Section 4: Evaluation of the Federal Initiative to Address HIV/AIDS in Canada 2008–09 to 2012–13 – Findings

4. Findings

The synthesis and analysis of the findings from this evaluation resulted in conclusions about the relevance and performance of the Canadian Public Health Service program. In turn, this led to three recommendations for senior management of the Public Health Agency.

4.1 Relevance: Issue #1 — Continued Need for the Program

4.1.1 What is the magnitude of HIV/AIDS in Canada and globally?

Canada's HIV epidemic is similar to that of most European countries and the United States. Like these countries, Canada is considered to have a concentrated, low-level epidemic. While direct comparison with other countries is challenging due to differences in the calculation of HIV diagnosis rates, as seen in table 2 Canada's rate of new HIV infection in 2011 (7.6 per 100,000)^{Footnote 3} follows that of the United States and the United Kingdom (18.8 per 100,000 and 11.0 per 100,000 respectively), with Australia exhibiting a lower rate (4.6 per 100,000).

Overall Prevalence and Incidence

Incidence is defined as the occurrence of new cases of disease that develop in a population in a fixed time period, usually one year. Prevalence, however, measures the proportion of the total population living with infection and depends on the rate at which new cases of disease develop as well as the duration or length of time that individuals have the disease.

In the case of HIV/AIDS in Canada, the incidence — the number of new cases each year— has remained steady while the prevalence has increased partly because of improvements in treatment that resulted in dramatic reductions in the number of deaths. In 2011, the Public Health Agency of Canada estimated that there were about 3,175 new HIV infections in Canada and about 71,300 Canadians living with HIV in 2011.^{Footnote 20} As demonstrated in Appendix 5, between 2008 and 2011, the number of people living with HIV (including AIDS) rose 11.4 per cent, from an estimated 64,000 in 2008 to 71,300 in 2011.^{Footnote 21} Although overall prevalence provides an indicator of population burden, incidence can reflect the effectiveness of the prevention and research interventions that are part of the federal mandate in HIV/AIDS. As noted, HIV incidence in Canada in 2011 is considered to be stable. Appendix 5 shows the number of new cases of positive test results reported to the Public Health Agency of Canada since 1996. From 1996 to 2011, the number of new cases of positive HIV tests ranged between 2,092 and 2,730. Between 2008 and 2011, there was a decrease in the estimated number of new infections at the national level which is attributed to the reduction in injection drug use.^{Footnote 22}

Vulnerable Populations

The Canadian HIV epidemic is characterized by high incidence and prevalence in specific vulnerable populations. The populations most affected include: gay and other men who have sex with men; people who inject drugs; Aboriginal people; people from countries where HIV is endemic; people in prison; women; and youth at risk for HIV infection. Gay and other men who have sex with men account by far for the most new infections in Canada, representing 49 per cent of all positive HIV tests with a known exposure category in 2011.

In addition to the high HIV incidence rates for gay and other men who have sex with men, the following trends in HIV statistics have been observed among vulnerable populations in Canada:

• According to 2011 national HIV estimates, 35, 490 gay men and other men who have sex with men are living with HIV, which represents 50 per cent of all people living with HIV in Canada. The estimate includes 33,330 men whose HIV status was attributed to men having sex with men and 2,160 men whose HIV status could be attributed to either men having sex with men or injection drug use.^{Footnote 23}
• HIV incidence appears to be declining among people who inject drugs. Ninety-four per cent of people who inject drugs reported using sterile injecting equipment the last time they injected. Eighty per cent of people who inject drugs received an HIV test in the past 12 months and know their results. Overall, about eleven per cent of people who inject drugs are living with HIV. However, incidence has not declined among Aboriginal people who inject drugs. It is estimated that 66 per cent of all new Aboriginal cases  in 2008 were infected through drug injection (versus 17.0 per cent for all Canadians).^{Footnote 24}
• Aboriginal Canadians are disproportionately represented in new infections of HIV. While 4.3 per cent^{Footnote 25} of Canadians self-identify as Aboriginal, an estimated 12.2 per cent of all new infections in 2011 were among Aboriginal people.^{Footnote 26} Aboriginal Canadians' exposure patterns are different from other risk groups. Aboriginal men's main exposure categories are injection drug use, heterosexual sex, and men who have sex with men. Aboriginal women, who made up almost half of the affected Aboriginal population in 2008 (versus 20.7 per cent for non-Aboriginal women for the same time period) were most often exposed to HIV though injection drug use and heterosexual contact. Between 1984 and 2008, Aboriginal infants were overrepresented among all infants exposed perinatally to HIV (16.2 per cent), and those confirmed infected with HIV (9.5 per cent).^{Footnote 27 Footnote 28}
• People from countries where HIV is endemic have disproportionately high rates of infection that continue to rise, especially among Black people from African or Caribbean countries where HIV/AIDS is endemic. Immigration of HIV-infected people does not account for the high infection rates: people in this population appear to be at higher risk of contracting HIV in Canada.^{Footnote 29} In 2008, this population accounted for about 16.0 per cent of new infections in Canada, up from 3.0 per cent in 1998 and 8.5 per cent in 2004.
• Among incarcerated people in federal prisons who have undergone testing, the HIV infection rate in 2008 was 1.7 per cent, a rate that appears to have been stable since 1999. The prevalence of HIV in women offenders is higher than among men in federal penitentiaries. In 2008, HIV prevalence among women offenders was 4.7 per cent versus 1.6 per cent for men.^{Footnote 30}
• Specific groups of youth are considered to be at increased risk of HIV infection. These include street-involved youth, Aboriginal youth, sexually diverse and gender variant youth, youth in foster care and detention, youth who have been sexually abused, and youth from visible minority groups.^{Footnote 31} By the end of 2009, there were 17,490 HIV cases among youth aged 15-29 reported to the Public Health Agency of Canada, and 3,418 youth diagnosed with AIDS, representing 15.8 per cent of cumulative AIDS cases.^{Footnote 32}

4.1.2 In what areas has the HIV and AIDS environment changed most in the past five years?

Since the Federal Initiative was launched, prevention needs have not waned; diagnosis, care, treatment and support needs have increased, and research needs remain strong.

Prevention

As new cases continue to be diagnosed in Canada, there is a clear and continued need for investments in the area of prevention. As noted earlier, the only decline in HIV incidence has been among people who inject drugs. In many respects, the issue is less that prevention needs have evolved, but that they have remained constant and unresolved due to the complexity of approaches needed to address the disease.

Diagnosis, Care, Treatment and Support

Advances in anti-retroviral treatment since the late 1990s means that people are living longer with the disease. As a result of steadily rising prevalence rates of the disease, there is a growing demand for diagnosis, care, treatment and support programs in Canada. These issues tend to have an indirect effect on other activities. Some key informants noted that national surveillance is needed to monitor adherence to the full spectrum of diagnosis, care, treatment and support services, to assess the effectiveness of the Canadian response and to understand outcomes for diagnosis, care, treatment and support. Others noted that new technologies related to HIV viral diagnosis have resulted in increased demand to develop new laboratory techniques to closely monitor the disease to ensure effectiveness of treatment (in keeping with the "treatment as prevention"^{Footnote v} approach).

Research

While significant achievements have been made, some key informants have noted that continued research is needed to advance progress in existing research areas and advance knowledge in emerging areas such as aging and HIV/AIDS, and co-morbidities. Additional investments in the area of intervention research are needed in these and emerging areas such as vaccine and cure research.

4.2 Relevance: Issue #2 — Alignment with Government Priorities

The Federal Initiative aligns with current government priorities even though the approach to address HIV/AIDS has shifted since 2004.

Alignment with Priorities

The Federal Initiative continues to align with the federal government's overall priorities. The 2010 Speech from the Throne states that "protecting the health and safety of Canadians and their families is a priority of our Government." Budget 2012 also commits to "Supporting Families and Communities by protecting the health and safety of all Canadians and their communities...". These statements broadly underline the importance that the Government of Canada places on the prevention and control of community associated infectious diseases such as HIV/AIDS, which is a recognized public health risk to all Canadians.

The Government of Canada's G8 website affirms its commitment to fight infectious disease both domestically and abroad, stating: "A vigorous response to the threat of infectious diseases, the leading cause of death worldwide, is essential to global development and to the well-being of the world's population. Major viruses/diseases such as HIV/AIDS, tuberculosis, malaria, and measles continue to exact a heavy toll on economies and societies around the world, particularly in developing countries, impeding achievement of Millennium Development Goals (MDGs)."^{Footnote 33}

Shifts in Government Directions

Over the past five to seven years, there have been shifts in government direction relating to some aspects of the implementation of the Federal Initiative.

In 2008, harm reduction was formally acknowledged by the federal government as an area within provincial and territorial jurisdiction, in a statement made by the then Minister of Health, the Right Honourable Tony Clement, at the Standing Committee on Health. The Public Health Agency of Canada, however, continues to invest in a broad range of interventions and strategies for people who inject drugs through funding for community-based capacity building activities with vulnerable populations and public health capacity building to prevent the initiation of drug use and related risk behaviours, promote abstinence and facilitate and increase access to drug treatment to those with addictions.

The Government of Canada also reviewed its advertising and public opinion research policies which resulted in a reduction in the frequency of monitoring of attitudinal changes through public opinion research and a shift away from large-scale government-led social marketing campaigns to provide greater support for community-based education and awareness campaigns through its grants and contributions.

In 2012, Ministerial direction was provided to the Public Health Agency of Canada to enhance the integration of HIV/AIDS activities within a broader holistic approach in areas where efficiencies can be gained. This includes sexually transmitted and bloodborne infections, tuberculosis co-infections and mental health.

4.3 Relevance: Issue #3 — Alignment with Federal Roles and Responsibilities

4.3.1 Is the Federal Initiative aligned with the roles and mandates of Federal Initiative partners? Are these roles understood by partners and are they different from or similar to the roles of provinces and territories, and non-governmental organizations?

The Federal Initiative aligns well with the mandate of each of the federal government partners. There is an appropriate role for the federal government in national and international leadership, coordination and knowledge translation for HIV/AIDS prevention, diagnosis, care, treatment, support and research. The Federal Initiative role aligns with the federal role of other countries such as Australia, the United Kingdom and the United States.

Alignment with Mandate

The Federal Initiative authorities align with the mandate of each federal partner department, meaning that the partner departments are conducting HIV/AIDS activities that are within the parameters of their respective mandates.

Public Health Agency of Canada

According to the Public Health Agency of Canada Act (2006), the Public Health Agency of Canada was established for the purpose of assisting the Minister in exercising or performing the Minister's powers, duties and functions in relation to public health. It also explicitly supports international health engagement with foreign governments and international organizations. The Department of Health Act (1996) identifies, among other responsibilities, the following areas of federal public health responsibility which align with the Public Health Agency of Canada's role under the Federal Initiative:

• the promotion and preservation of the physical, mental and social well-being of the people of Canada
• the protection of the people of Canada against risks to health and the spreading of diseases
• investigation and research into public health, including the monitoring of diseases
• subject to the Statistics Act, the collection, analysis, interpretation, publication and distribution of information relating to public health
• cooperation with provincial authorities with a view to the coordination of efforts made or proposed for preserving and improving public health.

Canadian Institutes of Health Research

According to the Canadian Institutes of Health Research Act (2000), the objective of CIHR is to "excel, according to internationally accepted standards of scientific excellence, in the creation of new knowledge and its translation into improved health for Canadians, more effective health services and products and a strengthened Canadian health care system".^{Footnote 34} This mandate aligns directly with CIHR's responsibilities under the Federal Initiative, which are to:

• create new scientific knowledge through research
• enable the translation of knowledge
• fund research in support of the objectives of the Federal Initiative
• support capacity building and training of the next generation of HIV/AIDS researchers.

Health Canada — First Nations and Inuit Health Branch

The mandate of Health Canada's First Nations and Inuit Branch is to ensure the availability of, or access to, health services for First Nations and Inuit communities; assist First Nations and Inuit communities to address health barriers, disease threats, and attain health levels comparable to other Canadians living in similar locations; and build strong partnerships with First Nations and Inuit to improve the health system. In accordance with this mandate FNIHB provides for, or supports, the delivery of community-based health programs on-reserve and in Inuit communities south of the 60th parallel, and provides drug, dental and ancillary health services to First Nations and Inuit, regardless of residence. The Branch also provides primary care services on-reserve in remote and isolated communities where provincial services are not readily available. This mandate aligns directly with the role of FNIHB, which is to:

• deliver effective interventions to targeted communities according to evidence-based research and surveillance
• build capacity of front-line community health workers and nurses
• promote community awareness
• invest in developing the proper infrastructure and internal capacity of the program to engage in more effective and efficient coordination, assessment, planning, implementation, monitoring, reporting and evaluation.

Correctional Service Canada

CSC is the federal government agency responsible for administering sentences of a term of two years or more, as imposed by the court. CSC is responsible for managing institutions of various security levels and supervising offenders under conditional release in the community. According to the Corrections and Conditional Release Act (1992), CSC has a legislated role to provide inmates in federal correctional institutions with essential health care and reasonable access to non-essential mental health care that will contribute to the inmate's rehabilitation and successful reintegration into the community. In line with its mandate and under the authority of the Federal Initiative, CSC has a role in:

• developing knowledge through the establishment of surveillance resources
• implementing program interventions to enhance education, support, harm reduction and ensuring continuity of care components of its infectious disease programs.

Program authorities outline specific activities relating to the Federal Initiative

Federal Initiative funded partners are specifically entrusted to conduct activities in the following five areas:

• knowledge development
• program and policy interventions
• communication and social marketing
• coordination, planning and reporting
• global collaboration (see Appendix 1 for a description of the areas of action).

Together, Federal Initiative partners work collaboratively to implement these mandates.

Additional HIV/AIDS Mandate Outside Federal Initiative Authority

The Federal Initiative appears to enhance the federal mandate of Health Canada and CSC. In the case of Health Canada (specifically the First Nations and Inuit Health Branch) as well as CSC, which also have mandates for the direct delivery of diagnosis, care, treatment and support, Federal Initiative funded activities allow for a focus on prevention activities. For these two departments, the Federal Initiative program authorities are focused in the area of prevention, while primary care activities are financed through separate funding envelopes.

Some of these types of primary care activities are also covered by other jurisdictions. Provincial governments, for example, provide HIV/AIDS care services and treatment to First Nations (on-reserve and off-reserve), however Health Canada provides those services (on-reserve) in remote and isolated communities where provincial services are not readily available.

Multi-sectoral Response

Because HIV/AIDS is a complex disease, program authorities outlined the need for a multi-sectoral approach to address the disease. Program authorities indicate that part of the rationale for creating the Federal Initiative was based on a call by stakeholders for overall national and international coherence of people, organizations and systems addressing HIV/AIDS. The Federal Initiative was intended to strengthen federal, provincial, territorial and municipal partnerships, and increase collaboration and engagement with voluntary, professional and private sectors. It was also intended to increase Canada's leadership and influence on efforts to coordinate and strengthen the global response, as well as the provision of technical and policy expertise.

Key informants generally agreed that the current Federal Initiative partners were the right ones to be at the table and there was a high level of consensus that additional federal partners were not needed. Other government departments relied on bilateral collaborative activities to fulfil their own objectives. However, internal key informants indicated that collaboration should be enhanced with other federal government departments who have mandates for the broader social determinants of health.

This is consistent with the program framework, which indicates that the federal investment in HIV/AIDS would incorporate the efforts of a number of federal government partners (the Public Health Agency of Canada, Health Canada, CIHR, CSC, Canadian International Development Agency and Department of Foreign Affairs and International Trade), and work collaboratively with other partners to prevent the spread of HIV infection, and to improve the health and quality of life of those suffering from HIV/AIDS. This is also consistent with the World Health Organization's multisectoral approach to addressing HIV/AIDS which views other sectors (social, economic, cultural and environmental) as being key partners in this area.^{Footnote 35}

Defined and understood roles

Through a review of Federal Initiative program documents, the evaluation found that the roles and responsibilities of each partner in the Federal Initiative are well defined. However, among a number of key informant interviews, both internal and external to the Federal Initiative, the evaluation found that there was some confusion and lack of knowledge about the role of each partner. Although not universal, knowledge of the roles and responsibilities of partners among national representatives of the four departments was generally higher than that of key informants within regional offices of some partner departments. Generally speaking, external informants were typically knowledgeable about the roles and responsibilities of at least two and sometimes three of the departments, but were not consistently able to speak to the roles of all four partners.

Shared jurisdiction

Through the Federal Initiative, the federal government is fulfilling many roles in the area of national coordination, surveillance, laboratory science, knowledge development, community-based and research funding, and international policy and technical support. 

Based on key informant interviews and document review, there are several roles which are more exclusively aligned with the federal role. These include funding research, national surveillance and laboratory activities, international engagement, public health and primary care services in First Nations communities and in federal institutions (although as mentioned previously, primary care delivery is resourced through different funding envelopes and is not part of the Federal Initiative).

While prevention is an area of shared jurisdiction with provincial and territorial governments, funding communities is a clear federal role as outlined in program authorities. The importance of this role is supported by outcome studies demonstrating that targeted HIV/AIDS community-based prevention approaches are effective. Through a number of mechanisms including formal requests for provincial and territorial government concurrence in the approval of funding for community-based projects, the federal government works collaboratively with provincial and territorial governments to ensure complementary approaches to HIV/AIDS, avoid duplication of funding, and fill gaps in HIV/AIDS programming in Canada.

International comparisons

The federal role in the implementation of the Federal Initiative aligns with stakeholder perceptions of what a federal government should be doing. In particular, key informants reported a strong leadership, coordination, and knowledge translation role for the federal government, which is consistent with the national role in other countries. When compared to Australia, England and the United States, the federal level consistently plays a role in the coordination and reporting of surveillance data. Like Canada, these countries are also consistent in providing funding to research agencies or centres for research in HIV/AIDS. Among the comparator countries, the federal level provides support, often to national or community-based organizations for prevention programming. Provincial/territorial/state level governments also contribute to prevention and health promotion and support and strengthen community action. Similar to Canada, in the area of testing, the federal level typically plays a leadership role in developing recommendations or guidelines for testing, as well as quality assurance. Like Canada; Australia, England and the United States also provide funding to the Global Fund to Fight HIV/AIDS.

In developed countries, there is a trend towards addressing sexually transmitted and bloodborne infections in an integrated way (as opposed to addressing diseases in isolation). HIV infection increases the risk and rapidity of contracting tuberculosis^{Footnote 36} and tuberculosis infection makes HIV progress to AIDS faster. Tuberculosis is the leading cause of mortality among HIV-infected patients. Those with sexually transmitted infections are more susceptible to acquiring HIV, and co-infection with HIV and other infections (notably gonorrhea, syphilis and chlamydia) are so frequent that the Centers for Disease Control and Prevention recommends testing for all at once.^{Footnote 37} Recent policy directions for the Federal Initiative to move towards an integrated sexually transmitted and bloodborne infections approach are in line with these international trends. For example, Australia and England have to varying extents integrated their efforts to address HIV/AIDS along with related bloodborne viruses and sexual health issues. While the United States has separate funds appropriated for a National HIV/AIDS Strategy, a strategic priority is to foster collaboration across programs supporting interrelated health issues.

Areas in which there are some differences include ways in which countries are focusing their prevention efforts. In Australia, harm reduction has been a significant focus, and in both the United States and Australia, the "treatment as prevention" or "treatment with prevention benefits" is being implemented to varying degrees. In addition, treatment of HIV/AIDS is supported federally in Australia, England and the United States by drug assistance programs. Delivery of health services and care falls within the provincial/territorial/state jurisdiction in Australia, England and the United States, although the federal level may also play a role in care and support through funding to national or community-based organizations. In Canada, health services, including those addressing HIV/AIDS, are also primarily at the provincial level, with the federal role including national surveillance, public health guidance, and building community capacity through knowledge exchange and funding to community organizations. In Canada, harm reduction approaches have been adopted to varying degrees by provincial and territorial governments. While HIV treatment is available in each province and territory to those who need it, no national treatment access mechanism exists in Canada, as treatment is the responsibility of provincial and territorial governments. Thus far, the only Canadian jurisdiction to explicitly adopt the "treatment as prevention" approach has been British Columbia.

4.4 Performance: Issue #4 — Achievement of Expected Outcomes (Effectiveness)

The Federal Initiative recognizes that HIV/AIDS is a complex issue that requires a collaborative, multisectoral response that is informed by surveillance, research and community-based evidence. The Initiative seeks to increase knowledge and awareness of the nature of HIV/AIDS and ways to address the disease, increase individual and organizational capacity as well as national and international collaboration and engagement. There should be reduced stigma and discrimination for those with the disease, improved access to effective prevention, diagnosis, care, treatment and support as well as an informed federal response. Ultimately, this should result in a lower infection rate and an improved quality of life for those living with the disease.

There are difficulties when assessing outcomes that are inter-related. For example, an indication that there has been an increase in knowledge or that knowledge has been applied can demonstrate a number of other outcomes, such as enhanced individual or organizational capacity. In addition, knowledge development cannot exist without strong partnerships and collaborations between knowledge creators and those involved in using the knowledge products. Promoting learning helps build capacity across all sectors, not only in the research community or health care sector, but also in the civil society, in people living with HIV, non-governmental organizations, nationally and on the global stage.

The evaluation considered the inter-related nature of the Federal Initiative outcomes in its assessment. 

4.4.1 To what extent has progress been made towards the achievement of first level expected outcomes?

Expected outcome #1:
Increased knowledge and awareness of the nature of HIV/AIDS and the ways to address the disease

A wide array of knowledge has been created and products have been produced and disseminated on the nature of HIV/AIDS and ways to address the disease. There is evidence that these products have led to increased knowledge, including in target populations. However, there is a continued need to provide information to vulnerable populations.

The Federal Initiative aims to increase the knowledge and awareness of community-based organizations, non-governmental organizations, provincial/territorial/national and international governments and the research community with regard to HIV/AIDS, the factors that contribute to its spread, and ways to address the disease.

The Federal Initiative also intends to increase the knowledge and awareness of the general population and target populations about the nature of the disease; the need for testing; reducing risk behaviours; methods of prevention and effective responses for diagnosis, care, treatment and support.

In order to understand if a program is having an impact, it is important to know it has been successful in reaching its target populations. Evidence gathered as part of this evaluation shows that all four partner departments appear to have achieved this objective to some extent. For example, between 2010 and 2013, the three most downloaded documents from the Public Health Agency of Canada's website were HIV/AIDS surveillance documents; between 2008 and 2012, it is estimated that 1.2 million individuals were reached through AIDS Community Action Program projects; between 2008 and 2012, national grants and contributions reached more than 606,000 individuals, 63 per cent of which were either from a pre-determined funding target audience or one of the Federal Initiative's eight key target populations; and from 2008-09 to 2011-12, the Centre for Communicable Diseases and Infection Control disseminated 8,878 copies of the Status Reports (People from Countries where HIV is Endemic and Aboriginal Peoples) and subproducts (presentations, fact sheets). From October 2008 (the year the first Population-Specific Status Report was released) to August 2012, an additional 1,511 copies of the report were requested through CATIE (667 copies of the Aboriginal report and 844 of the Endemic report).

Public Health Agency of Canada

The Public Health Agency of Canada produces a large number of surveillance products, including routine surveillance reports, enhanced surveillance reports, Epi Updates, presentations for conferences, and surveillance tables.^{Footnote 38 Footnote 39 Footnote 40} Key informants stressed that these reports provide a much needed snapshot of HIV/AIDS in Canada. Not only does the Public Health Agency of Canada produce knowledge products, it also attempts to ensure that these products are well understood by stakeholders through presentations made at meetings and conferences throughout Canada. In addition, the Public Health Agency of Canada shares its technical expertise and knowledge internationally with, for instance, the World Health Organization (WHO), UNAIDS, other country governments, health agencies and institutions and civil society organizations.

According to internal key informants, the main way to transfer technological knowledge and expertise is through peer review publications. The National HIV and Retrovirology Lab works to transfer its knowledge developed through research to other laboratories in Canada and internationally through its contributions to peer publications and presentations. There are other examples of the impact of the knowledge generated by Federal Initiative partners. The National HIV and Retrovirology Lab has written or contributed to a large number of peer-reviewed articles that have been cited or referenced 1,643 times, indicating the relevance and usefulness of their work. The number of citations has steadily increased since 2008 (53 citations) to 2012 (414 citations). Other groups within the Public Health Agency of Canada are working to transfer knowledge through products such as the Canadian Guidelines on Sexually Transmitted Infections which have been used in curriculum and training in over 90 per cent of Canadian medical schools.Footnote 41 Additionally, 95 per cent of respondents to a survey on the guidelines indicated they were either confident or very confident with the information found in the guidelines; 46 per cent of physicians indicated that they used the guidelines monthly, 39 per cent reported using them weekly, 7 per cent reported using them annually, and 4 per cent reported using the guidelines daily.

CATIE, Canada's source for HIV/AIDS and hepatitis C information, is funded as the Federal Initiative's knowledge broker, through the National HIV/AIDS and Knowledge Exchange Fund. In 2008, CATIE expanded its knowledge exchange role, going from an HIV treatment information exchange, to covering HIV prevention, diagnosis, care, treatment and support. At the same time, it also expanded its publication development and distribution, educational program and the promotion of its publications. CATIE reaches front-line workers through conferences, education and training sessions, web conferencing and its national ordering centre. According to the Evaluation of the Building Excellence in HIV Knowledge Exchange project, CATIE is "now Canada's largest distributor of HIV print resources, disseminating more than 1 million resources a year".^{Footnote 42} The 2011 impact evaluation of CATIE's programs and services for front line workers showed that CATIE reached front-line workers and organizations. In 2011, a national survey concluded that 70 per cent of front line workers used CATIE at least once a month. In addition, the HIV Knowledge Exchange project evaluation found that CATIE was effective at increasing knowledge of HIV for front-line workers, with the majority of those surveyed reporting that they regularly found the information that they were looking for and the vast majority reporting that they were very satisfied with the information.^{Footnote 43 Footnote 44}

A study of another Agency knowledge translation tool, the Population-Specific Status Reports, noted that the Public Health Agency of Canada ensures that knowledge translation tools are tailored to the needs of specific populations by creating a working group for each of its population-specific reports engaging researchers, policymakers, and representatives of community organizations in expert advisory working groups.Footnote 45 The status reports were disseminated by mail to identified individuals and organizations; placed on several websites such as the Public Health Agency of Canada website, CATIE's website and various community organizations' websites; presented at international and national conferences; presented to provincial and territorial partners and community organizations and presented to Public Health Agency of Canada senior policy officers.

From 2008 to 2012, the Non-Reserve Fund supported 20 projects reaching approximately 84,000 people (59 per cent Aboriginal people and 41 per cent general public). These projects increased individual and organizational knowledge and awareness through awareness campaigns, workshops, presentations and community events.

Community-based projects have also reported a change in knowledge in participants reached. An assessment of ACAP indicated that projects are successful in increasing awareness and knowledge. From 2009 to 2012, approximately 70,000 individuals reached reported that they had increased their knowledge of HIV transmission and its risk factors as a result of an ACAP intervention and activity.

Canadian Institutes of Health Research

CIHR is the Government of Canada's agency for health research and has four funding streams that support the HIV/AIDS Research Initiative: Biomedical/Clinical Research; Health Services/Population Health Research; HIV/AIDS Community-based Research and CIHR Canadian HIV Trials Network (CTN).Footnote vi CIHR offers a wide range of research funding opportunitie to support knowledge development and translation including, for example, Catalyst Grants for HIV/AIDS and Aboriginal Health; Team Grant for HIV Comorbidity; Centres for Population Health and Health Services Research Development in HIV/AIDS; Community-based Research Program; Priority Announcement competitions and Dissemination Grants.Footnote 46 Footnote 47 Footnote 48

Through these strategic research funding opportunities, CIHR funds a large number of research grants through the Federal Initiative (160 in 2012-13) which are generating extensive knowledge across a range of priority areas. Bibliometric data indicates that the annual number of Canadian HIV/AIDS publications continues to grow and that the quality of the publications, as defined by citation rates, is well above the world average. Key informants also acknowledged that CIHR has had success in terms of knowledge generation and knowledge translation.^{Footnote 49}

As a specific example of the impact of Federal Initiative investments through CIHR, the CTN has developed knowledge and facilitated its translation to users in a variety of ways including peer review publications, national and international conference presentations and poster sessions, community publications, as well as by social media. The CTN also shares knowledge through workshops and knowledge exchange campaigns. An evaluation of the CTN found that researchers funded through the CTN from 2008 to 2011 were among the top ten producers of HIV/AIDS publications for this time period, including both clinical trial papers in the field of HIV/AIDS and publications in the field of HIV/AIDS related research. The evaluation concluded that, while the CTN produced a relatively small number of papers in the field of HIV/AIDS, they were of the highest quality as measured by Average Relative Citations (2.0 — the highest Average Relative Citations score among the top ten producers of HIV/AIDS publications in the world) and Average Relative Impact Factor scores (1.69 — the highest Average Relative Impact Factor score among the top ten producers of HIV publications).^{Footnote 50}

Health Canada – First Nations and Inuit Health Branch

First Nations communities are funded by the First Nations and Inuit Health Branch to do a variety of HIV/AIDS work including raising awareness and knowledge of First Nations people. This work is done through community health centres and nursing stations that provide culturally sensitive awareness sessions, print materials, presentations, and workshops. Funding in First Nations communities has supported training to increase knowledge on care, prevention, treatment and sexual health. The Communicable Disease Control Cluster Evaluation (2010) reported that Aboriginal participants were knowledgeable about HIV/AIDS, were able to correctly identify how HIV/AIDS is transmitted and were aware of the seriousness of the disease. However, there were some gaps in awareness and knowledge, including the belief by about half of the participants, that HIV/AIDS can be diagnosed through a physical examination and the assumption by one in five individuals that self-diagnosis is possible.^{Footnote 51}

Correctional Service Canada

Inmates require knowledge about HIV/AIDS transmission and prevention in order to make informed decisions about risk behaviours. Such knowledge is particularly important in correctional environments because inmates often have a history of high risk behaviours, such as injection drug use, sex work and unprotected sex.
 
Health promotion/education programs provided by CSC have enhanced inmates knowledge about HIV/AIDS.^{Footnote 52} For example, the Reception Awareness Program is offered to newly admitted inmates in CSC institutions, and provides information on the programs, services and resources available for the prevention of HIV. The Choosing Health in Prisons Program provides information about healthy living, nutrition, stress, and infectious diseases. The Peer Education Course trains inmates to become peer educators to provide information and support to other inmates affected by HIV/AIDS. The Aboriginal Peer Education and Counselling Program trains Aboriginal inmates to become peer counsellors to provide culturally appropriate information on HIV/AIDS, hepatitis C and other infectious diseases faced by Aboriginal offenders. Evidence indicates that these courses have led to an increase in inmate knowledge. The Choosing Health in Prisons Feedback Survey Summary, conducted in 2012, indicated that 81 per cent of offenders read the Choosing Health in Prisons newsletter and 52 per cent reported having made a change to their lifestyle as a result of the information contained in the newsletter. A General Knowledge Questionnaire was administered before and after the Peer Education Course. Results pointed to an increase in knowledge, with a pre-course score of 84 per cent and a post-test score of 96 per cent. At the end of the course participants were asked if they would do anything differently based on what they had learned in the course, and the majority indicated that they would.^{Footnote 53 Footnote 54 Footnote 55}

Overall challenges in meeting this outcome

Strategic performance measures monitor the implementation and effectiveness of an organization's strategies, demonstrate the gap between actual and targeted performance and demonstrate organizational effectiveness and operational efficiency. However, the evaluation has found that benchmarks, baseline data and targets are generally absent from the Federal Initiative's performance measurement strategy, making it difficult to place performance in context in terms of impact.

Some internal key informants noted that the Centre for Communicable Diseases and Infection Control has set self-defined targets to disseminate results within a year of data collection or less, six months to a year being the ideal timeframe. The majority of dissemination is done through publications and presentations made at conferences because of significant challenges publishing in a timely manner. The recent Community Associated Infections Evaluation also concluded that timeliness was a key obstacle, limiting stakeholders' use of Agency products.^{Footnote 56}

Internal key informants noted that Health Canada's First Nations and Inuit Health Branch has encountered difficulties collecting surveillance data specific to First Nations and especially specific to First Nations on-reserve, partly because of the transient nature of the population, and while several provinces and territories include Aboriginal ethnicity categories in their case report forms and some include a breakdown for First Nations (on or off-reserve), Inuit and Métis; this information is not always completed in the case reports. In 2011, of the provinces and territories that include a category for race/ethnicity and submit this information to the Public Health Agency of Canada, only 30 per cent of HIV positive test reports included ethnicity information. Also, the Public Health Agency of Canada reports generally aggregate First Nations, Inuit and Métis case counts into an overall Aboriginal category which does not always provide the First Nations specific context required by FNIHB. In addition, there are confidentiality issues to consider in requesting that type of information.

Finally, evidence of the application of the vast amounts of knowledge that has been created via the Federal Initiative is limited. While there are pockets of knowledge exchange (e.g. CIHR's Community-based Research Program), both internal and external key informants noted that the application of knowledge could be enhanced and others specifically noted that this practice should be systematically tracked.

Expected outcome #2:
Increased individual and organizational capacity (outside of FI partners)

There is evidence that individual and organizational capacity has been enhanced through the Federal Initiative's activities. Achievements in organizational capacity could be strengthened through more systematic and strategic knowledge exchange mechanisms.

Individual capacity means that individuals have the skills, networks and ability to make informed healthy decisions. For the Federal Initiative, this increased individual capacity means that individuals are able to make informed decisions regarding HIV/AIDS prevention, diagnosis, care, treatment and support. Organizational capacity means that organizations have the collective skills, resources, structures, partnerships, processes and ability to implement needed activities. The Federal Initiative aims to increase the capacity of both the research community and community-based organizations to address HIV/AIDS.

Public Health Agency of Canada

National and regional community-based projects reported many activities in organizational capacity development, such as training for staff and volunteers, partnership development, linkages with other organizations, and leveraging of additional resources.

The Centre for Communicable Diseases and Infection Control is building capacity through its enhanced surveillance systems (the Track surveys) and external stakeholders have provided feedback pointing to the Division's success in this area. Key informants noted that they have helped build capacity within the community. Enhanced surveillance is conducted in partnership with provincial/local health authorities, local community organizations, and community-involved (university-based) researchers. The Public Health Agency of Canada provides support in the form of technical, administrative, and financial resources.

The National HIV and Retrovirology Laboratories have an advanced laboratory testing quality assurance program (used nationally and internationally in countries such as those in Africa) to ensure that people receiving antiretroviral drugs are actually managing their infections with the drugs. The lab also worked with international partners to advance technical capacity, and international researchers come to the lab to learn more about its lab practices to enhance their own diagnostic ability.

As outlined in an assessment of ACAP outcomes, projects helped participants to increase knowledge and awareness about HIV/AIDS by giving them tools to manage their illness and/or that of family members. Some participants reported that this provided them with a sense of empowerment that helped them manage their illness and adopt protective behaviours.^{Footnote 57}

Participants from a sample of 18 projects noted that ACAP helped treat all of their needs including medical, psychological and spiritual. They also reported that ACAP projects provided them with up-to-date information about treatment developments and options which allowed them to make more informed choices about their care. Project data suggested that ACAP projects are especially important in rural and remote areas, where medical staff was reported by some to be less familiar with HIV management. Some participants noted that ACAP projects provided the information necessary to help prevent transmission of the disease. ACAP projects have also helped teach people living with HIV/AIDS that one can live a lot longer than originally expected with HIV/AIDS.

Community-based partnerships and networks were also enhanced through the national knowledge exchange and capacity building activities of CATIE, allowing for increased ability of organizations to respond to the needs of their community. CATIE has been effective in increasing the capacity of front-line organizations to plan and deliver programs and services. The majority of front-line workers not only learn new knowledge through CATIE, they also apply that knowledge in their work. CATIE is particularly effective at providing information that increases the ability of front-line workers to respond to the needs of their communities.^{Footnote 58 Footnote 59}

Canadian Institutes of Health Research

CIHR uses a multi-dimensional approach to build capacity (e.g. individual training awards, including priority areas such as community-based research as well as including capacity building as key objectives in other large strategic initiatives (e.g. CTN, Centres for Population Health and Health Services Research Development in HIV/AIDS). CIHR supports approximately 75 per cent of the funding for HIV/AIDS research in Canada and thus contributes substantially to the overall research capacity and scientific output from Canadian researchers. Several measures of research capacity are available from bibliometric analysis of publications in the field of HIV/AIDS. A recent analysis indicates that Canadian investigators are on average about 65 per cent more productive than a decade ago and that there were 2½ times more Canadian HIV/AIDS authors publishing in 2009 than in 2001. Overall, the bibliometric analysis showed that there has been significant growth in Canadian HIV/AIDS research capacity since 2000.

More specifically, CIHR's HIV/AIDS Community-based Research Program is building research capacity in communities and academia through a number of tools, including developing and hosting workshops and funding grants (operating and catalyst) and awards (Master's and Doctoral programs). In addition, CIHR has funded Community-based Research Facilitators through a unique grant program, available to communities and academia to help them build research capacity and partnerships and to provide technical assistance for research proposals and ongoing projects.^{Footnote 60 Footnote 61} In 2008-09, an evaluation of the HIV/AIDS Community-based Research program concluded that the program is helping communities and academia respond to the HIV/AIDS epidemic, and is building research capacity at the community level and in academic circles.^{Footnote 62}

In addition, the CTN provides quality research training and mentorship to support capacity building by prioritizing learning opportunities for students as well as community members and researchers. In an evaluation of the CTN program, all respondents to the postdoctoral survey expressed satisfaction with the training and mentoring provided by the Clinical Trials Network.^{Footnote 63}

Notably, CIHR has worked through challenges to build capacity in needed areas. For example, key informants reported that CIHR held a workshop for people living on-reserve to respond to low application pressures in the Aboriginal funding stream. As a result of this and other efforts, there was a 900 per cent increase in the Aboriginal funding stream applications in 2010-11 compared to 2008-09. In addition, since 2010-11, CIHR has hosted two workshops in Saskatchewan to build capacity particularly because of the increasing burden of the epidemic in that province.

The mid-term evaluation of the Centres for Reseach Development showed that capacity building in the area of health services and population health HIV/AIDS research is occurring through training and mentoring. In terms of building long-term research capacity, the evaluation assessed whether participation in the program increased the likelihood that participants will choose a career in the research field. Almost all those surveyed intended to continue in research, with over half attributing this to the Centres.

Health Canada – First Nations and Inuit Health Branch

FNIHB provides capacity building to front-line community health workers, staff and volunteers. Between 2008 and 2011, approximately 500 program staff received training. FNIHB projects also provide training to staff and volunteers to increase knowledge and skills. In addition, funded projects carry out capacity building activities to develop the skills of community health nurses. Between 2008 and 2012, projects reported carrying out 246 capacity building activities, with over 4,200 health and community workers reached.

According to the Communicable Disease Control Cluster Evaluation, FNIHB has had a significant impact on community capacity through increased access to training and other resources for Community Health Nurses and others in the communities. Between 2005-06 and 2007-08, 48 skill development sessions were held, involving over 1,500 participants. Seventy-six per cent of the Community Health Nurses and Health Directors reported that they have received some form of training or professional development through the Cluster and most found the training they received to be very useful.^{Footnote 64}

Correctional Service Canada

CSC offers a comprehensive HIV/AIDS program which includes screening and testing; treatment, care and support; health promotion and education; and discharge planning. There are policies in place to ensure access to testing and other services, for example, Commissioner's Directive 821 states that all inmates presenting themselves for testing shall be offered pre- and post-test counselling by a health services professional.Footnote 65

As already mentioned, CSC offers a Peer Education Course to inmates. Between 2008 and 2012, 134 inmates interested in becoming peer education coordinators or volunteers completed the Peer Education Course. In this timeframe, the percentage of CSC institutions with active Peer Education Courses rose from 70 per cent to 90 per cent. The Peer Education Course provides inmates with specific information on the prevention, care and treatment of HIV/AIDS, and in particular educates them on the use of harm reduction measures giving them the necessary knowledge and tools to support other offenders to make healthier choices.^{Footnote 66 Footnote 67} CSC has a comprehensive discharge planning process for offenders. Institutional nurses work with institutional parole officers and offenders in the preparation of most discharge plans, including, but not limited to follow-up appointments in the community with general practitioners and/or specialists, and medication continuation. CSC has Regional Discharge Planning Coordinators who are social workers and Regional Health Services Release Planners who are nurses for cases in which an offender has very complex health needs upon discharge. For those cases, the Regional Discharge Planning Coordinators and/or the Regional Health Services Release Planners assist the institutional nurse and the institutional parole officers in the discharge plan. For all offenders, medical information is shared with the institutional parole officers, Regional Discharge Planning Coordinators and Regional Health Services Release Planners only if written consent from the offender has been obtained.

Overall challenges in meeting this outcome

The extent to which capacity is enhanced is difficult to assess. It is hard to say whether the Federal Initiative as a whole has enhanced individual and organizational capacity since the responsibility centres are not consistently measuring and tracking all of the capacity building activities.

It is apparent that capacity building is happening and there are pockets of knowledge exchange in this area. There are lots of individual examples of capacity building activities and there is evidence that an increase in capacity is occurring, especially in the research field.

A challenge identified by several key informants, especially within FNIHB, is the fact that high rates of staff turnover increases training costs and reduces operational efficiency, therefore any capacity gains are lost when staff leave. This challenge was reiterated in the Communicable Disease Control Cluster Evaluation, with a recommendation to lessen the level and impact of staff turnover at the national, regional and community levels.^{Footnote 68}

Expected outcome #3:
Increased Canadian engagement and leadership in the global context

Federal Initiative partners have made substantial contributions to the global community. Partners are participating in international partnerships, providing policy, surveillance and lab capacity expertise and advice, sharing promising practices, developing international partnerships and providing training as well grants for international community-based projects. Evidence suggests that Canada is a global leader in addressing HIV/AIDS.

Increased engagement means that the funded Federal Initiative partners are participating in international partnerships, delivering training to other organizations abroad, participating in the development of joint documents, and providing policy advice and technical expertise. Increased leadership means that Canadian contributions to international HIV/AIDS efforts are recognized by other countries

Public Health Agency of Canada

The Office of International Affairs for the Health Portfolio and the Programs and Partnership Division in the Centre for Communicable Diseases and Infection Control produced and/or informed approximately 140 international documents, many of which influenced official policy documents (e.g. the WHO Global health sector strategy on HIV/AIDS 2011-2015, the United Nations Joint Programme on HIV/AIDS (UNAIDS) Global HIV and AIDS Strategy 2011-2015, the International Labour Organization (ILO) Recommendation #200: HIV and the World of Work, the 2011 Political Declaration on HIV/AIDS: Intensifying Our Efforts to Eliminate HIV and AIDS, and the WHO Rio Political Declaration on Social Determinants of Health). Country progress reports were also produced in accordance with the United Nations General Assembly Special Session (UNGASS) Declaration.

The Office of International Affairs for the Health Portfolio led the Government of Canada's involvement in the biennial International AIDS Conferences. Specifically, the Office produced policy papers outlining priorities for the Government of Canada's strategic engagement in international AIDS conferences; developed the Minister of Health's and other senior officials' programmes at these conferences, including bilateral meetings, and undertook the development of a number of side events to advance the Government of Canada's priorities in public health. The Office also represented Canada at the World Health Assemblies by coordinating Government of Canada expertise and policy advice related to HIV. As a result, the Office was able to influence the texts of key policy documents related to HIV or issues intersecting HIV in a way that is aligned with Health Portfolio priorities (e.g. WHO Resolution on Prevention and control of multi-drug resistant tuberculosis and extensively drug-resistant tuberculosis).

Between 2008 and 2012, the Office of International Affairs hosted four International Policy Dialogues in collaboration with the Public Health Agency of Canada and CIHR, which engaged a wide range of stakeholders representing foreign governments, academia, and non-governmental and multilateral organizations to discuss emerging issues related to HIV and AIDS, including Disability, Indigenous Peoples, Reinvigorating HIV Prevention, and Mental Health. These Dialogues not only promoted "learning between domestic and international responses" but also significantly increased "Canada's contribution of policy guidance and technical support" and served to inform federal and global policies on key topics.^{Footnote vii} More specifically, the dialogue on Reinvigorating HIV Prevention led to the development and implementation of a network aimed at sharing research information, policy and programmatic approaches to respond to HIV/STI prevention challenges. The dialogue on HIV/AIDS and Indigenous Peoples provided an opportunity for international discussion and the development of policy recommendations specific to the Indigenous populations and allowed Indigenous leaders who attended the Dialogue to formalize their international network under the title "Indigenous Working Group on HIV & AIDS", which resulted in the inclusion of discussions on HIV and Indigenous Peoples issues at the 2010 International AIDS Conference in Vienna. Outcome reports from the Policy Dialogues were disseminated through the UNAIDS website and network, and events were organized to share results of the Dialogues at the 2008, 2010 and 2012 International AIDS Conferences through satellite sessions and other conference events.

Similarly, the Public Health Agency of Canada has provided technical support to the WHO HIV Drug Resistance Strategy (WHO HIV ResNet) through the provision of epidemiologic and surveillance expertise by the Centre for Communicable Diseases and Infection Control's lab's technical expertise and quality assurance programs. The lab's international leadership and reputation is acknowledged through the accreditation from several international bodies. The Public Health Agency of Canada has also provided both epidemiologic and modelling support for the WHO Technical HIV Incidence Assay Working Group and the Joint United Nations Programme on HIV/AIDS (UNAIDS) Reference Group on HIV Estimation, Modelling and Projection.

Canadian Institutes for Health Research

CIHR is responsible for setting priorities and administering the Federal Initiative's extramural research program. As such, CIHR plays an ongoing role in the global response by developing funding opportunities, such as Priority Announcements, open to HIV research projects focused on national and international issues. Research projects are funded, facilitating Canadian scientists' engagement in solving global problems.

Through a Strategic Training Initiatives in Health Research grant, CIHR has provided funding for the International Infectious Disease and Global Health Training Program, which provides unique capacity building opportunities for advanced trainees from around the world. Trainees come to train in one of four major research centres involved in the program (based in Winnipeg, Manitoba; Nairobi, Kenya; Bangalore, India; and Medellin, Colombia). The International Infectious Disease and Global Health Training Program has three major research foci (HIV, emerging infections and global health) and four themes (Aboriginal health, ethics, knowledge translation and professional development).

In 2012, CIHR collaborated in the organization of/participation in the 7th International Policy Dialogue on HIV and Mental Health. As a follow-up, Health Canada led the organization of a satellite session on the topic at AIDS 2012 and CIHR contributed its expertise by participating in the organizing committee for the satellite session and funding to support Canadian researcher participation in the event. In addition, CIHR significantly increased its international collaborations through engagement in the International AIDS Society led "Towards an HIV Cure" global scientific strategy. The strategy is aligned with priorities of the CIHR HIV/AIDS Research Initiative and is expected to significantly advance the field of HIV cure research. The Scientific Director of the CIHR Institute of Infection and Immunity is a member of the International AIDS Society Stakeholder Advisory Board for the Cure strategy.

In January 2013, CIHR, in partnership with the Canadian Foundation for AIDS Research and the International AIDS Society, announced a new initiative to support Team Grants in HIV Cure Research. This $10 million initiative is aligned with the international scientific strategy, Towards an HIV Cure, and is expected to contribute to the global search for a safe and effective cure for HIV by bringing together experts from different disciplines working collaboratively on a number of inter-related research projects under a unified program of research. Assessments of this activity are not possible at this time as the results from this partnership are yet to be realized.

Expected outcome #4:
Enhanced engagement and collaboration on approaches to address HIV/AIDS

Many collaborative activities over the past five years have occurred, ensuring that participation by targeted stakeholders is ongoing, discussions are occurring and organizations are involved. Collaborative mechanisms are changing, but it is too early to assess their impact on engagement.

Federal coordination aims to strengthen engagement between federal/provincial/territorial governments and non-government organizations/civil society organizations, and among domestic and global strategies.The impact of engagement should therefore be to strengthen the evidence base and development of strategies and initiatives to address the social determinants of health, HIV/AIDS and other infectious diseases. Enhanced engagement means that the participation by desired stakeholders is achieved, discussions are occurring and organizations are involved and ready to act in a collaborative manner.

Public Health Agency of Canada 

The Public Health Agency of Canada fosters collaboration and engagement with the Federal Initiative's partners, other government departments, civil society organizations, researchers/academics, health professionals, provinces and territories, inter-sectoral organizations, and international organizations (including international health organizations and other country governments). This collaboration takes the form of multisectoral meetings, international and national policy dialogues, workshops, technical networks, satellite sessions, and other international learning and capacity development events. The Public Health Agency of Canada has also provided secretariat support to the Public Health Network's Communicable and Infectious Diseases Steering Committee and a time-limited task group on sexually transmitted and bloodborne infections issues, inclusive of HIV, to identify areas for future collaboration.

Collaboration and engagement with the Federal Initiative's stakeholders on the technical aspects of HIV response: facilitate the development, delivery and maintenance of surveillance systems in cooperation with provinces and territories; provide technical support and advice to partners and stakeholders – both domestically and internationally; and help develop and disseminate surveillance knowledge products for research and reporting. The development and maintenance of Track Surveillance systems came about through the establishment of Memoranda of Agreements between the Public Health Agency of Canada and the partner(s). The Public Health Agency of Canada provides laboratory function to support national and international partners in conducting surveillance for HIV, reference services, quality assurance and research.

Through the regional offices, the Public Health Agency of Canada liaised directly with community stakeholders to facilitate their access to funding that supports community-based programming for key populations at risk and to complement the development and implementation of provincial and territorial programs to support the community-based HIV/AIDS work.

Internal key informants noted that partnerships have permitted the complementarity of research, improved the quality of information collected, increased understanding by stakeholders of the difficulties in collecting national data and improved buy-in in working together towards mutual goals. Ongoing discussions on the technical aspects provide feedback and guidance around what's needed.

Canadian Institutes of Health Research

CIHR uses a consultative model for the development of its priorities and funding opportunities, and a variety of consultative activities ranging from meetings with advisory and steering committees to workshops, discussions with partners and other stakeholders. People living with HIV are involved in a wide range of activities of the Initiative including participation in key advisory bodies such as CIHR HIV/AIDS Research Advisory Committee and the Community-based Research Steering Committee; ad hoc consultations; and peer/merit review of research proposals. CIHR also engages in collaborative partnerships by establishing joint funding arrangements and/or sharing expertise and resources to foster the national coordination of the research effort.

Outside of Federal Initiative partners, CIHR has established many diverse partnerships including with the Ontario HIV Treatment Network, the Canadian Association for HIV Research and the Co-morbidity Initiative partners. CIHR has partnered with the following organizations for the Co-morbidity Initiative: Canadian AIDS Society, CATIE, Canadian Treatment Action Council, Canadian Working Group on HIV and Rehabilitation, Mental Health Commission of Canada, various CIHR institutes and the Public Health Agency of Canada to develop and endorse the research agenda and related funding opportunities. The CIHR HIV/AIDS Research Initiative has a long-standing partnership with the Canadian Association for HIV Research, and they have partnered on activities including: an assessment of the HIV/AIDS funding landscape in Canada, a Community-based Research training workshop in Saskatoon, the development of a Community-based Learning online video series targeted at the community, and joint training award funding programs. CIHR also has long history of collaboration with the Ontario HIV Treatment Network. The two organizations have partnered on a series of Community-based Research workshops intended to help students and community-based organizations to enhance their grant writing skills to help improve their success in joint funding competitions. In addition, CIHR and the Ontario HIV Treatment Network have collaborated to offer joint research training opportunities (e.g. New Investigator Award competitions). Finally, as a Federal Initiative partner, CIHR has collaborated in the organization and/or participation in various International Policy Dialogues including: the Policy Dialogue on HIV/AIDS and Indigenous Persons (2009); the Policy Dialogue on HIV/AIDS and Reinvigorating HIV Prevention (2011); and the Policy Dialogue on HIV and Mental Health (2012).   The mid-term evaluation of the Centres for Research Development in HIV/AIDS program found that 77 per cent of survey respondentsFootnote viii agreed or strongly agreed that the Centre's collaborative model led to increased cohesion and a sense of shared purpose among researchers and other stakeholders working in health services and policy research or population health research in HIV/AIDS.Footnote 69 The 2012 CTN evaluation provided evidence that the network model is promoting collaboration between researchers and trainees, as well as between researchers and community/partner organizations. The bibliometric data assessing rates of inter-institutional collaboration, as measured by the percentage of publications that included at least two institutional addresses, indicated the CTN has the highest rate of collaboration (over 85 per cent) when compared to the top 10 countries contributing publications in the field (average of 48 per cent). The CIHR HIV/AIDS Community-based Research Program allowed communities and people impacted by the epidemic to play a central role in HIV/AIDS-related health research along with policy-makers and service providers to produce action-oriented solutions.Footnote 70

Correctional Service Canada

CSC engages in collaborative partnerships with governmental and non-governmental organizations to share knowledge or expertise, to address emergent issues related to HIV/AIDS and the federal prison population. It participates in working groups/committees such as Federal/Provincial/Territorial Heads of Corrections Working Group on Health, which includes representatives from health services in correctional services in each province and territory, along with representatives from CSC. The Group works collaboratively to provide proactive leadership and advice to the Heads of Corrections on trends and promising practices as they relate to health in a correctional setting. In addition, CSC participates in several task groups of the Public Health Network. A Community Consultation Committee was established to exchange information and opinions on issues related to the prevention of infectious diseases within federal penitentiaries. In some regions, CSC regional offices have close collaborations with regional offices of other Federal Initiative partners (Public Health Agency of Canada and Health Canada) along with provincial/territorial counterparts.

Health Canada — First Nations and Inuit Health Branch

Health Canada undertakes collaborative partnerships with First Nations and Inuit communities; federal, provincial/territorial and local authorities; social, health, and educational authorities; and other organizations in order to develop local strategies and approaches to enhance community-based HIV/AIDS initiatives. Interviews with national and regional coordinators as well as representatives of other programs, conducted by the Communicable Disease Cluster Evaluation team, confirmed that the Cluster regularly networks and collaborates with other organizations and that the level of collaboration has further increased or at least stayed the same over the past few years.Footnote 71

Overall challenges in meeting this outcome

External key informants are generally satisfied with the current level of engagement and noted some positive trends in recent engagement. However, some noted what they perceived to be a reduction in opportunities to engage in policy discussions across the federal government.

Some internal and external key informants expressed concern over the potential impact of reduced collaborative activities. They observed that factors outside the control of the Federal Initiative, such as fiscal constraints and a new approach to collaboration (e.g. having time-limited task groups instead of ongoing working groups and placing restrictions on external stakeholders to provide policy advice) are impacting the Federal Initiative's ability to engage stakeholders at the same level as in the past. This may translate into reduced ability to carry out the federal role, especially with respect to the technical aspects of the HIV response. On the other hand, some internal key informants noted the positive side to this new approach. They indicated that the changes may lead to more efficient processes and more focused discussions on priority areas. The new targeted approach through time-limited working groups seems to have received some positive appreciation from external stakeholders.

There is limited evidence on how regional work (across the Public Health Agency of Canada, Health Canada and CSC) is coordinated with national activities/planning/learning. Key informants from regional offices in the Public Health Agency of Canada and Health Canada reported that the collaboration between national and regional offices has diminished in the past years. However, there is some evidence that national and regional activities are being coordinated. For example, at CSC these activities are being coordinated through the Health Services Executive Team. A joint national and regional priority setting exercise will take place at Health Canada, with the intent to develop a national approach to addressing bloodborne and sexually transmitted infections in Aboriginal communities.

It should be noted that the Centre for Communicable Diseases and Infection Control will now lead the coordination for all of the Public Health Agency of Canada's national and regional funding. The Centre will also lead the international collaboration/engagement given that the Office of International Affairs for the Health Portfolio no longer has the role. How this change in structure will impact internal coordination should be taken into consideration during the conduct of the next evaluation of the Federal Initiative.

4.4.2 To what extent has progress been made toward the achievement of second level expected outcomes?

Expected outcome #5:
Reduced stigma, discrimination and other barriers

There are examples of successful local or community-based activities to reduce stigma and discrimination. However, stigma, discrimination and other barriers still hinder access to prevention, diagnosis, care, treatment and support in Canada.

The Federal Initiative aims to reduce stigma, discrimination and other barriers such as lack of housing, poverty and addiction, by increasing knowledge and awareness of HIV/AIDS.

The social determinants of health, the conditions in which people are born, grow, live, work and age,^{Footnote 72} can have a significant effect on an individual's ability to access health services and information.^{Footnote 73} The determinants of health, such as lack of housing and poverty, also play a role in increasing a person's vulnerability to HIV infection.^{Footnote 74} In addition to these barriers, stigma can have a significant impact on the lives and well-being of people living with HIV/AIDS, often inhibiting them from accessing HIV prevention, diagnosis, care, treatment and support. HIV/AIDS stigma is complicated by the fact that the disease disproportionately affects vulnerable individuals such as gay and other men who have sex with men, Aboriginal people and people who inject drugs. The UNAIDS report, HIV – Related Stigma, Discrimination and Human Rights Violations, found that "From the start of the AIDS epidemic, stigma and discrimination have fuelled the transmission of HIV and have greatly increased the negative impact associated with the epidemic.^{Footnote 75} Even though there has been a lot of national and international attention on the issue of stigma and discrimination in HIV/AIDS, worldwide levels of stigma and discrimination remain stable.^{Footnote 76}

The 2011 UNAIDS Political Declaration on HIV/AIDS builds on previous declarations that recognize discrimination on the basis of HIV status is a violation of human rights. The Declarations call for national government leadership to build multi-sectoral approaches to addess HIV/AIDS awareness to alleviate stigma.^{Footnote 77 Footnote 78}

Originally, the social marketing campaigns were intended to increase knowledge and awareness of the nature of HIV/AIDS, and influence individual and community attitudes and behaviours. However, as mentioned in section 4.2, the 2008-10 national social marketing campaign to address stigma and discrimination did not take place as planned, resulting in a shift towards community-based education and awareness campaigns.

Public Health Agency of Canada

National and regional community-based project activities appear to address stigmatizing attitudes at the local level. For example, from 2008 to 2012, 281 ACAP projects addressed stigma and discrimination. ACAP participants reported that projects helped by advocating for them in situations where they felt stigmatized or discriminated against.^{Footnote 79}

One of the goals of the Specific Populations HIV/AIDS Initiatives Fund is to provide socially and culturally appropriate or gender-specific services and to reduce the stigma and discrimination experienced by these populations. Another national fund, the Non-Reserve Fund, is intended to increase access to testing, counselling and care by creating social support opportunities for those living with or affected by HIV/AIDS. For example, one of the national projects found that it was successful in reducing stigma in the community by using culturally appropriate methods to educate the target population, making it more common to discuss HIV/AIDS at Aboriginal Interagency meetings.

Data from the Outcome Assessment of the AIDS Community Action Program (ACAP) indicated that ACAP projects have helped reduce the social isolation of people living with HIV/AIDS, giving them many opportunities to increase their knowledge and access to support. For example, some participants said it allowed them to remain living in their smaller communities rather than move to a bigger centre to access health services. ACAP projects have also helped individuals from countries where HIV is endemic.

Canadian Institutes of Health Research

CIHR funded intervention research supports activities related to HIV and stigma. Research results showed that the program strengthened participants' ability to take action with regard to disclosure and enhanced their perception of having control over their lives. According to key informants, some of the work that is being done within the Community-based Research Program has addressed the stigma and discrimination faced by certain populations affected by HIV/AIDS. This finding was supported by phase I of the Evaluation of CIHR's HIV/AIDS CBR (Community-based Research) Program that indicated that projects funded through the program are raising awareness of HIV/AIDS in the community, helping reduce stigma around the disease, and stimulating discussions about HIV/AIDS.^{Footnote 80}

Health Canada – First Nations and Inuit Health Branch

Health Canada addresses stigma and discrimination through funding to local First Nations communities. Key informants noted that Health Canada's Saskatchewan Regional Office of FNIHB was successful in developing innovative approaches to enhance surveillance through social networks and to deliver peer led education to communities in addressing stigma and discrimination of HIV/AIDS-infected individuals.

Some progress has been made in increasing knowledge and reducing the associated stigma within the First Nations communities. Both National and Regional Coordinators reported pockets of success, with approximately 18 per cent of communities reporting significant progress. Some representatives noted that HIV/AIDS awareness projects, conferences, workshops, culturally appropriate materials and other health strategies in the community have facilitated more open discussion regarding HIV/AIDS related issues among community members.

Correctional Service Canada

CSC offers screening for infectious diseases to all inmates which helps reduce stigma as evidenced by the increasing numbers of inmates tested over time (5,939 in 2008-09 to 7,434 in 2012-13. Commissioner's Directives provide policy direction in the correctional environment, incorporating public health principles. Commissioner's Directive 821 was designed to direct comprehensive management of infectious diseases in correctional settings, providing direction to staff and inmates to help prevent and control infectious diseases such as HIV/AIDS. There are a number of principles laid out in Commissioner's Directive 821 including: provision of screening and testing; approved harm reduction items be readily and discreetly accessible to inmates; education and training; gender and cultural requirements of individuals to be respected; inmates living with infectious diseases to be provided with humane treatment and support, in an environment free of discrimination; and an inmate's infection status to remain confidential.Footnote 81

Overall challenges in meeting this outcome

Public opinion research indicates that attitudes regarding stigma and HIV/AIDS remain largely unchanged since 2006. As of 2012, approximately twenty-two percent of Canadians hold a moderate degree of stigma towards people with HIV/AIDS, and another seven percent exhibit a high level of stigma.^{Footnote 82}

Overall, there was a high level of consensus among both internal and external key informants that stigma and discrimination continue to act as significant barriers to accessing prevention, diagnosis, care, treatment and support. In studies comparing Aboriginal and non-Aboriginal people living with HIV/AIDS, Aboriginal people living with HIV/AIDS experience increased mortality; reduced access to health care and medical treatment; increased food insecurity; and increased experiences of discrimination in accessing housing. The stigma and discrimination experienced by Aboriginal people living with HIV/AIDS can be intensified if they are also members of other marginalized groups, such as women, two-spiritFootnote ix, gay, lesbian, bisexual or transgender, sex workers or people who inject drugs.Footnote 83

There are several other behaviours that act as barriers to adopting safer practices; for ACAP participants, the use of alcohol and the injection of drugs were reported to be the most frequent barriers to reducing risky behaviors in both an on-line survey of men who have sex with men and a survey of youth at risk (22 per cent and 57 per cent respectively).Footnote 84 Economic factors such as the need to buy food instead of condoms and the fact that clients of prostitution will pay more for sex without condoms were also reported by youth at risk and sex workers to be a consideration for risky behavior. Participants reported that ACAP projects helped them to access the health and social service system, even accompanying them to appointments and advocating for them in situations where they felt stigmatized or discriminated against. Even though there is some evidence of success, perceived lack of confidentiality and fear of stigma remain barriers.

HIV stigma and discrimination are important drivers in HIV transmission, contributing to an increased burden of HIV in Canada, because they fail to protect vulnerable populations, and create barriers to seeking help, support and protection for themselves.

Expected outcome #6:
Improved access to more effective prevention, care, treatment and support

Within the responsibility areas of each partner, there are many examples of improved access to more effective prevention, diagnosis, care, treatment and support. However, key informants noted that stigma, discrimination and other barriers continue to present a significant challenge to access.

Increasing individual and organizational capacity is expected to lead to an improved level of access to services by the target population and more effective health promotion, prevention, diagnosis, care, treatment and support. Current and emerging technologies (e.g. drug resistance genotyping and development of ultra senstitive testing for people with a low viral load) will also contribute to this goal.

Public Health Agency of Canada

Projects funded through national and regional grants and contributions facilitated access for vulnerable populations to social services and made referrals to various services such as testing, counseling and treatment. Performance reporting indicated that ACAP-funded projects made a total of 43,627 referrals — most frequently to various social services. The ACAP Outcome Assessment report found that ACAP facilitated access to practical supports that address underlying health determinants of HIV. In particular, ACAP projects have helped participants to access services such as social support, education and skills development, income and basic necessities, cultural services, housing and homelessness services, health and complementary services, and legal services. ACAP-funded projects have provided access to effective prevention, diagnosis, care, treatment, and support to participants either directly through its project facilities, or indirectly through ACAP's partnership with other organizations.

The community-based projects funded under the four different national funding streams were intended to strengthen the capacity of community organizations to plan and deliver programs and services to address HIV/AIDS. As an example, in 2010-11 CATIE conducted a comprehensive evaluation to assess Knowledge Exchange Fund outcomes. As mentioned earlier, almost all of the front-line workers surveyed found the CATIE services and resources providing HIV information very useful or useful in increasing their ability to respond to the needs of their clients and community. From 2008-09 to 2011-12, 21 per cent of projects (4 of 19) funded through the Non-Reserve Fund reported an increase in access to HIV/AIDS-related services and activities that include referrals for HIV testing and counselling, personal monitoring and support, and legal counselling.

The Public Health Agency of Canada, through its National Laboratory for HIV Reference Services, provided highly-specialized diagnostic services to provincial, national, and international partners. Performance reporting noted that in 2010-11, Reference Laboratories received a total of 2,841 samples submitted by provincial/territorial and international counterparts. From these samples, the Centre for Communicable Diseases and Infection Control's labs performed 8,388 tests (96 per cent) based on the samples provided by provinces and territories and 343 (4 per cent) based on the samples provided by international partners. The labs also provide quality assurance programs to national and international laboratories for HIV viral load testing and HIV antibody testing. The National HIV and Retrovirology Laboratories standardizes testing methods through these quality assurance programs to ensure HIV testing in Canada is among the best in the world. Accreditation by the Standards Council of Canada is a mark of competence and reliability recognized throughout the world, and the Centre for Communicable Diseases and Infection Control's labs were issued official accreditation to ISO 15189 by the Standards Council of Canada in the summer of 2008. 

The Public Health Agency of Canada has developed a series of promising practices and guidelines with the main goal to enhance practices of public health practitioners and clinicians and provide a resource for clinical and public health professionals — especially nurses and physicians — for the prevention and management of sexually transmitted infections across a diverse patient population. The majority (90 per cent) of respondents to a 2009 evaluative survey on the 2008 update of the Canadian Guidelines on Sexually Transmitted Infections indicated that they had used these guidelines at some point.

Canadian Institutes of Health Research

There are extensive examples of outcomes from CIHR-funded grants and awards that have increased knowledge of HIV and how to address the epidemic, which are contributing towards improved access to and more effective prevention, care, treatment and support for people living with and vulnerable to HIV/AIDS. Clinical Trials Network investigators led the development of National HIV Pregnancy Planning Guidelines, and the development of national treatment guidelines for HIV-HCV co-infection, which will be promoted and used as a promising practice in the treatment of HIV-HCV co-infection. With assistance from the Clinical Trials Network, dental health professionals in three clinics from Vancouver Coastal Health piloted and implemented an intervention which offers and performs, as part of the regular care, a rapid HIV test, known as the Point of Care test, in clinics located within high-risk populations.

Health Canada

Health Canada's Bloodborne and Sexually Transmitted Infections Program is contributing to the Federal Initiative by providing HIV/AIDS prevention, education, awareness and community capacity building, to facilitate access to diagnosis, care, treatment, and support to on-reserve First Nations and Inuit communities south of the 60th parallel. Performance information indicated that community organizations funded through contribution agreements at the regional level provided training to staff and volunteers in order to increase their knowledge and skills on HIV and related topics such as care, prevention, treatment and sexual health. Between 2008–09 and 2011–12, projects reported providing over 186 training sessions to approximately 2,500 staff and volunteers. Internal key informants noted that Federal Initiative funds support First Nations communities to develop their own strategies to increase access to testing, care, treatment and support.

Some illustrative examples of how Health Canada projects employ promising practices in care and treatment are as follows. In partnership with a Saskatchewan First Nation and a provincial Regional Health Authority, FNIHB Saskatchewan initiated the "Know Your Status" Project. This pilot project operationalized HIV Specialist services in a First Nations community using a multidisciplinary outreach approach to care and treatment, demonstrating seamless service delivery, sound clinical case management and timely communication for a client centered approach to managing HIV. Many funded organizations put in place support groups to promote healthy living and prevent disease within their communities through increased access to social services for people living with HIV/AIDS and those in high risk target groups.

Correctional Service Canada

Federal Initiative funding contributed to a CSC program that offers inmates HIV testing, pre- and post-test counselling, education on risk reduction, and medical treatment for HIV-infected inmates. The program offers voluntary risk-based screening for HIV to all inmates and referral of those who have tested positive for HIV to an infectious disease specialist for medical assessment and access to voluntary treatment. According to performance information, in 2011-12, CSC performed over 6,400 screening tests for HIV among inmates while incarcerated at CSC institutions. There was an increase in voluntary treatment uptake by inmates known to be HIV-positive, from 64.1 per cent in 2008-09 to 80.7 per cent by 2011-12. This might indicate reduced stigma and increased awareness, along with improved access to care, treatment, and support. 

Overall challenges in meeting this outcome

Despite many positive aspects, internal key informants identified multiple challenges in the area of access to services, especially in First Nations communities. In addition to challenges related to primary care, communities in some regions are lacking support for case management, which includes all the necessary steps to support those who have tested positive for HIV, from contacting their physician, contact tracing and testing, referral to specialist clinics, to referral to social services and community support. The transitory nature of the population, who leave and then return to the reserve, is also perceived as an important barrier to providing care. Some remote communities are facing a number of problems such as reduced access to testing and specialized care; stigma, discrimination and unavailability of confidential testing and treatment remain a major barrier in accessing health services. Encouraging information regarding testing has been noted on prenatal screening for HIV in pregnant women since screening for HIV has become part of routine prenatal care.

As a result of HIV treatment advances, people living with HIV have the potential to improve health outcomes and engage in a continuum of services, including testing, care and treatment. Internal key informants identified the lack of surveillance data to monitor these trends and the need to identify gaps in the continuum which may limit the effectivesnes of HIV programs and the response to the HIV epidemic.

Expected outcome #7:
Internationally informed federal response

The global contribution of Federal Initiative partners is recognized and more visible, and some noteworthy examples can be cited. However, the ways in which the domestic response is informed by international best practices is not systematically tracked.

Canadian domestic policies and practices cannot be considered in isolation from the global perspective. Canada's engagement and leadership in global efforts to eliminate HIV/AIDS has an impact on the federal response as many of Canada's domestic challenges are shared by other countries. Engagement internationally contributes to domestic as well as global efforts.

Public Health Agency of Canada

As mentioned under Outcome #3, Canada's engagement and leadership in the global context has been recognized. As a global leader, Canada has been a major contributor both of expertise and financial assistance. Like other nations with similar prevalence and incidence rates characterized by a concentrated low-level HIV epidemic, this global engagement has allowed Canada to learn from the experiences of other countries to inform its domestic response. For example, the Public Health Agency of Canada's recent policy direction to move towards an integrated and holistic sexually transmitted and bloodborne infections response aligns with international practices.^{Footnote 85 Footnote 86 Footnote 87}

There are additional examples of how international promising practices have been applied to the domestic response, primarily at the policy and technical levels. For example, the principles of "HIV cascade of care, prevention and treatment" were extensively discussed at the International AIDS Conference in 2012, in Washington D.C. Currently, Canada through the Federal Initiative is placing more emphasis on this approach. Work with UNAIDS on HIV and disability provided an opportunity to gain knowledge of common challenges and approaches being adopted by other governments, which helped inform both the domestic response in Canada and the global policy directions.

Canada has reaffirmed its policy position to ensure equal access to needed health services through its endorsement of the UN General Assembly (June 2011) Political Declaration on HIV and AIDS: Intensifying Our Efforts to Eliminate HIV and AIDS, which calls for the development of national plans to confront stigma, discrimination and other barriers. Through an integrated approach to policy and programming, federal partners collaborate to focus on the development of prevention measures, improve access to testing, diagnosis, care, and treatment and seek to address co-morbidities and the determinants of health which impact vulnerability and resiliency to HIV and AIDS.

The Office of International Affairs for the Health Portfolio provided leadership on the development and implementation of the 2006-11 UNAIDS Partnership Arrangement between Health Canada, the Public Health Agency of Canada and UNAIDS. Through activities such as the International Policy Dialogues referred to earlier (see outcome #3 in section 4.4.1), the Arrangement provided opportunities for Federal Initiative partners to gain knowledge of common challenges and various approaches being adopted by other governments and global organizations/institutions and to inform the domestic response.

Similarly, key informants have noted how the Office of International Affairs's role in coordinating the Government of Canada expertise and policy advice related to HIV at World Health Assemblies provided an opportunity for Federal Initiative partners to engage with and learn from international experts.

Canada has integrated the provisions of the International Labour Organization (ILO) Recommendation No. 200 Concerning HIV and AIDS and the World of Work, 2010. Recommendation 200 is the first international labour standard for the protection of human rights at work for persons living with and affected by HIV/AIDS. It was adopted  through the collaboration of the Public Health Agency of Canada and Human Resources and Skills Development Canada, and it recognizes that inequalities in the social determinants of health increase the risk of HIV transmission and that stigma and discrimination in the workplace increase workers' vulnerability to HIV. Canadian jurisdictions have already implemented many measures consistent with Recommendation 200 prior to its adoption. However, Canada's active participation to negotiate and adopt Recommendation 200 contributed to raising awareness of the issues and the exchange of a Canadian approach, promising practices, policy and programmatic responses across health and social sectors.

Canadian Institutes for Health Research

In alignment with the global scientific strategy 'Towards An HIV Cure' (led by the International AIDS Society), CIHR announced an initiative in 2013 to support team grants in HIV cure research where results will benefit the domestic and international response. Also, members of the CTN were part of the group of international experts convened by the International AIDS Society to develop the scientific strategy for research. In addition, the CTN's recent expansion to include partnering with five countries further enhances domestic - global interactions. Other major CIHR initiatives (e.g. HIV Comorbidity Initiative) have been guided by international perspectives through the engagement of international experts in the consultation sessions.

Correctional Service Canada

While CSC does not have an explicit role in international engagement as a partner under the Federal Initiative, there's evidence of international involvement, for example through participation at international AIDS conferences which have provided opportunities to learn and assess CSC's response to HIV, and compare rates of HIV and risk factors to those of other countries.^{Footnote 88}

Overall challenges in meeting this outcome

Despite some anecdotal evidence of examples where the Federal Initiative has integrated international practices, there are few documents that track this systematically. In addition, without specific goals or baselines in place, it is difficult to assess the achievement of this outcome.

Expected outcome #8:
Increased coherence of the federal response

Generally, federal coherence in the approach to HIV/AIDS is strong in spite of a lack of joint work planning and priority-setting exercises. But, with the evolution of the Federal Initiative, attention should now focus on strengthening knowledge exchange to ensure a more consistent and coordinated national approach.

Coherence of the federal response translates into adoption of shared directions and approaches by stakeholders, partners and the target audience. Increased collaboration and engagement of stakeholders is a critical step in reaching this outcome which entails the adoption and application of developed policies, directives, guidelines, frameworks, models, standards and promising practices. Promoting learnings between domestic and international response will also ensure coherence of federal response.

Data presented in performance reporting and information collected through interviews with internal key informants provided many examples of shared directions and approaches, resulting in greater coherence at both policy and technical levels of the Federal Initiative.

Ensuring a coherent approach is the goal of the Responsibility Centre Committee, the governance base of the Federal Initiative. Internal key informants emphasized the value of the horizontal management of the Federal Initiative, which guides the departments in achieving their common goals and ensures that evaluation and reporting requirements are met in a cohesive way. The Committee is the approving forum (within the Committee span of control) for the Federal Initiative's accountability commitments, including the Horizontal Initiative Results and Transfer Payment Tables (annexes to the Public Health Agency of Canada's Report on Plans and Priorities and Departmental Performance Report), which was cited in the Treasury Board Secretariat's Performance Reporting Good Practice Handbook 2011 as a promising practice for its horizontal reporting, in particular for its "identification of shared outcomes and targeted results".Footnote 89 The horizontal, inter-departmental reporting of results allowed for a common process of tracking the activities and their outcomes and the telling of a cohesive story. The many advisory bodies in place under the Federal Initiative: Ministerial Advisory Council; National Aboriginal Council on HIV/AIDS (NACHA); National Partners group; and the Global Consultative Group; help guide the federal response and, in some ways, its coherence. In particular, NACHA provides advice to the Public Health Agency of Canada and Health Canada on a number of Federal Initiative activities that may impact Aboriginal people.

As noted throughout the report, there are many examples of working within the Federal Initiative and across other jurisdictions to develop a coherent federal approach to addressing HIV/AIDS in Canada (i.e. Memoranda of Agreements, joint policies).

Some internal key informants provided examples where the national A-Track surveillance system was a positive example of coherence, considering its adoption by other partners. From December 2011 to June 2012, the A-Track survey was piloted in Regina, Saskatchewan with the aim to collect HIV related information among Aboriginal people. The successful implementation of the A-Track pilot survey prompted discussions between the Public Health Agency of Canada and Health Canada to consider conducting the A-Track surveillance system in other First Nations communities to better understand HIV infection and associated risk behaviours among Aboriginal people living on-reserves.

Furthermore, an example of adopting common approaches is in the area of promising practices and guidelines. The national guidelines for HIV treatment and testing, developed by the Public Health Agency of Canada, are a valuable resource for health professionals, especially nurses and physicians, for the prevention and management of HIV across a diverse patient population. The Public Health Agency of Canada's National HIV and Retrovirology Laboratories provides standards through quality assurance programs (e.g. HIV serology, HIV viral load, HIV drug resistance) to ensure consistent, quality HIV testing across provinces and territories. The lab standardizes testing methods to ensure HIV testing in Canada is among the best in the world. The lab also provides advice and expertise to Canadian laboratories performing HIV/HTLV testing.

Some internal key informants provided details of coordinated HIV work taking place at the regional level. One illustrative example is the funding model developed and implemented in Alberta, a collaboration between provincial (Alberta Health and Wellness) and federal (Public Health Agency of Canada) health departments and community organizations (AIDS Service Organizations). The model provides a framework for simplifying funding arrangements, enhancing coordination and reducing duplication. The pooled federal and provincial resources created the Alberta Community HIV Fund, which supports community-based responses through a collective action and a unified voice.

The CIHR HIV/AIDS Research Initiative brings together a collection of programs to form a comprehensive and coherent strategic approach to HIV/AIDS research in Canada, defines priorities for HIV/AIDS research, and develops related funding opportunities. The CIHR HIV/AIDS Research Advisory Committee guides the development of the CIHR HIV/AIDS Research Initiative and is mandated to make recommendations regarding research programs and priorities on HIV/AIDS. The Centres for Research Development in HIV/AIDS program encourages the national coordination of research efforts and meaningful collaborations between researchers and research users such as community-based organizations, people living with HIV/AIDS and policy makers. In the mid-term evaluation of the program, approximately three quarters of the survey respondents agreed that the program increased cohesion and a sense of shared purpose among researchers and other stakeholders. CIHR Funding initiatives have included consultation with stakeholders and Federal Initiative partners.

Finally, a notable example of federal cohesion was the pre-conference events preceding the 2010 and 2012 International AIDS Conference. Supported by FNIHB and the Public Health Agency of Canada, the events were organized by the International Indigenous Working Group on HIV/AIDS through the Canadian Aboriginal AIDS Network. The pre-conference provided an opportunity for a knowledge exchange forum where Indigenous service providers, researchers, policy makers, community leaders and Indigenous people living with HIV/AIDS come together to share and learn. Public Health Agency of Canada participation and statements made at the International AIDS Conferences enhanced Canada's international visibility. CIHR contributed to the planning and implementation of Government of Canada participation in international AIDS conferences (2008, 2010 and 2012).

Overall challenges in meeting this outcome

While there are some good examples of collaboration between and beyond Federal Initiative partners, there is currently no system to track these types of discussions, projects and/or partnerships that take place outside of Responsibility Centre Committee meetings. Internal key informants remarked that the meetings of the Committee represent a great opportunity for the Federal Initiative partners to connect, to share information and updates on their activities. They observed that some of the discussions initiated at these meetings materialized in bilateral partnerships, with a lot of side meetings and joint actions that might have contributed to the coherence of the Federal Initiative. While the discussions taking place at the Committee meetings were recorded in meeting minutes, there was a lack of documentation outlining the joint efforts taking place outside the formal horizontal management. There was limited evidence on joint work planning and priority setting exercises although this was a deliverable in response to a recommendation in the previous evaluation. Combined, these factors highlight an important challenge in ensuring synergies are achieved through joint work.

While the national Federal Initiative partnership promoted joint knowledge sharing and directions, regional key informants were less aware of the activities of other partner departments and appeared to be working in a more localized way. Key informants in the regional offices noticed that inter-departmental collaboration between Federal Initiative partners at the regional level varied. While some regions, including Ontario and Western, benefited from established partnerships between Federal Initiative partners, provincial/territorial governments, and other non-governmental organizations, the lack of engagement in other regions may have resulted in missed opportunities to work together towards a common outcome.

Generally, both internal and external key informants noted that there is limited sharing of promising practices of successful interventions and how these approaches are applied to policy and program directions. Some internal key informants stated that there are no means of communicating more broadly the success stories that are happening at the local and regional level, although recognizing that the Federal Initiative could play a significant role in bringing partners together across sectors and ensure that intervention work has a vision and a strategic plan. There was a perceived need to work collaboratively with the provinces and territories, with other sectors, to take over the implementation of these promising practices, to apply and adapt them to appropriate contexts.

4.5 Performance: Issue #5 — Demonstration of Economy and Efficiency

4.5.1 Did resource utilization in relation to the production of outputs demonstrate progress toward the expected outcomes?

Prevention of HIV/AIDS is more cost-effective than treating the infection. The Federal Initiative is demonstrating efficiencies in key areas, including laboratory science, research and community-based funding. The integrated approach in these areas of the Federal Initiative may lead to broader impact and greater efficiency of the investment. The governance of the Federal Initiative has clear benefits for partners and assists with the horizontal management of the Federal Initiative.

Economic Burden of HIV/AIDS in Canada

While not directly attributable to Federal Initiative activities, preventing HIV/AIDS is a cost-effective activity. The economic burden of HIV/AIDS is an important factor for understanding the impact of the disease within the broader public health, health systems and societal context.

Historically, HIV epidemics affected more men than women in Canada, with the highest proportion of cases among 30 to 39 year olds, which can affect lifetime care burden and potential economic contribution. A 2011 national study found the direct and indirect costs of people recently infected with HIV in Canada to total $4.03 billion, or $1.3 million per person (lifetime cost), as outlined in Table 3. In this study, direct medical costs were 19 per cent of the total ($765 million), with labour productivity costs estimated to be 52 per cent, and quality of life loss valued at 29 per cent of the total.^{Footnote 90}

The economic impact of each new case of HIV suggests that prevention could be a cost-effective area of intervention. A recent study examining the cost-effectiveness of HIV/AIDS prevention efforts has provided evidence to this effect. The study examined the economic effect of federal ACAP and provincial HIV prevention funding within the province of Ontario, and estimated that the lifetime direct medical costs avoided of each HIV case to be between $242,686 and $376,785 (in 2011 dollars). The study estimated that for every dollar invested in community-based prevention programs, $51 in direct medical costs was avoided.^{Footnote 91} Similarly, in Australia, for every $1 expended on HIV prevention programs, an estimated clinical care cost saving of $13 is achieved. About $4 of this was attributed to harm reduction programs, which have prevented a large number of cases among people who inject drugs.^{Footnote 92}

Federal Initiative Funding

Between 2008 and 2012, the total Federal Initiative investment was $363 million, and variances between planned and actual spending tended to be small — generally under 5 per cent per year. Of these small variances, the Public Health Agency of Canada tended to lapse the greatest proportion. Explanations for these variances are primarily due to the cancellation of a large social marketing campaign planned for 2008-10 as well as a delay in approvals for some key grants and contributions activities during a period of grants and contributions restructuring under the Government of Canada Blue Ribbon Panel (2010-12).

It should be noted that variances have decreased as the Federal Initiative progressed, except for the 2012-13 fiscal year. This may be due to a change in the transfer of funds process for the Federal Initiative. Before 2010-11, transfers only took place between different divisions within the Public Health Agency of Canada. However in 2010-11, changes to the Federal Initiative's governance structure resulted in the ability to reallocate and transfer resources to other Federal Initiative partners, such as CIHR. In addition, resources could be transferred to other Public Health Agency of Canada programs that shared similar objectives and outcomes, such as the Canadian HIV Vaccine Initiative and the Hepatitis C Prevention, Support and Research Program. Due to the improved strength of the governance structure, the Federal Initiative could be more nimble to address emerging needs or priorities in the future. 

There appears to be flexibility in advancing HIV/AIDS activities undertaken by all Federal Initiative partners. All partners tended to combine Federal Initiative funding with their own  ongoing funding each fiscal year to maximise activities to address HIV/AIDS. For example, CIHR supports projects directly through the Federal Initiative funding managed by CIHR, as well as through corresponding investments from other CIHR funding sources. From 2008-09 to 2011-12, through the different funding opportunities provided, CIHR increased the overall number of projects funded – from 370 in 2008-09 to 500 in 2011-12 and the total investment in HIV/AIDS research by CIHR increased to its highest annual investment level of $45.9 million in 2011-12.

Efficiencies

The integrated approach in some areas of the Federal Initiative may lead to broader impact and greater efficiency of the investment. Due to similar risk factors and transmission routes, evidence shows that people at risk of contracting HIV/AIDS are also at risk of contracting other sexually transmitted and bloodborne infections, such as hepatitis C, and are often co-infected. As such, many HIV/AIDS activities in the areas of prevention, testing, diagnosis, care and treatment can target multiple infections at once, as opposed to addressing HIV/AIDS in isolation. Key informants noted that integrated approaches help mitigate the impact of stigma and discrimination by including HIV/AIDS outreach within broader approaches that carry less stigma.

However, both internal and external key informants noted that there are other areas of HIV/AIDS work that are not as conducive to integration, and may necessitate disease-specific approaches such as laboratory diagnostics and related work, and HIV/AIDS-specific research, such vaccine and cure research. This is also supported by internal documentation. Furthermore, they noted that HIV/AIDS remains distinct from other sexually transmitted and bloodborne infections in many ways, such as the specific treatment and support needs of people living with HIV/AIDS.

Performance measurement

An implementation evaluation of the Federal Initiative was conducted in 2008. Recommendations in the evaluation concentrated on the development of performance measurement and strengthening of the governance. After an initial attempt at implementing an information technology tool and determining that it would not meet their reporting requirement needs, partners in the Federal Initiative developed and implemented a coordinated performance measurement system. Efforts have been realized to standardize data collection and reporting of performance data and this process resulted in the identification of common indicators which supported performance reporting. Currently, a centralized database system is being used for the collection and reporting of horizontal performance data to meet reporting requirements. There are indications that this system is, for the time being, fulfilling Federal Initiative performance measurement collection and reporting requirements.

Although there are some good examples of performance measurement within the Federal Initiative, as indicated throughout this report, the overall assessment of outcomes at the Federal Initiative level could be improved to ensure greater precision in defining concepts, selecting appropriate success indicators and assessing achievement of outcomes. For example, complex outcomes, such as capacity, generally tend to be inconsistently defined, making it difficult to accurately assess success and/or progress. Benchmarks, baseline data and targets are generally lacking from the Federal Initiative's performance measurement strategy, making it difficult to place performance in context. Performance measurement was not rolled up annually at a Federal Initiative level, limiting its use for overall Federal Initiative assessment to enhance strategic decision-making. Some internal key informants noted that there was limited human resource capacity to undertake this function but have stated that this task will be conducted in the future.

The value of horizontal governance

The Federal Initiative has a centralized management framework consisting of its Responsibility Centre Committee which is comprised of mid-level management representation from each of the responsibility centres which receive funding through the Federal Initiative. As previously mentioned, this mechanism allows for transfers of funding between responsibility centres to prevent lapsing of dollars and to move funds into areas of greater need. It also provides a venue for information sharing at meetings to reduce duplication, greater alignment of activity and potential collaboration on joint projects.

One key function of the Committee is to serve as an accountability mechanism for regular departmental reporting frameworks (Reports on Plans and Priorities, Departmental Performance Reports) through which the lead partner (Public Health Agency of Canada) reports to Canadians on the Federal Initiative's activities and results. Of note is the fact that in 2011, the horizontal results tables in the Public Health Agency of Canada's 2010-11 Departmental Performance Report were cited by Treasury Board Secretariat as a best reporting practice.

During a previous implementation evaluation (2009)^{Footnote 93} the horizontal management of the Federal Initiative was identified as an area that needed to be strengthened. In response to the evaluation, the Committee's Terms of Reference were revised, most notably to include a high-level description of annual priorities that the Committee added as an appendix. A Guidance for Strengthening the Horizontal Governance and Management of the Federal Initiative was also commissioned.

Areas of potential inefficiency:

The Responsibility Centre Committee mechanism is being used primarily for information sharing rather than decision making, strategic planning, and priority setting at the Federal Initiative level. One issue that warrants some attention is the fact that directors often delegate participation at the Committee to their managers, which limits the Committee's ability to function as a decision-making forum.

In 2010, as a response to the implementation evaluation recommendations, the Public Health Agency of Canada engaged Government Consulting Services to provide some guidance on horizontal governance and management for the Federal Initiative. According to that document, the Management Response and Action Plan agreed with the recommendation and undertook to "identify new and revised horizontal management tools for the Responsibility Centre Committee."

Part of the suite of management tools suggested for strengthening horizontal management included the development of a joint long-term plan, updated annually, and 'based on an integrated analysis of the external and internal environment, identifying priority areas for action and associated opportunities for coordination and joint work'.  Recognizing their own departmental priorities, each Federal Initiative partner would then develop its own detailed work plan to align with the joint work plan.

As noted in the previous section, a Terms of Reference document was revised to include an appendix containing priorities. However, priorities were focused on past accomplishments rather than future plans. To meet the commitments outlined above, it would be necessary to provide a forward looking plan and then report on progress of implementing the plan, documenting how "priorities" engaged partners across the Federal Initiative.

While governance of the Federal Initiative funds is an important focus for the Committee, many of the senior managers around the table have similar and broader roles to manage other related communicable diseases such as hepatitis C, sexually transmitted infections and tuberculosis. Efficiencies could be gained by expanding discussion to these topics.