|Partners in Prevention: International case studies of effective health promotion practice in HIV/AIDS (Best Practice - Key Material) (UNAIDS, 1998, 84 p.)|
by Mr Russell Armstrong, Executive Director, Canadian AIDS Society,
and Ms Dina Juras, Programme Consultant, AIDS Community Action
Programme, Health Promotion and Programmes Branch,
Manitoba/Saskatchewan Region, Health Canada
On an international level, Canada has done comparatively well in its efforts to curb the spread of HIV within its own boarders. This success is largely due to effective collaboration between community-based HIV/AIDS organizations and the federal government of Canada. This article describes how this partnership came to be and how it currently operates. We deal exclusively with the federal government and its relationship to community. There are other levels of government involved in supporting communities affected by HIV/AIDS. There are also other groups and individuals not part of the community-based response working to combat HIV/AIDS. All in their way have contributed to Canada's success. The community/government partnership is but one ingredient necessary for building an effective prevention response.
OVERVIEW AND CONTEXT
HIV in Canada
The latest information on HIV/AIDS trends in Canada was released by Health Canada's Laboratory Centre for Disease Control in May 1997. As of 15 April 1997, there have been a total of 14,836 cases of AIDS reported in Canada. Of these, 14,677 were adults and 159 were children under the age of 15. When the total number of cases is adjusted for delays in reporting or under-reporting, the number rises to as high as 20,000. As of 31 March 1997, there had been 10,837 reported deaths (Health Canada 1997). AIDS is the leading cause of death for men between the ages of 25 and 40 in all of Canada's major urban centres.
The largest portion of reported AIDS cases is still among men who have sex with men, although this has been declining. As of 1996, 62.2% of reported cases were among men who have sex with men. Rapid increases in proportions have been seen among women (25% in 1996), those who report injecting drug use (10.3% in 1996) and those who report heterosexual transmission (9.2% in 1996).
Health Canada estimates that there have been between 50,000 to 54,000 people in Canada infected with HIV since the epidemic began. At the end of 1996, there were between 36,000 to 42,000 people living with HIV. As only AIDS cases are reported at the national level and not cases of HIV infection, the extent of HIV infection in Canada can only be estimated. Between 3,000 and 5,000 new HIV infections occur each year in Canada.
Most new HIV infections are occurring among women, injecting drug users and young gay men, although there is significant regional variation in infection patterns. Aboriginal communities and ethno-cultural communities are also affected, although the extent of HIV infection in these communities has been difficult to estimate as information on race and ethnicity is not routinely collected with test results.
Some Facts and Figures About Canada
The current population of Canada is approaching 30 million. Seventy-seven per cent of the population lives in cities; the remaining 23% lives in rural areas. Canada is made up of ten provinces and two territories, each with its own government. The Canadian Constitution outlines the division of responsibilities between the provincial/territorial and federal governments. Provinces and territories have responsibility for delivery of direct services in health care. Some of this delivery is delegated to the regional or local level. Provinces and the federal government share the financial cost of health services. The federal government transfers health care and social service funds to the provincial level through a transfer payment scheme that has some limited conditions attached to the payments. These conditions ensure a consistent set of approaches in major areas of health and social programmes across all provinces. Federal government support for provincial programmes has declined significantly in recent years due to deficit problems. Canada is undergoing dramatic changes in the organizations of social and health services as a result.
Most of Canada's health care system is publicly funded. Doctors and other health professionals working in hospitals, clinics or in private practice are paid for their services through public monies. Health care facilities receive the most significant portion of their operating funds from government sources. Currently, it is illegal to set up private clinics and charge patients for services that are publicly funded.
To some degree, the community-based HIV/AIDS sector is supported by government funds. However, this level of funding is declining and the community-based sector is relying more and more on charitable contributions from private sources. Individuals in Canada receive income tax credits for contributions to charitable organizations. Community-based AIDS organizations are funded through a mix of government contributions and charitable donations from individuals, private foundations and business.
HISTORY AND STRUCTURE OF THE COMMUNITY-BASED RESPONSE
In the Canadian response to HIV/AIDS, community-based organizations have been at the forefront. These organizations have been remarkably effective at delivering targeted interventions specific to local community dynamics. They have emerged in this role, however, more as a result of troubled undercurrents in Canadian social attitudes, than as a result of supportive health policy decisions early on in the course of the HIV/AIDS epidemic.
Canada recorded its first case of AIDS in 1982. Gay men and haemophiliacs were hardest hit as the HIV epidemic took hold. HIV/AIDS was originally most prominently associated with gay men, and a quick response to the epidemic was frustrated by deeply entrenched public prejudice against gays and lesbians. Although the new epidemic was also affecting other groups in society (early commentators on the epidemic spoke of the four 'H's': homosexuals, haemophiliacs, Haitians, and heroin users), it was widely considered a gay disease and by extension a disease of the socially deviant who fell outside of the sphere of public compassion and responsibility. As a result, gay communities were challenged to respond to HIV/AIDS in the midst of extreme difficulties.
Indeed, HIV/AIDS emerged at a time of antagonism between gay and lesbian communities and public 'authorities'. Gay and lesbian communities, which had been gaining in strength and visibility throughout the decade that preceded HIV/AIDS, gradually provoked significant backlash from police and government in some regions of Canada. A Toronto bath house was raided by police and the national gay and lesbian news magazine The Body Politic was prosecuted for publishing an article on intergenerational relationships. Canadian customs authorities were beginning routine harassment of gay and lesbian booksellers. Magazines imported from abroad appeared in Canada with blank pages or large portions of pages blacked out. Explicit depiction of gay sexuality (whether in newspapers, magazines or novels) was considered degrading. For a time, Canada Customs focused particularly on depictions of anal sex and blacked out or simply banned any materials containing such depictions.
In responding to these multiple challenges, gay communities developed sophisticated skills in advocacy and community mobilization. Gay communities also became accustomed to giving money to support groups fighting the various causes of social oppression. All of this formed a strong base upon which to mobilize quickly and effectively in the face of HIV/AIDS. Despite a complete lack of support from public institutional sources, gay communities across Canada promoted awareness of the emerging epidemic through public information sessions, pamphlets, posters and newsletters. Messages included the latest news about the advancing epidemic, information about safer sex practices and warnings for gay men not to donate blood. In some cases, these were plain, typewritten sheets, photocopied and distributed through bars, saunas and other regular meeting points.
Gradually, as the magnitude of HIV/AIDS grew, government response increased and funding for prevention and support programmes became available. In the nearly decade-and-a-half long struggle with HIV/AIDS in Canada, a vibrant network of community-based organizations has grown to span the country from coast to coast. Most community-based HIV/AIDS organizations are organized under the umbrella of the Canadian AIDS Society (CAS). CAS is the national coalition of over a hundred such organizations. CAS members are autonomous; the national coalition exercises no authority over their affairs. Members must meet a set of clearly defined criteria in order to belong to CAS and must support community action principles. These membership criteria have helped keep a consistent identity and approach to the ever-expanding community-based sector. The criteria include a requirement for members to demonstrate significant and appropriate representation of people living with HIV/AIDS in all leadership or decision-making roles.
Community-based HIV/AIDS organizations in Canada cross a wide variety of organizational types and designs. Many have evolved from strong gay and lesbian roots and represent a transformation from local gay and lesbian community groups to a full fledged, multi-service HIV/AIDS organization complete with a board of directors, paid staff, a large volunteer pool and a sizable annual budget. These AIDS service organizations offer a range of interventions from support and counselling for people living with HIV/AIDS to education and prevention programmes for individuals and groups at risk of HIV transmission. Within this category, there are organizations with very particular focuses either in the service they provide or in the population they reach. This includes hospices or treatment organizations, for example, or organizations focusing specifically on women, Asian gay men or aboriginal people.
Also included in the Canadian network of community-based HIV/AIDS organizations are the PLWHA organizations. These may be small, relatively informal networks or larger, multi-service agencies. All are governed and often run by PLWHAs. Such organizations have a more specific focus for programmes in that they offer many forms of practical support and assistance as well as undertake advocacy on social welfare issues directly related to PLWHAs.
CONCEPT OF PREVENTION
The concept of HIV prevention and Canadian approaches to it have evolved over fifteen years of efforts to cope with the impact of the HIV/AIDS epidemic. This development can be seen most clearly in community-based HIV/AIDS prevention interventions and the policies of government funding programmes that support this work. Canada's approach to HIV prevention has been to deliver targeted interventions within communities most at risk of HIV transmission. This approach is founded in the principles of health promotion with a strong emphasis on community development.
Health promotion, as defined by the World Health Organization, is a process of enabling people to increase control over, and to improve, their health. Health, according to the WHO definition, is more than the absence of disease. It includes emotional, physical and social well-being. The community development approach holds that in order for people to gain control over their lives and the circumstances that affect their health, communities must identify their own problems, develop their own solutions and put them into action (WHO 1996).
In 1986, Health Canada formalized this approach into a framework document called Achieving Health for All (Epp 1986). This document identified three main health challenges: (1) reducing inequities; (2) increasing prevention; and (3) enhancing coping skills. As a response to these challenges, the framework outlined three health promotion mechanisms: (1) self-care (which encourages healthy choices); (2) mutual aid (people working together in their efforts to deal with their health concerns); and (3) healthy environments (altering or adapting social, economic or physical surroundings in ways that will preserve and enhance health). The framework also suggested three implementation strategies: (1) fostering public participation (helping people to assert control over the factors that affect their health); (2) strengthening communities and community health services; and (3) coordinating healthy public policy (all policies that have a bearing on health and people's capacity to make healthy choices need to be coordinated and involve other sectors). Within this larger health policy context, community-based HIV/AIDS interventions emerged and were, ultimately, largely supported through funding programmes that attempted to put into practice this language of health promotion and community development. To a significant extent, this policy language helped formalize and make explicit what gay and lesbian communities were learning to do in an intuitive sense as they faced the advancing epidemic.
In the early stages of the epidemic, community-developed pamphlets and posters contained basic information about HIV transmission, including risk reduction or risk avoidance information. The resources were mainly delivered through gay community sources and directed at sexually active gay men. Materials addressed such topics as: condom use; the risks involved in oral sex versus anal sex; the merits of testing; and the debate over whether there was a need to reduce the number of sexual partners versus consistently practising safer sex. Materials also recognized that a variety of contextual factors influenced the experience of HIV and risk. Gay men needed to be motivated to practise safe sex and to maintain a hopeful sense of their own survival in the midst of such adverse forces as an advancing epidemic and broad scape-goating of gay men and their sexual practices as threats to the well-being of society at large. Materials had an encouraging tone and discussed issues of self-esteem and pride in community.
These early efforts gained momentum as government funding programmes were gradually opened up to support and expand them. Between 1982 and 1989, Health Canada operated the Health Promotion Contribution Programme. Funding under this programme was targeted to various groups, including women, seniors and people with disabilities, to support the general health promotion mechanisms of reducing inequities in health status and strengthening the capacity of people to cope using self-help and mutual aid activities. Community-based HIV/AIDS organizations were also eligible to apply under this programme. Early interventions that were funded included programmes that focused on self-help strategies to cope with the personal impact of the epidemic and those that attempted to raise general awareness about HIV/AIDS in the community at large.
The first National AIDS Strategy and the AIDS Community Action Programme (ACAP) were created in 1989. Within the framework of the Strategy, the ACAP programme focused on ways to increase the prevention effort and formally recognized the value of targeting prevention messages. The first National AIDS Strategy described the approach to prevention in this way:
While national programming can be useful for increasing general awareness and promoting positive attitudes, real change in attitudes and behavior is more likely to be brought about through targeted messages, locally designed and delivered. It is important to aim programmes at those areas and people that are at greatest risk... Such programmes must reflect the language, values and practices of those to whom the information is directed, and involve those closest to the community concerned. (Health Canada 1989, p. 41)
Groups in the population most at risk for HIV infection were identified based on epidemiological data. HIV/AIDS prevention interventions needed to be tailored to the specific social or cultural make-up of these groups and needed to be delivered by a source credible to the group. Broad-based campaigns made specific target groups invisible; or they did not speak directly to the social or cultural context within which HIV risk transpired. What was supported through the programme were interventions that spoke explicitly about sex and HIV risk, for instance, in language and images credible and familiar to the audience these messages were intended to reach.
Alongside targeted, culturally sensitive interventions, the ACAP programme also funded projects designed to reduce barriers that prevented marginalized or socially isolated groups of people from accessing health care. In the context of HIV/AIDS, barriers to access were largely about stigma and lack of knowledge among institutions, policy makers, and public service providers about the issues and concerns of at-risk and/or HIV-infected populations. Interventions dealing with education on AIDS-phobia, homophobia, racism, sexism and poverty were developed and implemented with the support of the ACAP programme to address these barriers (Canadian AIDS Society 1989).
A further aspect of the ACAP programme involved support for activities that integrated messages within contemporary social and health interventions. The programme supported initiatives in cities and provinces where community-based HIV/ AIDS organizations worked with public education systems to integrate HIV/AIDS in sexuality education curriculum for schools. It also included situations where community-based HIV/AIDS organizations were contracted by provincial health departments to run province-wide telephone information lines on sexually transmissible diseases.
In 1993, following on from a national consensus conference and a series of federal government-led consultations with community educators and PLWHAs, a more expansive approach to prevention was set out (Health Canada 1992). The most significant shift in emphasis was the increased focus on health promotion for PLWHAs and the creation of supportive social environments as part of expanded prevention programming (Health Canada 1993). A separation between prevention and care was gradually eroded, based on advocacy on the part of PLWHAs to have their needs included in prevention initiatives, and, as well, on a growing understanding of prevention as part a continuum of care and support for both HIV positive and HIV negative members of HIV-affected communities.
Recently, government policies have begun shifting from a health promotion approach to one of population health (Health Canada 1996). Population health explores the interrelationship of multiple determinants of health on individual and population-based health outcomes (Health Canada 1996). This approach is not new to community groups working in the area of HIV/AIDS (Canadian AIDS Society 1996). Addressing the multiple social and environmental factors that determine health has been integrated in prevention approaches for some time. However, understanding the complexity of the interrelationship of multiple determinants of health, and developing strategies that address the impacts of these multiple determinants, have yet to be or are just starting to be incorporated into research agendas, evaluations, and policy and programme planning at both the community and government levels.
COMMUNITY AND GOVERNMENT
As noted above, HIV/AIDS emerged in Canada during a time that saw active hostility between forces identified with government or state and gay and lesbian communities. The roots of community organizing around HIV/AIDS were recently explored through the Commission of Inquiry on the Blood System in Canada. One of the areas for inquiry was how the HIV epidemic emerged in Canada and how the virus subsequently found its way into the blood system. The inquiry examined early community responses throughout Canada's gay and lesbian communities and contrasts these to government indifference or, in some instances, open hostility. Fortunately, the tragedy of AIDS and the challenge of an expanding HIV epidemic have provided the impetus to repair these early fissures and build in their place a strong, collaborative partnership.
The origins of more supportive partnerships in prevention between community and government begins at a particular moment in the history of the epidemic. In Vancouver, 'AIDS Vancouver', one of the first formally constituted community-based HIV/AIDS organizations, approached a regional Health Canada office for financial support to deliver prevention programmes. As noted above, Health Canada, at the time, was well positioned to respond since its policies and general funding programme incorporated principles of health promotion and community development. Funding was provided in gradually increasing amounts to local community organizations to provide targeted prevention programmes in explicit, direct. Public controversy arose occasionally, generally over materials aimed at youth that used direct sexual language, materials depicting safe S/M (sado-masochistic) practices, or materials that appeared to condone illicit activities like injecting drug use.
The formation of the Canadian AIDS Society in 1985 inaugurated a new era in government and community collaboration. CAS began as a national coalition of community-based HIV/AIDS organizations working at the local level in various regions of the country. In addition to providing a forum for exchange and support amongst these organizations, CAS took on a strong advocacy role at the national level. The result of this advocacy was a strengthened framework for community-based approaches to prevention. CAS lobbied the federal government to recognize the role of community organizations as the most effective delivery mechanism for prevention interventions targeted at those communities most at risk for HIV. CAS also lobbied the government for a national funding programme to support this role.
These lobby efforts were instrumental in the creation of the first National AIDS Strategy in 1989. Central to the Strategy was partnership, particularly partnership between government and members of HIV-affected communities. Although this partnership has functioned with relative effectiveness, it is at times highly antagonistic. In 1988, for instance, frustrated by the inaction on the part of the federal government in moving toward the creation of the first National AIDS Strategy, the federal minister of health at the time was burned in effigy by a community-based activist organization outside a national conference on AIDS. The minister was subsequently shifted to another portfolio and replaced by a new, more supportive minister. This event marked a climactic point in the strained relationship between community and government.
In general, the community-based HIV/ AIDS movement has shown remarkable skill in analysis and advocacy. Indeed, advocacy has been central to the partnership between community and government, with community providing the analysis to government for the work that needed to be done and spelling out the broader partnerships that were necessary to get the work done. Community-based HIV/AIDS organizations have also become adept at using the political process to achieve change and progress in government policy. Many of the leaders in advocacy have been PLWHAs, and they have brought an urgency and a focus to advocacy and policy development activities.
Partnership and collaboration between community and government were recently tested again. As part of the federal government's move toward a population health approach, national strategies, including the National AIDS Strategy, were scheduled to conclude and not be renewed. Instead, the government planned to take a more integrated approach and not parcel out its resources to various diseases or issues. For the community-based HIV/ AIDS movement, this meant neither a dedicated funding programme for HIV/AIDS nor any visible, high-level commitment on the part of the federal government to continue to deal with HIV/AIDS. In response, the CAS along with many community-based HIV/AIDS activists and PLWHAs led a strong lobbying initiative. Public support for a renewed federal commitment to AIDS was mobilized through media events. CAS member organizations were constantly asked to meet or write to their local member of parliament and to mobilize their own membership to do the same. The result was that during the recent federal election campaign, the federal Liberal Party announced its intention to renew the National AIDS Strategy for another five years at current funding levels. Subsequent to the Liberal's being re-elected to form the government, the commitment has been confirmed and a process has been under way to develop a third National AIDS Strategy in time for World AIDS Day, 1 December 1997.
MEASURES OF SUCCESS
True measures of success in HIV/AIDS prevention work are sometimes elusive. Demonstrating that a particular intervention results in reduced HIV transmission is difficult. Also, success is due to multiple sectors and partners. In Canada, since HIV/AIDS first emerged in the early 1980s, new cases of HIV infection declined after significant investment in prevention initiatives and as a result of collaboration between government and community-based HIV/AIDS organizations working within communities most at risk HIV infection. The extent of this decline and its relationship to particular interventions are difficult to establish. Indeed, the relationship is further called into question by the troubling fact that new cases of HIV infection have recently begun to increase.
In addition to ongoing epidemiological monitoring, Canada has used other measures to determine success in HIV/AIDS prevention. For instance, large-scale knowledge, attitude and behaviour studies have been conducted to determine the impact of HIV/AIDS prevention efforts within targeted, at-risk communities. The most significant study of this kind was the Men's Survey, conducted in 1991 (Myers et al. 1993), and the complementary study Entre Hommes (Between Men), conducted at the same time in the province of Quebec (Godin et al. 1993). Both were large-scale surveys administered by gay and lesbian volunteers in community venues. University-based researchers and community-based prevention specialists joined forces to develop and implement a research method that helped strengthen community action on AIDS, while at the same time gathering much needed data on the impact of prevention efforts.
Although the two studies differed somewhat in their recruitment strategies, they both confirmed that a tremendous change had occurred among gay and bisexual men across the country. At the same time, they pointed out that there were small but significant numbers of men who were not being reached by existing interventions. The regional consultation process that followed the survey in 1993 facilitated opportunities for educators to solve problems that had been identified in the research and plan prevention strategies to reach those who were not being reached by existing programmes. A series of recommendations resulted from the consultation and these have continued to guide prevention efforts at the both the local and national level (Canadian AIDS Society 1994).
Another measure of success used in Canada is the programme-based impact questionnaire by the AIDS Community Action Programme (Health Canada 1993). The questionnaire was developed in consultation with community HIV/AIDS organizations and other Health Canada funding programmes. It measures the impact of prevention projects using two health promotion indicators: (1) increasing public participation; and (2) strengthening organizations. First, if we maintain that, in order for people to gain control over their lives and the circumstances that affect their health, they must get involved, then we can measure involvement. If an issue is important to a community, they will name how it affects them, develop the solutions and take action. To measure a project's success at increasing public participation and involvement, the following assessment measures are used:
people who experience the health or social issue the project addresses are involved in making decisions about the project from planning to evaluation;
social supports and networks are expanded;
those involved with the project gain knowledge and skills through their involvement;
increased collective action results from involvement in the project;
those involved with the project form a foundation for ongoing social change.
Second, if organizations are a vehicle through which people have a voice in defining their issues, then community organizations must have the capacity to respond and cope with those issues. A project's success in strengthening community organizations is measured according to the following indicators:
· ability to build coalitions and to form partnerships;
· positive visibility, recognition and acceptance within their communities;
· increased knowledge, skills and understanding among group members;
· creation of a foundation to support future activities;
· cooperation with other groups and networks;
· ability to sustain the participation of community;
· an increased sense of the group collective power;
· ability to influence and/or participate in decision-making that affects the community.
Through the administration and assessment of the impact questionnaire results, a consistent method of evaluation has evolved across ACAP-funded projects, including prevention interventions. As well, results have been used to help refine and adjust funding priorities. However, the realities of measurement or making evaluation meaningful to communities has been challenging. More attention needs to be paid to this area. Community organizations often do not see evaluation as a relevant priority in their work. HIV prevention itself is often difficult to evaluate. A recent report by the CAS outlines the challenges facing community-based educators in the area of measuring success (Canadian AIDS Society 1996). In addition, there are complexities involved in creating an appropriate evaluation framework for these prevention interventions. Educators lack evaluation training and often function within a larger context of organizational instability that leaves little time to remedy these problems. As the annual rate of new HIV infections continues to rise in Canada, measuring success and learning from these measurements becomes an urgent priority.
AT WHAT COST?
Estimating Canada's expenditure on prevention in relation to the impact of these prevention interventions on the progress of the epidemic is a complex process. Funds for prevention work come from various levels of government as well as from individuals and business in the private sector. Expanding the impact of funds spent is the non-monetary contribution of the thousands of volunteers working with the community-based HIV/AIDS sector to assist in the delivery of prevention.
Canada's expenditures on prevention are currently being studied. The Canadian Policy Research Network will publish late in 1997 a comprehensive study that details how much has been invested in prevention and where this money has come from. At the national level, under Phase II of the National AIDS Strategy, spending on prevention takes up a significant portion of the overall budget. During Phase II, the overall strategy budget of CAN$42.2 million was allocated each year for the following programme areas:
· CAN$6.2 million on education and prevention initiatives;
· CAN$17.8 million on research and epidemiological monitoring;
· CAN$9.8 million for community development and support to non-governmental organizations;
· CAN$5.4 million for care, treatment and support;
· CAN$1.5 million for coordination and collaboration.
These figures represent only federal government spending through the National AIDS Strategy. It does not take into account spending by provincial or municipal governments on prevention, or contributions from the private sector. Equally absent is a sense of the countless hours of volunteer labour through community outreach programmes that has contributed immensely to a cost-effective prevention strategy.
One point is worth noting. Of the CAN$42.2 million annual budget of the National AIDS Strategy, only CAN$7.5 million is allocated to the AIDS Community Action Programme. This programme is the major source of support for community action on HIV/AIDS. Given the importance of community action in Canada, it is surprising to see that less than 20% of the national budget on HIV/AIDS supports this sector. This and other questions around the role of community in the delivery of prevention programmes will occupy a significant place in the discussions leading to the development of Phase III of the Strategy.
Canada's approach to prevention has been, for the most part, successful. The proof of this is in the shape of the epidemiological curve and in the significant shifts measured amongst men who have sex with men and other communities at risk for HIV infection. Social attitudes toward HIV/AIDS, including people living with the disease, have shifted remarkably during this country's fifteen-year struggle with the disease. Community mobilization partnered with government support has been very effective in developing appropriate programmes and responses. The involvement of PLWHAs has been crucial in the development of an effective community response to the disease. Consultation, community involvement and transparent processes have helped build successful partnerships. HIV/AIDS work has been a catalyst for larger social policy change.
In addition to these success, however, there remain some gaps. These are some of the more significant ones:
· There is still more work to be done. HIV prevention approaches have not worked for certain communities or are just starting to take hold and it takes sustained support over time to evolve an effective community response. Dramatic rises in new infection rates among women, young gay men, injection drug users, and aboriginal people have recently been observed;
· Models of community mobilization and intervention that have been successful in gay communities, for example, may not work for populations showing dramatic rises in rates of HIV infection. Rethinking prevention interventions will take time, energy and commitment. Much larger societal factors need to be addressed that are beyond the ability of current partnerships to change: for example, the federal government has recently tightened laws around possession of drugs and drug paraphernalia putting in jeopardy needle-exchange programmes. At the same time, in certain parts of Canada, rates of new infection among injection drug users have recently become the highest in North America;
· Community-based HIV/AIDS organizations are suffering from fatigue. Constant under-funding and uncertainty about future funding has lead to tension between the need for advocacy to maintain existing levels of support, while at the same time coping with increasing demand for services;
· Although funding has been provided to support an infrastructure of community-based HIV/AIDS organizations, community organizations do not participate on a level playing field with government. Financial support should be used to give communities an equal voice in the issues and not to make them solely responsible for these issues;
· HIV is advancing further into the socially and economically marginalized, therefore coalition-building across a broader spectrum of partners from other social movements needs to be further developed. There have been some very successful outcomes of working together. Recently, governments have positioned diseases and the organizations formed to cope with them as competitors for limited resources. AIDS and breast cancer are the main examples. This has been called a 'competitive misery model' by some. Coalition-building will help strengthen the need for better government investment in community mobilization across all health issues.
WHERE DO WE GO FROM HERE?
As previously noted the HIV epidemic is not over in Canada. In May 1997, new epidemiological data revealed between 3,000 and 5,000 new cases of HIV infection each year. Two years before this, this rate was between 2,500 and 3,000 (Health Canada 1997). Rising rates of HIV infection emphasize the urgent need for longer-term planning and vision. Without adequate government support for programmes and broader ownership of the issues, raising funds to support prevention efforts will supplant the actual work of prevention. Current government funding models are based on short-term project support, which has recently been show to be destabilizing and not conducive to effective prevention programmes. Rising rates of infection have also made improving evaluation more critical. Resources for HIV/AIDS have not significantly increased and are not likely to do so in the near future. Although the federal government has pledged to renew the National AIDS Strategy for a third five-year phase, it has done so at current levels of funding, despite that fact that there is now a greater number of people living with HIV/AIDS in Canada. Being able to demonstrate the success of prevention programmes will be crucial as government and community alike struggle to use precious programme dollars effectively.
The HIV epidemic is more complex than when it first emerged. Newer populations becoming infected with HIV have complex health and social needs. Ideally, a population-based approach will provide new opportunities for more multisectoral prevention work. As the consultation process for Phase III of the National AIDS Strategy gears up, we face the hopeful possibility of further expanding and reinforcing the effectiveness of prevention work done to-date.
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