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Canada

1998

Canada is an advanced industrial country stretching from the northern border of the United States to the Arctic Ocean. Geographically the second largest country in the world but somewhat sparsely populated with about 28 million citizens, Canada has a heavily decentralized political system in which the federal government shares power with ten provinces and two territories. The first case of AIDS in Canada was reported to the Laboratory Centre for Disease Control (LCDC) of the Department of Health and Welfare (now known as Health Canada) in February 1982, at which time the national AIDS Case Reporting and Surveillance System (ACRSS) was initiated. A retrospective evaluation of health records revealed that the first AIDS case in Canada was diagnosed in 1979.

The Canadian AIDS case definition for surveillance purposes was established using internationally accepted and objective case criteria. In July 1993, these criteria were expanded to include pulmonary tuberculosis, recurrent bacterial pneumonia, and invasive cervical cancer. This last alteration was consistent with changes made to AIDS case definitions in all European countries, Australia, and New Zealand but differed from the changes made in the United States, which included a CD4+ cell count of less than 200 cells per microliter as a criterion.

The LCDC of Health Canada defines a case of AIDS as involving a person who has an illness characterized by one or more of the specified indicator diseases and either who has tested positive for HIV infection or for whom there is an absence of specified causes of underlying immunodeficiency. This definition was developed in collaboration with the ten provinces and two territories and is used throughout Canada.

Although reporting of numbers of AIDS cases to the federal government is voluntary, all provinces and territories participate in ACRSS. Attending physicians complete a standardized case report form and forward it to the respective local medical officer of health. The health unit sends a copy to the respective provincial or territorial ministry of health, which in turn forwards the information to the Division of HIV/AIDS Surveillance at the LCDC.

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As of 1995, men who have sex with men (MSM) remained the dominant exposure category, accounting for approximately three-quarters of all AIDS cases reported. Three provinces, British Columbia (17.1 percent), Quebec (31.1 percent), and Ontario (40.6 percent), accounted for 88.8 percent of AIDS cases in Canada. In June 1995, the LCDC estimated that from 42,500 to 45,000 Canadians had been infected with HIV up to the end of 1994, an estimate that reflected a number of factors: reported HIV cases, data from epidemiological studies, and statistical modeling. Alberta, British Columbia, and Quebec do not require that HIV seropositivity be reported to their provincial health departments, which limits the completeness of national HIV data.

As of 1995, there had been a slow but steady increase in the number of women who have AIDS, so that they accounted for 6 percent of the total reported cases. Similarly, HIV infection among injecting drug users (IDUs) in Canada was worsening, as confirmed by an outbreak among IDUs in Vancouver, British Columbia, and by data from Montreal, Quebec, and Toronto, Ontario. The most rapid increase in new HIV infections was occurring among women and IDUs.

Under the terms of the British North America Act of 1867, through which Canada was created, health was assigned to the provinces. Although considered to be a local, minor responsibility at the time, health has become a major social policy area since then. The provinces jealously guard their preeminence and have developed their own unique health care delivery systems. The federal government's health role is limited and is focused on areas such as immigration, quarantine, federal public servant health, the health of Native Americans who live on reserves (including Indians, Métis, and Inuit), and the protection of consumer health.

HIV/AIDS has demanded a strong, national direction, but Canada's federalized structure has made a national approach difficult to achieve. Over the years, the federal government has developed various mechanisms to achieve national consensus and consistency on health matters. Through its primacy in taxation policy, the federal government has used financial incentives, such as grants or cost-sharing arrangements, to enable the evolution of universal medical and hospital care. The federal government has also exercised its legislative role to set national standards, such as those under the Canada Health Act (1984). In recognition of the division of power and the necessity of joint action on important health initiatives, federal, provincial, and territorial advisory committees were established by the Council of Ministers of Health and the Conference of Deputy Ministers of Health.

In June 1987, the Conference of Deputy Ministers of Health convened the Federal/Provincial/Territorial (FPT) Advisory Committee on AIDS. Its role is to enhance consultation with a primary emphasis on policy and coordination as opposed to operational elements. It focuses on policy advice, trend monitoring, making recommendations for policy and legislation, and facilitating joint planning and projects. The FPT Advisory Committee on AIDS has had a strategic role in the development of a national approach in spite of its being only an advisory rather than a rule-making body. Over time, provinces and territories have developed programs with common elements such as a long-term strategy, public education, public and private testing and counseling services, support for research, the development of treatment and support systems, and funding for AIDS service and community-based organizations. The level of performance of the provinces and territories reflects the degree of HIV infection and the number of AIDS cases in their jurisdictions. With almost 90 percent of the country's AIDS cases among them, British Columbia, Ontario, and Quebec have the most comprehensive and mature programs and policies in Canada.

Federal support of national organizations and local, community-based groups has had an important impact as well. Resources made available under the National AIDS Strategy (NAS) provide both infrastructure and project support, which are especially important in poorer provinces and territories where the local ability and/or willingness to implement AIDS programs and services are limited.

From the outset, the LCDC took the lead in epidemiological surveillance and testing protocols at the federal level. In 1983, an ad hoc task force on AIDS was created within the federal Health Protection Branch (HPB); the task force proved to be the precursor of the National Advisory Committee on AIDS (NAC-AIDS), launched in August of 1983, at a time when some 31 cases of AIDS had been reported. The NAC-AIDS was set up as an expert scientific advisory committee to the federal health minister with a mandate "to review the status of AIDS in Canada and in other countries, and to make recommendations to the Minister of National Health and Welfare and other appropriate agencies which will lead to the implementation of medical care, research and other strategies with regard to the diagnosis, treatment, control and prevention of AIDS in Canada."

The NAC-AIDS met privately, with its public face visible only in the guidelines for both public and professional educational information to be offered by Health Canada. The NAC-AIDS evolved over the years, eventually opening up its membership to be more reflective of the AIDS community in Canada. Part of its mandate has been to provide a national forum to promote, enhance, and encourage collaborative initiatives and partnerships among key communities.

The National AIDS Centre was established in 1986 within the LCDC to focus federal activity. In July 1987, in recognition of the growing importance and complexity of the AIDS issue, the Federal Centre for AIDS was created within the HPB. It marked the first comprehensive approach to HIV/AIDS at the federal level. A five-year plan funded at $39 million was announced in 1986 and, two years later, was augmented to $116 million (all figures in Canadian dollars). In 1988, work began on a national AIDS strategy, which was announced at the Fifth International AIDS Conference in Montreal in 1989.

The federal health minister was instrumental in the development of an ad hoc committee of parliamentarians to discuss the issues that would form part of the policy of the NAS. The all-party committee held public hearings in early 1990, prior to the actual launch of the NAS on June 28, 1990, in Toronto at the annual meeting of the Canadian Public Health Association. The strategy was set out in HIV and AIDS: Canada's Blueprint, which was the result of extensive consultations. The overall responsibility for HIV/AIDS coordination was assigned to the National AIDS Secretariat. The establishment of the strategy and the secretariat was seen as an important initiative, but considerable concern remained that federal policy was evolving in isolation from provincial policies. Although there was a federal strategy, there was still no comprehensive nationwide strategy as of 1997.

The federal NAS was renewed in 1993 for a further five years until 1998 at a level of $40.7 million per year. In 1995, testimony before the House of Commons Subcommittee on HIV/AIDS challenged the efficacy of Health Canada's leadership and coordination of the NAS. The subcommittee (part of the House of Commons Standing Committee on Health) called on Health Canada to enhance its leadership and coordination and to refocus efforts in the HIV/AIDS field. Concerns about an ongoing federal government commitment after 1998, expressed by most witnesses before the subcommittee, led to the recommendation "that Health Canada maintain an appropriate integrated AIDS Strategy with a corresponding budget."

Overall, AIDS cases in Canada have been concentrated in three metropolitan areas: Toronto, Vancouver, and Montreal. In each of these centers, there were large, well-established gay communities, and in the early years of the epidemic, it was the gay community that responded with programs and support services well before any government initiatives began. Societal homophobia, a lack of appreciation of the potential impact of AIDS, disjointed service provision, a lack of caregiver preparedness, and a failure of public leadership all played important roles in the delayed response by government, the public health system, and the professions to HIV/AIDS.

The AIDS Committee of Toronto (ACT) was created in 1983 as the cohesive, well-organized gay community in Toronto began to provide education, support, and advocacy programs. It pressured the city health department and city council to take AIDS seriously, and by 1985, the public profile of AIDS was such that testing, counseling, treatment options, and an experienced cadre of caregivers were in place. Increased advocacy and concern about the lack of provincial and federal leadership led to the formation of AIDS Action Now! (AAN!), a militant group modeled on the U.S.-based protest group ACT UP, and the Persons with AIDS (PWA) Coalition in 1987 as an outgrowth of ACT.

It was AAN! that organized the famous Toronto demonstration which featured the burning in effigy of the federal health minister on May 17, 1988. This event sent shockwaves through government and professional circles and is often referred to as the watershed episode of the 1980s that secured both political and public attention for AIDS. The Toronto activist groups have been relatively cohesive since the onset of the epidemic and have influenced public policy concerning HIV/AIDS. The City of Toronto Department of Public Health worked closely with the affected community to develop innovative awareness education and prevention programs well before the provincial government did so.

Vancouver has had the highest per capita incidence of AIDS in Canada. The first community AIDS group in Canada, AIDS Vancouver, was founded in 1983 and led the fight to get Vancouver and British Columbia to recognize the importance of AIDS and the devastating effect it was having on the gay community. In spite of a hostile provincial government during the 1980s, Vancouver's health department and provincial health officials were able to develop sound policies at the municipal and provincial levels. The first free, province-wide testing and counseling services in Canada were established in British Columbia. In Vancouver, building on a street nurse program first established in 1947, HIV/AIDS services were offered on an outreach basis. The establishment of a centralized AIDS treatment service at St. Paul's Hospital in downtown Vancouver was instrumental in the development of the British Columbia Centre of Excellence on HIV/AIDS, which has become a model for other jurisdictions.

The activist community in Vancouver has been less cohesive than that of Toronto. Other AIDS groups, such as Vancouver PWAC and the local branch of ACT UP, have at times competed with AIDS Vancouver for prominence. Although key groups are now housed together in the Pacific AIDS Resource Centre (PARC), some tensions continue to exist. Vancouver also became the first Canadian city to establish a needle-exchange program in 1989. The successful needle-exchange and outreach programs established at the Downtown Eastside Youth Activities Society (DEYAS) led the federal government to establish needle-exchange programs in Toronto and Montreal.

Montreal has been the site of the majority of the AIDS cases in Quebec; unlike in Vancouver and Toronto, Montreal has long had a significant number of HIV/AIDS cases among heterosexuals, especially in the immigrant Haitian population of the city. The Quebec health system is highly decentralized, which led to an uneven, uncoordinated response to AIDS during the 1980s. Similarly, although Montreal has a large gay community, it is split along ideological lines and between the French-speaking and English-speaking communities.

AIDS service organizations within Montreal's gay community have never developed the cohesion and public profile of those in Toronto and Vancouver. The Montreal AIDS Resource Committee was established in late 1983, and the Groupe Haitien pour la Prévention du SIDA was set up in 1985 to help prevent HIV among Haitians. In spite of its difficulties, the activist community has been able to effect changes in public policy and in the educational curricula of the province. By 1988, AIDS action teams were set up in Montreal and Quebec City, and in 1989, the Centre québécois de coordination sur le SIDA was set up to coordinate policy and programs with government departments and community groups on a provincial basis.

Another major issue in Canada has been the quality of the blood supply. On October 4, 1993, the federal health minister established the Commission of Inquiry on the Blood System in Canada to determine the root causes that permitted more than 1,200 hemophiliacs and transfusion recipients to be infected with HIV between 1980 and 1985, as well as 12,000 recipients of blood and blood products to be infected with the hepatitis-C virus between 1980 and 1990. It was also intended to recommend changes to ensure that a similar disaster would not occur again. The inquiry, headed by Justice Horace Krever of the Ontario Supreme Court and known as the Krever Commission, held 244 days of hearings with 353 witnesses over a two-year period. The commission produced over 300 potential findings of misconduct, involving virtually all the key players in the Canadian blood system.

Krever identified four major areas of failure in the notices he issued to those who could potentially be held liable for criminal prosecution or civil lawsuits. First was a lack of urgency in providing factor concentrate that was heat-treated to kill the hepatitis and AIDS viruses, particularly after it became clear that products were likely to be contaminated. Second was the eight-month delay between the approval of an AIDS test kit in the United States in March 1985 and the testing of blood in Canada in November 1985. Third, Krever cited a failure to inform and educate physicians and people in general about the risks of hepatitis and AIDS to stop their spread. Finally, the commission noted the absence of follow-up measures after the breadth of the tragedy became obvious, particularly the decision not to track down the 3.5 million Canadians who received blood and blood products when infectious diseases had infiltrated the system.

Since 1979, the blood system in Canada has been characterized by three major management components that produced a decision-making process which was unwieldy and problematic. The Canadian Blood Committee (later the Canadian Blood Agency), the Canadian Red Cross, and the federal health department are the agencies that are responsible for the blood system. Since revelations about the scope of the blood scandal became public, federal and provincial governments have responded with financial assistance programs, reviews of the roles and responsibilities of the various players, and promises to prevent another blood-borne pathogen crisis.

On November 26, 1997, Krever released his long-awaited final report. He did not make findings of criminal or civil liability, an issue that delayed the report by more than a year. Within a week, the Canadian Hemophilia Association filed a formal complaint with the Royal Canadian Mounted Police (RCMP) demanding that criminal charges be laid against those whose actions and inaction contributed to the "needless waste of innocent lives" in the tainted blood tragedy. As of early 1998, the RCMP was investigating whether criminal charges would be laid. Meanwhile, a number of civil cases have been making their way through Canadian courts. After years of review, it was expected that there would be years of litigation.

In terms of AIDS research, most funding in Canada has been provided by the government. Under the NAS, $17.8 million per year has been allocated for all types of research and epidemiological monitoring. The Medical Research Council (MRC) of Canada has spent $2 million per year on dedicated HIV/AIDS research. In Canada, virtually all clinical trials of anti-HIV therapies and drugs to treat and control opportunistic infections have been conducted by the Canadian HIV Trials Network (CTN). The network's infrastructure is supported under the NAS, but the NAS does not pay for the actual research. Clinical trials have been supported by the international pharmaceutical industry with some support from provinces and grant agencies. This imposes some significant limitations as pharmaceutical companies only sponsor trials that are of interest and benefit to them.

The National Health Research and Development Program (NHRDP) has supported research since the AIDS epidemic first began in Canada. Up to the end of the 1994-1995 fiscal year, cumulative NHRDP HIV/AIDS funding amounted to $49.3 million, and MRC had invested approximately $16.7 million. Of the seven most industrialized democracies, Canada has had the third highest incidence of HIV infection yet has provided the least money for HIV/AIDS research. The dearth of funding support for HIV/AIDS research has been a reflection of the general lack of government support for all types of research in Canada. However, agreement about the need for a national HIV/AIDS research strategy led to the development and implementation of a national research forum in 1995, a development that was expected to improve priority setting, coordination, collaboration, and the public profile of research.

Canada has played a prominent role in the international AIDS crisis. The Canadian International Development Agency (CIDA) has been the lead agency in focusing Canada's international AIDS efforts. It has taken a broad developmental approach that stresses the importance of poverty reduction and that concentrates resources on such basic human needs as primary health care and education, human rights, and, in particular, the rights of women. Through CIDA and its national and international partners, Canada has been involved in HIV/AIDS programs in the countries of Africa, Asia, and Latin America since 1987 and has devoted over $100 million to AIDS education and care programs. Since 1987, Canada had been the fourth largest donor to the Global Programme on AIDS (GPA), the precursor to the Joint United Nations Programme on HIV/AIDS (UNAIDS). CIDA has supported the work of a number of Canadian nongovernmental organizations (NGOs) and university-based consortia that work in the developing world.

The International Development Research Centre (IDRC) has supported research that originates in the developing world and is carried out by developing country scientists. It has promoted sexual health as the main focus for its HIV/AIDS research program support. IDRC considers HIV/AIDS to be an issue that requires attention to socioeconomic factors and has been shifting its funding toward social and behavioral research, with increasing attention on primary prevention in high-risk areas, using a participatory, community-based model. Since 1986, IDRC has supported HIV/AIDS projects in 13 countries in Africa, Latin America, and Asia. It was a cosponsor and organizer of the Fifth International AIDS Conference in Montreal and was instrumental in the development of the HIV Dip Stick, a rapid and inexpensive HIV screening test that allows developing country health services to institute or extend their blood screening services.

Canadian NGOs have also been at the center of international HIV/AIDS advocacy and programs. International HIV/AIDS organizations such as the International Council of AIDS Service Organizations (ICASO), the International Community of Women Living with HIV/AIDS (ICW), and the Global Network of People Living with HIV/AIDS (GNP+) have Canadians involved in key roles.


Related Entries:

Australia and New Zealand; Europe, Northern; United Kingdom and Republic of Ireland; United States-The Midwest; United States-Mountain Region; United States-New England; United States-Western Pacific Region


Key Words:

AIDS Action Now! (AAN!), Canada, Krever Commission, [specific provinces, territories, and cities by name]


Further Reading

Bureau of HIV/AIDS and STD, Laboratory Centre for Disease Control, 1994 Annual Report of AIDS in Canada: AIDS Case Reporting and Surveillance System Data, Ottawa, Ontario: Health Canada, December 1995

Bureau of HIV/AIDS and STD, Laboratory Centre for Disease Control, Quarterly Surveillance Update, AIDS in Canada, Ottawa, Ontario: Health Canada, January 1996

Canada Together Against AIDS, Ottawa, Ontario: Government of Canada, 1992

Canadian International Development Agency, Background to Development: HIV, AIDS and Development CIDA's Reponse, Ottawa, Ontario: The Canadian International Development Agency, November 1995

Confronting a Crisis: The Report of the Parliamentary Ad Hoc Committee on AIDS, Ottawa, Ontario: House of Commons, June 1990

King, A., et al., Canada Youth and AIDS Study, Kingston, Ontario: Queen's University Press, 1988

Kirp, D. L., and R. Bayer, eds., AIDS in the Industrialized Democracies: Passions, Politics and Policies, Montreal, Quebec, and Kingston, Ontario: McGill-Queen's University Press, 1992

McGill Centre for Medicine, Ethics and Law, Responding to HIV/AIDS in Canada, Toronto, Ontario: Carswell, 1991

Ornstein, M., AIDS in Canada: Knowledge, Behaviour and Attitudes of Adults, Toronto, Ontario: University of Toronto Press, 1989

Picard, A., The Gift of Death: Confronting Canada's Tainted Blood Tragedy, Toronto, Ontario: HarperCollins, 1995

Picard, A., "Krever Allegations Revealed," The [Toronto, Ontario] Globe and Mail (February 12, 1996)

Report on Canadian Policy Formulation in Support of HIV/AIDS Treatment and Prevention, Toronto, Ontario: Ortho Biotech, 1991

Royal Society, AIDS: A Perspective for Canadians, Ottawa, Ontario: Royal Society of Canada, 1988

Steering Group on International Coordination, An International HIV/AIDS Strategy for Canada: Proposed Blueprint for Action, Ottawa, Ontario: The Steering Group on International Coordination, October 1995 (unpublished)

A Study of the National AIDS Strategy: A Report of the Subcommittee on HIV/AIDS Standing Committee on Health, Ottawa, Ontario: House of Commons, 1995


The Encyclopedia of AIDS: A Social, Political, Cultural, and Scientific Record of the HIV Epidemic, Raymond A. Smith, Editor. Copyright © 1998, Raymond A. Smith. Carried by permission of Fitzroy Dearborn Publishers.

Encyclopedia of AIDS $25 US/832 pp/Illustrated

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