Group (GTAG) and its Platform for Action, which details four steps for Canada to play an active role in the global response to HIV/AIDS; a recent announcement by the Government of Canada regarding funding of the international response to HIV/AIDS; and, the release of a consultation paper on the statutory review of Canada’s Access to Medicines Regime. In the discussion that followed, the Ministerial Council asked the International Affairs Committee to prepare a formal submission on the consultation document for consideration by the Ministerial Council. It also asked the Secretariat to prepare a letter to the Minister of International Cooperation thanking her for the Government of Canada’s support for the international response to HIV/AIDS as highlighted in the recent announcements.

6.6 Championing Committee

The Championing Committee provided its report to the Ministerial Council on HIV/AIDS.

7 Update from the Federal / Provincial / Territorial Advisory Committee on AIDS (FPT AIDS)

Frank McGee, Provincial Co-Chair of FPT AIDS, gave the Ministerial Council on HIV/AIDS an update on the committee’s activities since the last meeting. He reported that the committee had met at the end of October, where it was advised of its new status within the Public Health Network. Among other things, the committee discussed the FPT statement, which is being shepherded through the PHN for eventual approval by the Council of Deputy Ministers of Health. The committee has also taken on a role for itself in advising PHAC on the development of a policy framework for HIV testing and counselling. The Ministerial Council asked the Secretariat to forward to its members background materials related to the proposed testing and counselling framework including revised guidelines for point-of-care rapid HIV testing.

8 Report from the Public Health Agency of Canada

Grafton Spooner, Manager, External and Government Relations of the HIV/AIDS Policy, Coordination and Programs Division (HIV/AIDS Division) of the Public Health Agency of Canada (PHAC) provided the Ministerial Council on HIV/AIDS with an update on the activities of PHAC related to the Federal Initiative. He referred the Ministerial Council to a copy of a written update in the meeting binders, and highlighted a number of issues for further discussion: United Nations General Assembly Special Session (UNGASS); Leading Together: Canada Takes Action on HIV/AIDS; HIV/AIDS Attitudinal Tracking Surveys; HIV Testing Policy Framework; HIV/AIDS Prevention in Canada; and, Canada’s 2006 World AIDS Day Report.

The Ministerial Council discussed its participation in a stakeholder forum on prevention being planned for March 2007, and identified a number of potential representatives to that meeting. It also asked the Secretariat to provide it with a breakdown of spending under the operations and management budget line of the Federal Initiative.

9 Committee Structure of the Ministerial Council on HIV/AIDS

The Ministerial Council on HIV/AIDS agreed to postpone a discussion of the structure and membership of its committees until after the appointment of the new Ministerial Council.

10 Presentations on Community-Based Research and Ethics Review

Robb Travers, Director of Community-Based Research at the Ontario HIV Treatment Network (OHTN), Geneviève Dubois-Flynn, Senior Ethics Policy Advisor, CIHR, and Jennifer Gunning, Team Lead for HIV/AIDS, CIHR, joined the meeting to present on community-based research (CBR) and ethics review. They provided an overview of research ethics, its definitions and some of the major milestones in the development of norms to guide the ethical conduct of research. They highlighted some of the challenges faced by community-based researchers who, because they are often not affiliated with an organization with its own research ethics board (REB), must enter into partnerships of convenience with academic researchers based out of universities or hospitals in order to access ethics review. While there are examples of successful partnerships, they often entail a loss of independence and ownership of the research and can lead to lengthy delays. The presenters noted that there were 11 REBs in Canada that handle CBR but that only 2 of these would review research protocols from outside their own institution. CIHR, which is responsible for administering the Federal Initiative’s CBR Program, recognizes that the requirement for ethics review is a major obstacle for groups applying for CBR funding and is undertaking a study in collaboration with the National Council on Ethics in Human Research (NCEHR) to better understand the issues faced by community-based researchers, build capacity and organize a national dialogue to identify potential solutions and next steps. OHTN is developing guidance and a process for ethics review for CBR in Ontario’s HIV sector.

The Ministerial Council thanked the presenters and noted that the functioning of the CBR Program was an issue that it had followed with interest over the years. It indicated its desire to work with CIHR, OHTN and others as they address the challenges identified and invited CIHR to be in touch with its Secretariat regarding its participation in the NCEHR-CIHR collaboration.

11 Presentations on Canada’s Engagement in the Global Response to HIV/AIDS

Chris Armstrong, Assistant Team Leader of Social Development Policies, Canadian International Development Agency (CIDA), Marita Killen, International Affairs Division (IAD), Health Canada, Michael McCulloch, HIV/AIDS Division, PHAC, and Valerie Percival, Senior Health Advisor, Human Rights, Gender Equality, Health and Population Division, Foreign Affairs and International Trade Canada (DFAIT), joined the meeting to present on various aspects of Canada’s engagement in the global response to HIV/AIDS. Following their presentation the Ministerial Council on HIV/AIDS engaged in a discussion with the presenters in which it raised a number of issues in relation to Canada’s international response.

These issues included:

• Questions regarding how the government chooses the organizations it funds;
• The need to encourage states to fulfill their international obligations to children;
• Questions regarding the 2006 World AIDS Day announcement of $120 million in funding for HIV/AIDS;
• Questions regarding Canada’s response to the brain drain from the health systems of low- to middle-income countries and what Canada is doing to mitigate the problem;
• Questions regarding the status of departmental HIV/AIDS strategies and the involvement of other departments in the international response. 

The Ministerial Council asked the presenters to send the Secretariat information so that it could provide comments on the draft testing and counselling guidelines developed by the World Health Organisation, and asked to remain in touch regarding the selection of a topic for the Fall 2007 International Policy Dialogue, which Canada is organizing.

12 Presentations from Correctional Service Canada

Françoise Bouchard, Director General of Health Services at Correctional Service Canada, Frédéric Borgatta, Director of Special Projects, Research Branch, and Rita Rouleau, Project Officer with CSC’s Infectious Diseases Program, joined the meeting to present an overview of how CSC uses its funds from the Federal Initiative and to discuss the agency’s research activities, particularly the 2007 National Inmate Infectious Diseases and Risk Behaviour Survey. They distributed copies of the report from PHAC to CSC entitled Prison Needle Exchange: Review of the Evidence (April 2006).

Dr. Bouchard described the programs that have been put in place with the support of Federal Initiative as well as other programs not supported by the Federal Initiative that address HIV, infectious diseases and harm reduction in federal prisons. She noted that the Honourable Stockwell Day, Minister of Public Safety, had recently cancelled the safer tattooing project which had been piloted in several prison institutions in the last year. She also said that CSC welcomed partnering with outside researchers as it lacked some of the internal capacity required. However, she urged that external researchers work with CSC before submitting their research proposals for funding since all research conducted within federal prisons must be approved through CSC’s internal processes. She said that CSC was dedicated to addressing infectious diseases and health in prison but that work was needed to raise awareness among the Canadian public.

Dr. Borgatta introduced the Ministerial Council on HIV/AIDS to the work and mandate of the Research Branch of CSC. He also provided a detailed update on an upcoming survey of prisoners, which CSC is co-funding with PHAC. The objectives of the survey, which will be implemented from January to March 2007, are to provide an understanding of:

• Risk behaviours that could result in sexually transmitted and blood-borne infections before and after admission to CSC;
• Inmate testing and treatment for infection and infection status before, at and after admission (using inmate recall);
• Those sociological and cognitive factors that could reduce risk, including: information on the extent to which inmates know the risks of blood-borne and sexually transmitted infections (specifically HIV/AIDS and hepatitis C) and their prevention; information on inmate awareness and utilization of health education, health promotion and harm reduction programs offered by CSC Health Services; and, static (e.g. length of sentence) and dynamic (e.g. social support) criminogenic factors.

Following the presentation, the Ministerial Council asked questions for clarification and raised a number of issues with the presenters. It expressed its regret over the government’s decision to cancel the safer tattooing project. It also suggested that CSC consider conducting a follow-up survey that includes mental health issues, since mental health problems are linked to the predicament of many prisoners and many of the first-line treatments for HIV can cause depression and other mental health challenges.

At the end of the session, the Ministerial Council thanked the presenters and offered its support to CSC as it addresses HIV/AIDS in prisons. It said it looked forward to an update on the results of the survey later in the year.

13 Presentations on HIV Surveillance and Epidemiology

Chris Archibald and Gayatri Jayaraman of the Surveillance and Risk Assessment Division (SRAD) of PHAC joined the meeting to present the 2005 estimates of HIV prevalence and incidence in Canada and to update the Ministerial Council on HIV/AIDS on work to develop indicators for monitoring access to, and use of, HIV-related care in Canada.

Dr. Archibald described the sources of data used in developing the estimates as well as their limitations. He noted that the 2005 estimates were considered more accurate than earlier estimates and had resulted in a downward revision of previously stated figures. Despite this, the number of new infections each year could not be said to be decreasing and may in fact be increasing in some groups. He offered a number of explanations as to why and suggested a number of implications for the policy and programmatic response.

Dr. Jayaraman gave a short overview of HIV monitoring, the overall goal of which is to provide the data to guide decision making at the local, provincial and national levels. She described in detail two indicators that SRAD is developing to monitor access to, and use of, HIV-related care in Canada. The proposed indicators are: 1) the percentage of people diagnosed with HIV who access care within a specified time period (such as 6 months or 1 year); 2) the proportion of those diagnosed with HIV infection that are on anti-retroviral treatment (ART). The indicators will use viral load testing as a proxy for access to care. Dr. Gayatri noted that the much of the data for building these indicators exists in databases in use across the country, although linking them presents a challenge. She noted that the secondary objectives of the project include: understanding the stages of infection at which HIV diagnosis is occurring and care is being accessed; the HIV-related morbidities and clinical outcomes of those who access care; and the factors associated with not accessing care. The Division is working on a larger set of 20 indicators, which it hopes to have in draft form by March.

Following the presentation, the Ministerial Council engaged in a discussion with the presenters in which it asked questions for clarification and raised a number of issues. It noted a number of the limitations of using viral load as a proxy for access to care and provided suggestions for obtaining the data and information for building the indicators and improving the next round of estimates.

At the end of the session, the Ministerial Council thanked the presenters and offered its support to the Division as it moves forward in this area and extended an invitation for a follow-up presentation once a draft of the 20 indicators is ready.

14 Debriefing on Ethics Review and Community Based Research Presentations

The Ministerial Council on HIV/AIDS debriefed on presentations it received the day before on ethics review and community-based research (see 10:  Presentations on Community-Based Research and Ethics Review, above) and identified a number of action items for follow up. It asked the Secretariat to prepare letters on its behalf thanking the presenters, and indicating its support for OHTN’s work on establishing an ethics review board for researchers without access to ethics reviews. The Ministerial Council asked the Research Committee to prepare letters on its behalf to the President of the Canadian Association for HIV/AIDS Research informing him that it will be raising the issue of a national research ethics board for researchers who do not have access to ethics reviews with the Minister of Health and seeking his views on how to move this forward. It also agreed to write to CIHR regarding the need for a national research ethics board for researchers who do not have access to ethics reviews.

15 Debriefing on Presentations on Canada’s Global Engagement

The Ministerial Council on HIV/AIDS debriefed on the presentations it received the day before on Canada’s engagement in the global response to HIV/AIDS (see 11: Presentations on Canada’s Engagement in the Global Response to HIV/AIDS, above), and identified a number of actions for follow up. It asked the Secretariat to prepare letters on its behalf to the presenters thanking them for their informative presentations and raising a number of issues, including:

• The Ministerial Council would like to be kept up to date on Canada’s involvement in the establishment of the new UN women’s agency.
• The Ministerial Council would like to be kept up to date on Canada’s commitments to UNGASS and would like to continue its involvement in the preparation of future national reports to UNGASS, which should cover the entire Canadian response to HIV/AIDS (not just those parts that are federally funded).
• The Ministerial Council encourages the federal government to continue its work with stakeholders to improve awareness of Canada’s commitments to UNGASS.
• The Ministerial Council would like to be consulted as the government makes plans for the Fall 2007 International Policy Dialogue.
• The Ministerial Council would like to participate in the process to develop the national testing and counselling policy framework and the various related guidelines.

The Ministerial Council also asked the Secretariat to obtain copies of the civil society guidelines for circulation to members. It asked the International Committee to look at existing guidelines for decisions on which treatments are offered internationally and national treatment targets and to report back with recommendations for action. A small working group of members agreed to prepare comments on the World Health Organization’s draft revised testing guidelines and forward these to the appropriate individuals within government.

16 Debriefing on CSC Presentations

The Ministerial Council on HIV/AIDS debriefed on the presentations it received the day before on the 2007 National Inmate Infectious Diseases and Risk Behaviour Survey and CSC’s HIV/AIDS programming (see 12: Presentations from Correctional Service Canada, above), and identified a number of actions for follow up. It agreed to write separate letters to the Minister of Health, with copies to the Minister of Public Safety, 1) expressing its disappointment over the government’s decision to cancel the safer tattooing pilot project; 2) raising its concerns about the calls for mandatory testing of prisoners being made by one of the prison unions and urging that he raise the issue with his Cabinet colleagues; and, 3) urging the implementation of a prison needle exchange pilot project given the April 2006 advice from PHAC. The Ministerial Council also agreed to write to the presenters thanking them for their presentations and for their positions and programming initiatives on a number of issues related to the response to HIV/AIDS in federal prisons.

17 Debriefing on the HIV Surveillance and Epidemiology Presentations

The Ministerial Council on HIV/AIDS debriefed on the presentations by Dr. Archibald and Jayaraman earlier in the day and asked the Secretariat to prepare a letter, for Co-Chair signature, thanking them for their presentations and indicating that Council would like to take up their offer to brief Council on their work to develop indicators.

18 Presentation on HIV Phylogenetics and Pubic Health

James Brooks, Chief of the National HIV Genetics Laboratory, joined the meeting to present on potential uses of phylogenetic research in guiding HIV prevention strategies. He noted that all organisms develop mutations in their genetic code over time and between generations. By identifying and mapping these mutations scientists can build phylogenetic trees showing the relatedness of organisms to each other. Mutations occur in HIV at a very high rate that is as much as 1 million times the frequency in human cells. Most of these mutations result in weaker viruses that are unable to replicate or infect cells, but every once in a while a more virulent form may be created that is resistant to one or more of the drugs used in treatment cocktails. While the mutations that persist can confer drug resistance they also provide a genetic signature that can be used in phylogenetic analysis to build a family tree that connects viruses (not individuals) through common ancestors. This information can be used to identify clusters of infection that can provide opportunities for public health intervention.

Dr. Brooks described the Canadian HIV Strain and Drug Resistance Surveillance Program (CHSDRSP), which was established to monitor the emergence of drug resistance in HIV. Each year, CHSDRSP produces a surveillance report on HIV-I strain and primary drug resistance in Canada. It has also allowed the development of a phylogenetic tree of the circulating subtypes of HIV, which Dr. Brooks described as being useful to increasing the “resolution” of the public health response to HIV. Used with epidemiological tools, phylogenetics can allow public health officials to identify families of viral subtypes circulating in different populations. Dr. Brooks strongly emphasized that phylogenetic analysis could not be used to determine the direction of transmission (e.g., from person A to person B) or whether members of a cluster have ever met. He acknowledged however that it was difficult to eliminate the risk of the information being misused.

The Ministerial Council raised its concerns about possible misuse of the information but acknowledged its significant public health benefits. It thanked Dr. Brooks for his presentation and asked that he keep Council informed on developments.

19 Next Meeting Dates

The Ministerial Council on HIV/AIDS Council agreed to hold its next face-to-face meeting in Ottawa on March 17, 18 and 19, 2007, with a possible orientation session provided for new members on March 17. It asked the Secretariat to send an email out to members confirming the meeting dates. It also identified a number of items for the Executive Committee to consider when it meets to set the agenda for the March meeting.

20 Close of Meeting

The Co-Chair thanked members of the Ministerial Council on HIV/AIDS for their work during the meeting and the Secretariat and PHAC for their support.