Public Record of Meeting - Ottawa November 17-18, 2002

Health Canada Report

United Nations General Assembly Special Session on HIV/AIDS (UNGASS)

It was reported that the UNGASS Declaration of Commitment on HIV/AIDS (paragraph 100) calls for an annual report to the UN Secretary General to outline progress towards realizing the commitments set out in the Declaration of Commitment. The UN Secretary General is expected to table the first annual report on the Declaration at the 57th UN General Assembly in November 2002. It was explained that, in its capacity as substantive secretariat, the Joint United Nations Programme on HIV/AIDS (UNAIDS) compiled into one global report the approximately 100 progress reports submitted by UN Member States (including Canada). The report will account for all progress made in implementing the Declaration of Commitment since the UNGASS meeting was held in June 2001. It was stated that UNAIDS is expected to prepare a complementary document which provides regional overviews on the implementation of the Declaration.

It was reported that the UN call to Member States for the second annual report on the implementation of the Declaration is expected to be issued in early 2003. The year 2003 is when the first set of targets in the Declaration becomes due.

It was suggested that for the 2003 report, Health Canada look for new ways to circulate the draft report.

It was reported that the Interagency Coalition on AIDS and Development (ICAD) held a workshop on UNGASS in September 2002. At the workshop, strategies were identified for how NGOs could be involved in the preparation of Canada's progress report. It was stated that the report of this meeting will be available shortly and that some Canadian NGOs are using the Declaration of Commitment in their work.

It was stated that the Canada's 2002 progress report did include information on Aboriginal-specific activities and that it would be important to ensure that the 2003 report also include such information. It was reported that the Declaration of Commitment itself did not use the words "Aboriginal" or "indigenous". It was suggested that Health Canada ensure that Aboriginal organizations are included in the preparation of the 2003 report.

Also reported was that there was not much in the 2002 report about individuals from HIV endemic countries living in Canada and that this oversight should be corrected when the 2003 report is prepared. It was suggested that the report include activities at the grassroots level.

National Aboriginal Council on HIV/AIDS (NACHA)

It was reported that NACHA held a full council meeting on September 16-18 in Montréal, Québec. The meeting covered a number of topics such as governance, communication, linkages with other forums, including Ministerial Council, and strategic directions. The next NACHA meeting is scheduled for January 2003 in Ottawa.

Continuously Emerging Antiretroviral Drug Resistant HIV

It was reported that F/P/T AIDS has received and discussed the report of the working group on multi-drug resistant HIV. Presentations were made by the Centre for Infectious Disease Prevention and Control by Dr. Chris Archibald, Director of the Division of HIV/AIDS Epidemiology and Surveillance and by David Hoe, Senior Policy Advisor, HIV/AIDS Policy Coordination and Programs Division.

It was stated that there are two dimensions to this issue: (a) the research and surveillance required to measure the extent of the spread of multi-drug resistant HIV; and (b) the clinical applications.

It was reported that only a few provinces are offering testing for multi-drug resistant HIV. It was stated that it would be helpful to know which of the recommendations of the working group were being acted on, and also what work is being done in the provinces. As well, more research is needed on the utility of the tests for multi-drug resistant HIV. It was reported that Québec has a formal program for multi-drug resistant HIV, but that it is clear whether other provinces have established formal programs.

Vaccines

It was reported that Health Canada has struck an internal Working Group on HIV Vaccine Development and Equitable Distribution. The working group, composed of representatives of the Centre for Infectious Disease Prevention and Control and led by the HIV/AIDS Division, held its first meeting in September 2002 to develop terms of reference and related project timelines.

It was stated that although finding an effective vaccine is an explicit goal of the CSHA, a Canadian vaccine plan will need to involve multiple players, some of whom work outside of HIV/AIDS. It was explained that because important aspects of vaccine development are often outside the jurisdiction of Health Canada, the Department will be required to play a strong central coordinating role to move this initiative forward.

It was reported that the working group will develop a Canadian vaccine plan, but that it is not realistic to expect that this will be done by October 2003 (a date that was suggested by one stakeholder).

National Steering Committee on HIV/AIDS Awareness

It was reported that on September 12-13, 2002, the National Steering Committee on HIV/AIDS Awareness met for its initial face-to-face meeting to begin providing input on the strategic orientation of the National HIV/AIDS Awareness Campaign. The meeting resulted in the overall recommendation of a broad communications platform to "put HIV/AIDS back on the map" utilizing the following potential themes:

• negotiating safety and empowering behaviour (self evaluation of risks);
• solidarity and acceptance;
• secondary prevention (i.e., prevention for people living with HIV/AIDS); and
• reaching the "unknown 15K" (i.e., the estimated 15,000 people who not aware that they are HIV positive).

It was stated that Health Canada is developing a communications approach as well as options for the campaign's strategic orientation. In developing options, a key activity will be to explore opportunities for securing additional resources, both from within Health Canada (i.e., partnering with other programs that have awareness campaigns) and with external partners (i.e., the private sector).

Canadian Youth, Sexual Health and HIV/AIDS Study

It was reported that Health Canada has funded the Council of Ministers of Education (CMEC) to undertake a national study on youth sexual health and HIV/AIDS. The Canadian Youth, Sexual Health and HIV/AIDS (CYSHHA) Study is designed to determine if factors, such as income and social status, social supports, social environments, culture, health services, gender, health practices and coping skills influence sexual health with regards to HIV/AIDS prevention risk behaviours. The study represents a follow-up to the 1988 Canada Youth and AIDS Study.

The main objectives of the study are:

• To describe the relationships among determinants of health, adolescent sexuality, and the sexual health status of youth. (These determinants include elements of income/social status, social support, social environment, culture, health services, health practices/coping skills, gender and sexual orientation.)
• To compare descriptive analyses of selected aspects of adolescent sexual health, especially in relation to HIV/AIDS prevention, with the Canadian Youth and AIDS Study data published in 1988.
• To provide national data that can inform policy, program development, and professional practice.

It was reported that the surveys were administered to youth in grades 7, 9 and 11 in sample classrooms during the 2001/2002 school year in every province and two territories (the newly created territory of Nunavut was not in existence at the onset on the study).
It was reported that just over 11,500 surveys were returned; that the results of the study are in the initial stage of analysis; and that a final report is expected to be available in March 2003.

It was reported that a series of developments impacted on both the participation rate, and subsequently, the representativeness of the provincial and national sample. The major problems, were: (a) labour disputes and work-to-rule campaigns in some provinces, mainly in the West; (b) negative press in British Columbia that spread to other parts of Canada and that raised concerns about the sensitive nature of some of the questions on behaviours; ©) competing national studies in the schools at the same time as the CYSHHA; (d) and the requirement to obtain the active consent of parents before the students could be asked to participate.

It was reported that as a result of the problems encountered, only three provinces have large enough sample sizes to produce a credible provincial breakout: Newfoundland, Nova Scotia and Ontario. As well, since British Columbia and Alberta did not reach representative participation rates, the CYSHHA is not a nationally representative sample. It was indicated that the researchers describe the study as "a large survey of adolescents from across Canada." For this reason, it was reported, it will not be possible to prepare and disseminate a series of provincial and territorial reports (subsets of the national report) as had been expected at the beginning of the study.

Several Council members asked whether separate reports will be provided to the provinces containing an analysis of the results for their province. It was explained that all of the provinces will get the raw data for their province.

Health Canada Publication Enhancing Canadian Business Involvement in the Global Response to HIV/AIDS

It was reported that a new document that appeals to the Canadian corporate sector's sense of social responsibility, and examines how and why businesses must become engaged in the global response to HIV/AIDS, was launched by Health Canada at the XIV International AIDS Conference in Barcelona, July 2002. The report, entitled "Enhancing Canadian Business Involvement in the Global Response to HIV/AIDS," was developed by Health Canada's International Affairs Directorate. Its goal is to help stimulate a dialogue and encourage the involvement of Canada's private sector in the global response to HIV/AIDS. The report, which is essentially an information resource, explains the growing threat of HIV/AIDS in today's highly complex and interdependent world economy. It addresses the actual and potential business impact of HIV/AIDS, and makes the case that no business or organization is immune from the HIV/AIDS epidemic.

It was stated that the report is available in CD-ROM or print format from the Canadian HIV/AIDS Clearinghouse or in electronic format on the International Affairs Directorate's website

(http://www.clearinghouse.cpha.ca/
http://www.hc-sc.gc.ca/datapcb/iad/ih_hivaids-e.htm).

Discussion took place on whether there was a plan for how Health Canada will use the report to make the case for greater business involvement. It was stated that this was a good report and that it could present an opportunity for interdepartmental collaboration. For example, the Department of Foreign Affairs and International Trade (DFAIT) meets with pharmaceutical companies frequently. Health Canada could present this report at interdepartmental meetings to ensure that DFAIT does not get only the industry perspective.

Also suggested that without a good long-term action plan, the report will not be very useful. It was also suggested that a multi-stakeholder committee should be established to develop to develop an action plan and that the plan should have two thrusts: (a) what the private sector can do in Canada; and (b) what the private sector can do in terms of the international response.

It was decided that a letter should be sent to Health Canada outlining Council's recommendations for follow-up activity. The letter will propose that a multi-stakeholder group be formed to develop an action plan. The Communications & Liaison Committee will consider whether to include recommendations concerning the composition of the multi-stakeholder group.

CSHA Financial Status Report

The financial status report for the final quarter of 2002-03 was tabled. The report indicated a current overall forecast of $413,932 in overspending, but that an estimated surplus of $500,000 in Grants and Contributions has been identified. As in previous years, the HIV/AIDS Division has initiated its Quick Response Reallocation Mechanism, which has been in place for over four years to manage potential surpluses and pressures in the CSHA . It was added that more detail would be provided to Council to Council at a future meeting.

Strategic Operational Plan / Resource Allocation

Health Canada officials presented a description of two activities that are occurring in parallel: (a) the CSHA Strategic Planning process and (b) the process for the Five-Year Review of the Federal Role in the CSHA.

It was reported that the CSHA Strategic Planning process will produce (a) a design for the development of the plan; (b) a draft strategic plan; ©) a consultation process; (d) a final strategic plan; and (e) an implementation plan. The Five-Year Review process will produce (a) an options paper on the future federal role in the CSHA; (b) a final report that includes recommendations on the adequacy of funding and on the reallocation of existing resources; and ©) a federal action plan.

The joint outcomes of the two processes would be:

• an increased strategic and proactive response;
• a common vision and common objectives to guide the pan-Canadian (including federal) response;
• a clear understanding that the CSHA represents a pan-Canadian response, not solely a federal response;
• a clear understanding of the federal government's role;
• improved engagement in the pan-Canadian (including federal) response, particularly as it relates to other federal government departments;
• the integration of the UNGASS Declaration of Commitment into the pan-Canadian response; and
• a strong case for requesting additional resources to support the pan-Canadian (including federal) response.

World AIDS Day

Additional Health Canada officials joined the meeting to present on the WAD Report. It was reported that the WAD Report meets: (a) a 1997 commitment made by the former Minister of Health to release an annual progress report on WAD; and (b) a 1998 commitment made by Health Canada to Treasury Board to provide an annual report on federal activities funded under the CSHA. The WAD Report also provides an opportunity to raise awareness about HIV/AIDS, the efforts of Canadians to address the epidemic, and the challenges that lie ahead.

Health Canada staff reviewed the contents of the WAD Report, and described the process that was used to prepare the report, the composition of the Editorial Board and the plans for distribution. Several people pointed out that the process for producing the 2002 report was much better than the process that was used last year.

F/P/T AIDS Update

It was reported that the F/P/T Conference of Deputy Ministers of Health (CDMH), which provides advice to the F/P/T Conference of Ministers of Health and to the federal and provincial/territorial Ministers of Health, is currently implementing a new F/P/T health structure. The new structure includes the following standing advisory committees:

• Advisory Committee on Information and Emerging Technologies
• Advisory Committee on Health Delivery and Human Resources
• Advisory Committee on Governance and Accountability
• Advisory Committee on Population Health and Health Security

It was reported that HIV/AIDS and tobacco were the only two issues to be identified as requiring their own ongoing liaison committees (a new category of committee) under the Advisory Committee on Population Health and Health Security (ACPHHS). The definition and scope of the liaison committees are currently being defined and will be approved by the CDMH in December 2002. At that time, F/P/T AIDS will have a better idea of whether and how it will be able to obtain funding for its activities.

It was stated that F/P/T AIDS had undertaken a strategic planning process. A draft strategic plan will be completed by the end of March 2003. The plan will include a mission, a mandate, principles, strategic directions, and criteria for choosing priorities and alliances.

It was reported that on September 19-20, 2002, F/P/T AIDS hosted a panel of experts to discuss the issue of people who are unwilling or unable to prevent the transmission of HIV. The main goals of the event were to foster a multi-disciplinary dialogue and to identify potential directions and policy considerations for the committee. Experts representing a broad spectrum of perspectives, including public health, law and ethics, mental health, community and persons living with HIV/AIDS attended the roundtable discussion. A report of the meeting is currently being finalized. It will highlight areas of substantial agreement as well as issues that require further analysis and discussion. It was stated that F/P/T AIDS will hold a second meeting of the panel of experts in February 2003 to further define the various levels of risk of HIV transmission and a graduated response for interventions based on these different levels of risk. The committee is trying to achieve consistency in terms of how this issue is handled across the country.

Canadian Institutes for Health Research

CIHR would like the Council to designate someone for the Council seat and to provide advice concerning the process for selecting the two community representatives. For the latter, CIHR wants people who are affiliated with community organizations and who have some experience conducting research or working with people who conduct research.

Council agreed that René Lavoie will be its representative on the advisory committee. With respect to the process for selecting the community representatives, it was suggested, and the Council agreed to recommend, a process similar to the one used for selecting the members of the National Reference Group on Women.

Additional Items - Presentations

CBR Relocation Process

Nina Arron, Director of the HIV/AIDS, Coordination and Programs Division at Health Canada, joined the meeting for this discussion and provided an update on the relocation process.

The following information was provided:

• Originally, the program (for the full $1.8 million) was housed at the National Health Research Development Program (NHRDP) in Health Canada.
• It became clear, however, that this was not a the usual type of investigator-led program, and that administering the program through NHRDP was problematic.
• Consultations with stakeholders were held in 1999. The consultations led to changes in the design of the program and to a decision to split the Aboriginal portion from the general program.
• It became apparent that few submissions were passing peer review, so in 2000 capacity-building components were added to both the general program and the Aboriginal program.
• In 2001, NHRDP ceased to exist, and Health Canada got out of the investigator-led research business by transferring responsibility for such research to CIHR.
• It was recognized that the CBR programs were not sufficiently developed to transfer them to CIHR and that, in any event, CIHR was not ready to take them on. The CBR programs, therefore, were transferred to the HIV/AIDS Division on a temporary basis.
• In 2001, the CBR Steering Committee launched a redesign/relocation process.
• National consultations were held in the Fall of 2001 and the Spring of 2002, culminating in the release of the Bognar Report ("Building on the Strengths of Communities: Options for Redesigning and Relocating the Community-Based Research Program").

Health Canada reviewed the options presented in the Bognar Report and discussed them with the CBR Steering Committee.

• In the Fall of 2002, the CBR Steering Committee prepared recommendations on:
  
  • the characteristics of an ideal CBR program;
  • the characteristics of a new administrative home;
  • new administrative home selection criteria; and
  • program relocation options.

Nina reported that the CBR Steering Committee is currently looking at two relocation options for the general CBR program:

• a Health Canada-CIHR-community partnership which would result in the program being housed at CIHR; and
• issuing a request for proposals (RFP) to house the program.

Immigration

Dr. Brian Gushalak, Director General of Medical Services at Citizenship and Immigration Canada, joined the meeting to make a presentation on the preliminary results of HIV antibody testing of immigrants and refugees. Two officials from the HIV/AIDS Division, Michael McCulloch and Michael R. Smith, also joined the meeting for this presentation.

The following was presented:

Dr. Gushalak prefaced his presentation by explaining that in the data he was going to provide, the numerators (i.e., the numbers of people testing HIV-positive) were solid, but that the denominators (i.e., the total numbers of people entering Canada) were less clearly defined. He said that firmer numbers would be available after the end of December.

Dr. Gushalak said that as of June 28, 2002, when the new Immigration and Refugee Protection Act came into effect, refugees, refugee claimants and some sponsored persons in the family class were no longer subject to the excessive demand criteria. Dr. Gushalak reported that about 68% of the people testing positive are refugees or refugee claimants. Sponsored persons in the family class who are not subject to the excessive demand criteria make up about another 12% of those testing positive. This means that about 80% of the people testing positive are being admitted to Canada.

Since the new legislation took effect, Dr. Gushalak said, more people living with HIV are being categorized as medically admissible than was the case previously. This is because the categories of people who are exempt from the excessive demand criteria have been expanded. Dr. Gushalak pointed out however, that under the old system many of the people declared medically inadmissible were still being allowed into Canada on compassionate or humanitarian grounds.

Dr. Gushalak said that for those people who are HIV-positive and who are subject to the excessive demand criteria, an assessment is done to determine if they are expected to place excessive demand on Canada's publicly funded health and social services systems. As a general rule, he said:

• people with a CD4 count greater than 500 whose health is otherwise good are unlikely to require antiretroviral therapy in the next five years, so they are admitted;
• people with a CD4 count less than 500 whose viral load is under 55,000 copies per mL have a low likelihood of requiring antiretroviral therapy in the next five years, so they are admitted;
• people who are on antiretroviral therapy would normally be expected to place excessive demands on health and social services, so they would not be admitted.

Dr. Gushalak explained that, according to the regulations, demand is considered excessive if the projected costs over a five-year period are five times the average annual health care costs for Canadians. As of 2002, he said, the average costs for Canadians was calculated to be approximately $3,300.

In response to questions from Council members, Dr. Gushalak provided the following additional information:

• People who are taking antiretroviral therapy could still be admitted to Canada on a temporary residence permit or if a third party was paying for the medications.
• Australia and the United States have policies similar to Canada's; both do HIV testing.
• Visitors planning to stay more than six months will be required to undergo an HIV test if they are coming from certain designated countries.
• Short-terms visitors could be required to undergo an HIV test if they appear quite ill.
• The ultimate decision in each case is taken by the immigration officers. The medical officers make a recommendation on medical admissibility. In a person is deemed to be medically inadmissible, there is still a humanitarian process that could result in the person being admitted.
• Students from certain countries who are planning to study in Canada for more than six months are required to undergo a medical examination (including an HIV test). If they test positive, the determination of whether they are expected to cause excessive demand may depend on whether their province or territory of destination normally covers the health care costs of foreign students.
• The regulations state that the five-year period selected for estimating the costs that would be incurred by someone who is HIV-positive can be any five-year period within the first ten years after entry to Canada. However, in practice, because of the difficulty projecting out ten years, immigration officials are basing their estimates on the first five years following entry.
• About 2,000-2,200 people from other disease groups are found to be medically inadmissible each year.
• Refugee claimants whose applications were still in the pipeline on January 15, 2002 are assessed under the new rules. Anyone previously inadmissible under the old Act who has a new medical examination is also assessed under the new rules.

It was decided a letter should be sent to Dr.Gushulak commending him for desire to work closely with Health Canada on immigration and HIV/AIDS issues; welcome Dr. Gushulak's offer to work with Health Canada on a communications strategy on the issue of the numbers of HIV-positive persons entering Canada as refugees; mention that there are places in the community that CIC can feed into (e.g., HIV Endemic Task Force); and ask CIC to create mechanisms to ensure that all HIV antibody testing is accompanied by quality pre- and post-test counselling.

Meeting with the Minister

Council members met with the Minister of Health and discussed the following issues:

• World AIDS Day
• Canadian Strategy on HIV/AIDS Funding
• Interdepartmental Issues
• Safe Injection Site/Facilities
• Medical Use of Marijuana

Ministerial Council's Strategic Plan

Council discussed the recommended strategic plan prepared by consultants. It was stated that Council needs a document that clearly states where the Council wants to be in three years and that identifies three or four key strategic issues. It was suggested that perhaps the Council should devote appropriate time to working on a vision, on priorities and on strategic directions, and then let the committees do their piece.

It was decided that the Communications and Liaison Committee, in consultation with the Executive Committee, would take the lead in terms of planning the next steps for the development of Council's strategic plan. The Communications and Liaison Committee will consider the following scenario: have each committee prepare a plan for its area of responsibility on Day One of the next Council meeting; and have the Council discuss the committees' plans on Day Two or Three of the next Council meeting.

Committee Membership

Through a process of self-selection, Council determined the membership of its committees, as follows:

• Communications and Liaison Committee: Lindy Samson, Gerry McConnery, Dionne A. Falconer
• Special Working Group on Aboriginal Issues: Louise Binder, Art Zoccole, Barney Hickey, Sholom Glouberman, Dionne A. Falconer, Esther Tharao
• Championing Committee: Louise Binder, Barney Hickey, Esther Tharao, Richard Elliott, Sheena Sargeant
• Research Committee: Lindy Samson, Jacqueline Gahagan, Margaret Dykeman, William Flanagan, Esther Tharao, Michael Grant, René Lavoie.

Other Business

It was suggested that Council members should get copies of the UN reports that have recently been issued. These Reports follow up on resolutions adopted by the UN Commission on Human Rights (with Canada's support) that relate to HIV/AIDS and access to medication as a human rights issue. They should be available from UNAIDS or the office of the United Nations High Commissioner for Human Rights.

Dates for Future Meetings

• March 1-3, 2003
• June 7-9, 2003
• September 20-22, 2003