Section 2: Evaluation of the Federal Initiative to Address HIV/AIDS in Canada 2008–09 to 2012–13 – Program description

2. Program Description

2.1 Program Context

The Canadian Strategy on HIV/AIDS was launched in 1998. It set out to create an ongoing, nationally shared approach to HIV/AIDS, with increased collaboration across all sectors of society.

Through the Canadian Strategy on HIV/AIDS, it was acknowledged that HIV/AIDS must be addressed not only from a medical/physiological point of view but also from social, economic and human rights perspectives, taking into account the root causes, determinants of health and other dimensions of the epidemic. There was recognition that people living with HIV/AIDS and those vulnerable to HIV infection should be both at the centre of and key contributors to the response, and that increased public accountability was needed to ensure that the response was adaptable to the changing epidemic.

The launch of the Federal Initiative, in 2005, signalled a renewed and strengthened federal role in the Canadian response to HIV/AIDS. The Federal Initiative was launched to work toward a Canada free from HIV and AIDS, and free from the underlying conditions that make Canadians vulnerable to the epidemic.

2.2 Program Profile (as of 2013)

The Federal Initiative is a horizontal initiative involving four federal government organizations: the Public Health Agency of Canada (lead), the Canadian Institutes of Health Research (CIHR), Correctional Service Canada (CSC) and Health Canada. Officially launched in January 2005^{Footnote 2}, the Federal Initiative builds on the federal government's original Canadian Strategy for HIV/AIDS which committed $42.2 million annually. The Federal Initiative commits an additional $30.4 million annually for a total of $72.6 million to address the following four goals:

1. Prevent the acquisition and transmission of new infections.
2. Improve the quality of life for those at risk and living with HIV and AIDS.
3. Contribute to the global effort to reduce the spread of HIV and AIDS and mitigate its impact.
4. Reduce the social and economic impact of HIV/AIDS.

The Public Health Agency of Canada is the lead for the Federal Initiative, responsible for overall coordination, communication, public awareness, reporting, evaluation, national and regional programs, policy development, surveillance and laboratory science, and leadership on international health policy and program issues. Within the four partners, the work of the Federal Initiative is divided among Responsibility Centres, each having distinct roles, responsibilities and contributions towards the Federal Initiative's goals. The Responsibility Centre Committee is the governance body for the Federal Initiative. It is comprised of directors from the Responsibility Centres which receive funding through the Federal Initiative. Led by the Public Health Agency of Canada, the Responsibility Centre Committee is intended to promote policy and program coherence among the participating departments and agencies, and ensures that evaluation and reporting requirements are met.

Figure 1 outlines the activities carried out by the four government partners involved in the Federal Initiative. The role and contribution of each Responsibility Centre is described below.

Figure 1: Federal Initiative to Address HIV/AIDS in Canada Partners

Public Health Agency of Canada

Centre for Communicable Diseases and Infection Control

Programs and Partnerships  

The Centre is the focal point for the coordination of the Federal Initiative. Its expected outcomes include: increased collaboration and engagement, increased coherence of the federal response at the global and national levels, and increased knowledge and awareness. The Centre is also responsible for the administration of a transfer payment program aimed at building the capacity of community organizations to deal with the impact of HIV/AIDS; developing approaches to address issues affecting key populations affected by HIV/AIDS; and supporting partnerships to achieve greater national cohesion with regard to HIV/AIDS.

Surveillance

The Centre has a mandate to design and implement the Public Health Agency of Canada's communicable disease surveillance and epidemiology initiatives and programs. The Centre is responsible for the management of a national communicable disease surveillance system, leading epidemiological research, and providing technical epidemiological support to provincial and territorial governments, international institutions (i.e. WHO, PAHO, European Centre for Disease Prevention and Control), and foreign government institutions (i.e. United States Centers for Disease Control and Prevention).

Professional Guidelines and Public Health Practice

The Centre works to enhance the practices of public health professionals and clinicians to prevent and control communicable diseases in Canada. The Centre develops guidelines and  public health intervention research; identifies and disseminates promising practices, and supports technical knowledge transfer and exchange, including modelling, estimations, and projections.

National Microbiology Laboratory

National HIV and Retrovirology Laboratories

The National HIV and Retrovirology Laboratories provide a comprehensive range of laboratory science services, surveillance research and expertise related to HIV and emerging retroviruses. The provision of National laboratory services for the purpose of enhancing diagnosis, care, treatment and diagnosis of HIV infected Canadians is mandated under the Federal Initiative. It is comprised of the National Laboratory for HIV Genetics, the National Laboratory for HIV Reference Services, the National Laboratory for HIV Immunology and the Molecular Epidemiology and Viral Evolution Unit.

Regional Operations

Regional Operations implements the AIDS Community Action Program (ACAP) across regional offices of the Public Health Agency of Canada and contributes to the Federal Initiative through the administration of grants and contributions, funding programs and projects that support community-based programming for key populations at risk and work to enhance capacity of community-based stakeholders in the prevention and control of HIV/AIDS. Community-based organizations are well-positioned to reach Federal Initiative target populations and influence their behaviour. As such, ACAP supports local, regional, and provincial/territorial AIDS service organizations and community-based organizations that promote the health of people living with HIV; prevent new infections; strengthen community-based organizations' capacity to respond to HIV/AIDS; and create supportive environments by addressing social barriers that limit access to HIV/AIDS care and services.

ACAP is managed by the Public Health Agency of Canada Regional Offices in five regions: Atlantic, Quebec, Ontario, Manitoba/Saskatchewan, Western and the Northern Region.

Portfolio Shared Services Partnership

Office of International Affairs for the Health Portfolio

The Office of International Affairs for the Health Portfolio is responsible for the Global Engagement Component of the Federal Initiative^{Footnote i} which aims to establish a strong, coherent health sector response to ensure that Canada fulfills its international commitments and contributes to global efforts to address HIV/AIDS. 

The Office of International Affairs focuses on ensuring policy coherence of Canada's international HIV/AIDS activities; promoting learning between domestic and international responses; increasing Canada's contribution of policy guidance and technical support; and sharing health sector experience and knowledge.

Global engagement activities aim to complement the respective policy and development assistance roles of the Department of Foreign Affairs and International Trade and the Canadian International Development Agency's,^{Footnote ii} recognizing the need for domestic policy coherence and coordinated approaches for a comprehensive, multi-sectoral response to HIV/AIDS.

Canadian Institutes of Health Research

CIHR is the Government of Canada's agency responsible for funding health research in Canada. CIHR's mandate is the creation of new scientific knowledge and enabling its translation into improved health, more effective health services and products, and a strengthened Canadian health care system.

CIHR is responsible for setting priorities and administering the Federal Initiative's extramural research program. To oversee its activities related to HIV/AIDS, CIHR created the CIHR HIV/AIDS Research Initiative, which is managed by one of CIHR's 13 Institutes: the CIHR Institute of Infection and Immunity. There are four Federal Initiative-mandated funding streams that support the CIHR HIV/AIDS Research Initiative: Biomedical/Clinical research; Health Services/Population Health research; HIV/AIDS Community-Based Research Program; and CIHR Canadian HIV Trials Network (CTN).

The CIHR HIV/AIDS Research Initiative aims to bring together a collection of programs to form a comprehensive strategic approach to HIV/AIDS research in Canada; defines priorities for HIV/AIDS research and develops related funding opportunities, thereby trying to target research where it is needed most and facilitating the translation of research into effective programs, policies and services.

Health Canada

First Nations and Inuit Health Branch

Health Canada's First Nations and Inuit Health Branch (FNIHB) provides HIV/AIDS prevention, education, awareness and community capacity building, and facilitates access to quality diagnosis, care, treatment, and support to on-reserve First Nations and Inuit communities south of the 60th parallel. FNIHB also provides non-insured health benefits, such as antiretroviral medications for HIV-positive clients, to eligible First Nations and some Inuit communities, regardless of residence. It also makes available some primary health care services, such as HIV testing, for First Nations living on-reserve in some remote and isolated areas across Canada. The program works closely with other federal partners, such as the Public Health Agency of Canada, other FNIHB service programs, non-governmental organizations, provincial health authorities, as well as First Nations and Inuit organizations to support culturally appropriate programming. The five program elements currently in place are:

1. Collaboration (with federal partners, other FNIHB service programs, provincial government health authorities, as well as First Nations and Inuit health authorities).
2. Knowledge development and dissemination (activities that lead to programming based on best practices and evidence-based analysis, knowledge resources developed and disseminated).
3. Program design and implementation (activities that facilitate the development and implementation of operational policies regarding HIV/AIDS).
4. Prevention education (activities that facilitate the development of primary and secondary prevention activities for First Nations and Inuit vulnerable to and/or living with HIV/AIDS).
5. Capacity building (develop capacity within First Nations and Inuit communities south of the 60th parallel to increase participation of health professionals, community leaders and community members in prevention education programs).

Correctional Service Canada

CSC, as part of the criminal justice system and respecting the rule of law, contributes to public safety by actively encouraging and assisting offenders in becoming law-abiding citizens, while exercising reasonable, safe, secure, and humane control. More specifically, CSC is responsible for administering court-imposed sentences for offenders sentenced to two or more years.

Under the Corrections and Conditional Release Act, CSC is mandated to provide every inmate with essential health services, including services related to the prevention, care and treatment of HIV/AIDS. With Federal Initiative funding, the CSC offers inmates HIV testing, pre- and post-test counselling, education on risk reduction, and medical treatment for HIV-infected inmates. The CSC aims to broaden its surveillance capacity to provide a clearer description of the prevalence of HIV/AIDS in federal prisons so as to better inform policy and program development.

2.3 Program Logic Model and Narrative

The Federal Initiative supports five primary areas of action: Research, Surveillance and Knowledge Development; Program Interventions and Policy Development; Communications and Social Marketing; Global Collaboration; and Coordination, Planning and Reporting. For each of these five Areas of Action, some activities are performed directly by the federal government while others are performed by organizations who receive grants and contributions funding.

Through these activities, the Federal Initiative seeks to address a number of expected outcomes. This evaluation will focus on first and second level outcomes, namely:

• increased knowledge and awareness of the nature of HIV/AIDS and ways to address the disease
• increased individual and organizational capacity
• increased Canadian engagement and leadership in the global context
• enhanced engagement and collaboration on approaches to address HIV/AIDS
• reduced stigma, discrimination and other barriers
• improved access to more effective^{Footnote iii} prevention, care, treatment and support
• internationally informed federal response
• increased coherence of the federal response.

The connection between these activity areas and the expected outcomes is depicted in the 2010 logic model. The evaluation assessed the degree to which the defined outputs and outcomes were achieved over the evaluation timeframe. (see Appendix 1 for more information on the logic model and narrative).

2.4 Program Resources

In 1998, the Canadian Strategy on HIV/AIDS began with an emphasis on sustainability and integration, increased focus on those most at risk and increased public accountability. Health Canada, CIHR and CSC received a total of $42.2 million to achieve these goals.

Starting in 2005, the federal role in addressing HIV/AIDS in Canada was strengthened and expanded through the Federal Initiative. The original $84.4 million commitment was affected by reductions announced in Budget 2005 as well as time-limited re-allocations to the Canadian HIV Vaccine Initiative. After the reductions, the allocation amounted to $72.6 million to undertake Federal Initiative activities. Of this allotment, the Public Health Agency of Canada received $45.4 million, Health Canada received $5.6 million, CIHR received $21.0 million and CSC received $4.2 million. Further information on the Federal Initiative Allocation and Expenditures can be found in Appendix 2.

While this evalution will focus on activities associated with funding received via the Federal Initiative, it should be noted that all partner departments use additional funding to further address HIV/AIDS. 

Within the Public Health Agency of Canada, some additional funding is dedicated to preventing and controlling community associated infections. Due to the integrated nature of the work involved, it is difficult to identify the additional specific resources allocated and spent only to prevent and control HIV/AIDS. This can be explained by the integrated approach recently implemented to tackle the wide variety of community associated infections and related activities. For example, the Canadian Guidelines on Sexually Transmitted Infections work is jointly funded by the Federal Initiative and community associated infections funding.

Partner departments also use additional funds to supplement HIV/AIDS activities. In 2011-12, CIHR was allotted $21.4 million through the Federal Initiative. However, total spending on HIV/AIDS related activites amounted to $45.9 million. In both 2010-11 and 2011-12, additional funds were used to cover the cost of HIV/AIDS activities in CSC through their public health budget. At Health Canada, in 2010-11 and 2011-12, an additional $0.5 million was dedicated from the First Nations and Inuit Health Branch reference levels to activities related to the Federal Initiative.