2019-2020 Progress report for the Government of Canada Five-Year Action Plan on Sexually Transmitted and Blood-Borne Infections
Organization:Public Health Agency of Canada
Published: June 27, 2022
Table of Contents
- Priority #1: Moving toward truth and reconciliation with First Nations, Inuit and Métis Peoples
- Priority #2: Stigma and discrimination
- Priority #3: Community innovation – Putting a priority on prevention
- Priority #4: Reaching the undiagnosed – Increasing access to STBBI testing
- Priority #5: Providing prevention, treatment and care to populations that receive health services or coverage of health care benefits from the federal government
- Priority #6: Leveraging existing knowledge and targeting future research
- Priority #7: Measuring impact – Monitoring and reporting on trends and results
Accelerating our response: Government of Canada five-year action plan on sexually transmitted and blood-borne infections (STBBI) is built from the vision, guiding principles and pillars of the Pan-Canadian STBBI Framework for Action, and articulates the Government of Canada's approach to addressing STBBI.
The Action Plan takes a whole-of-government approach to addressing STBBI, recognizing that overcoming barriers to STBBI prevention, testing, treatment and care intersects across many federal mandates that aim to improve the lives of Canadians. Ten federal departments are working together to build upon the Pan-Canadian STBBI Framework for Action that was jointly released in 2018 by federal, provincial and territorial ministers of health.
This Progress Report is the first in a series that will provide an overview of federal activities from 2019 to 2024 to address the Action Plan's priorities. Like the Action Plan, the Progress Report is organized by the seven priority areas: 1) moving toward truth and reconciliation with First Nations, Inuit and Métis Peoples; 2) stigma and discrimination; 3) community innovation—putting a priority on prevention; 4) reaching the undiagnosed—increasing access to STBBI testing; 5) providing prevention, treatment and care to populations that receive health services or coverage of health care benefits from the federal government; 6) leveraging existing knowledge and targeting future research; and 7) measuring impact—monitoring and reporting on trends and results. This current Progress Report will detail activities undertaken in the 2019-2020 fiscal year to address STBBI in Canada.
It is important to note that this report highlights activities that began or were completed prior to the onset of the global COVID-19 pandemic, which became prominent within the Canadian context in March 2020. Future Progress Reports on the Action Plan will include activities carried out during and in response to the impacts of the COVID-19 pandemic on STBBI prevention, care, treatment and support.
The Government of Canada remains committed to improving the life of Canadians, achieving the strategic goals of the Pan-Canadian STBBI Framework for Action and accelerating efforts to meet global targets for STBBI laid out by the World Health Organization and the Joint United Nations Programme on HIV/AIDS. Our continued shared efforts will ensure progress is being made in addressing STBBI burdens in Canada.
The *10 federal partner departments:
- Public Health Agency of Canada (PHAC)
- Canadian Institutes of Health Research (CIHR)
- Correctional Service Canada (CSC)
- Department of Justice (DOJ)
- Department of National Defence (DND)
- Department for Women and Gender Equality (WAGE)
- Health Canada (HC)
- Immigration, Refugees and Citizenship Canada (IRCC)
- Indigenous Services Canada (ISC)
- *LGBTQ2 Secretariat housed within the Department of Canadian Heritage (PCH) (Secretariat now sits within the Department for Women and Gender Equality)
Priority #1: Moving toward truth and reconciliation with First Nations, Inuit and Métis Peoples
The Action Plan reiterated the Government of Canada's commitment to implementing the Truth and Reconciliation Commission's Calls to Action and renewing nation-to-nation, Inuit-Crown, and government-to-government relationships with First Nations, Inuit and Métis Peoples to reduce the health impacts of STBBI. To contribute to reconciliation with First Nations, Inuit and Métis Peoples, the Government of Canada:
- Co-developed a renewed approach to STBBI-related engagement with First Nations, Inuit and Métis Peoples, as well as an interdisciplinary approach to Indigenous research and a research-training model.
- Prioritized Indigenous-led, culturally safe STBBI prevention, education, awareness, and community capacity-building initiatives by supporting:
- An enhanced program to prevent hepatitis C through harm reduction and employment services in two Atlantic First Nations communities. This allowed the Wagmatcook and Eskasoni communities to offer STBBI testing on-site rather than referring to a visiting practitioner or to services offered outside the community;
- The implementation of Saskatchewan's Know Your Status (KYS) integrated model of care; in which 30 communities now have access to "full" KYS (comprised of three components: testing, harm reduction and support for specialized nursing/outreach), and 42 communities now have access to "partial" KYS (one or two components) for a total of 72 communities;
- The development and implementation of the Native Women's Association of Canada's trauma-informed approach to culturally specific and gender-based STBBI interventions for Indigenous women and girls to address and decolonize STBBI-related stigmas;
- The creation of the Manitoba Mino Pimatisiwin Model of STBBI Care to increase knowledge of culturally safe approaches among service providers and opportunities for Indigenous-led partnerships, in order to improve STBBI care by ensuring it is experienced as safe and welcoming by Indigenous service recipients; and
- A culturally safe peer-mentoring service model led by Cote First Nation Health in the town of Kamsack, Saskatchewan, aimed at assisting First Nations people who share drug-use equipment.
- Supported the development and implementation of Indigenous-led research that respects the principles of Indigenous data sovereignty, ownership and control and is grounded in Indigenous knowledges by:
- Collecting gender-based data to build greater understanding of key social determinants of health and health inequities that may contribute to STBBI vulnerability and resilience; and
- Improving the availability and accessibility of community-level data through enhanced STBBI surveillance. This included monitoring and preventing the emergence of antimicrobial resistant gonorrhoea, as well as supporting Tribal Councils to conduct HIV, hepatitis C and syphilis bio-behavioural surveys.
- Invested $12.5 million over five years to support Centres for HIV/AIDS, Hepatitis C and other STBBIs Research, which aim to improve health and access to effective programs and services for people living with and at risk of STBBI, particularly for populations most affected. Two of the three funded Centres focus exclusively on Indigenous populations and are grounded in Indigenous knowledges and methodologies to reduce STBBIs in First Nations, Inuit, Métis and/or Urban Indigenous communities: the Feast Centre for Indigenous STBBI Research and the Waniska Saskatchewan/Manitoba Indigenous Centre for HIV/HCV/STBBI Inequities.
Priority #2: Stigma and discrimination
The Government of Canada acknowledges that stigma and discrimination can create barriers and thus undermine the provision of, and access to, effective STBBI prevention, care, treatment and support. To reduce STBBI-related stigmas and promote the uptake of best practices to address it, the Government of Canada:
- Convened 15 organizations implementing HIV and Hepatitis C Community Action Fund projects to share lessons learned and best practices. This resulted in the development of a National Community of Practice on Stigma with over 175 members from 59 community-based organizations.
- Raised awareness of the adverse impacts of stigma and discrimination by:
- Developing a toolkit for stakeholders to promote new resources on their own social media channels;
- Funding POZitivity, an Anti-Stigma Campaign that was promoted at 24 Pride events across Canada, through social media and the Slay Stigma Canadian Drag Tour, which prompted over 11,000 individuals to commit to reducing HIV-related stigmas;
- Developing a set of video testimonials to profile the transformative impact that the Undetectable=Untransmittable (U=U) campaign has had in reducing HIV-related stigmas, promoting HIV treatment adherence, and supporting healthier and happier lives for people living with HIV, also detailed in CATIE's Can't Pass It On campaign;
- Updating the content and layout of the Sexually Transmitted Infections booklet for youth, which received 2,030 page views and 131 downloads in its first two months and provides information on sexual health and technology, how to talk to youth, and information for healthcare professionals; and
- Supporting the implementation of the People Living with HIV Stigma Index, which documents and provides interventions to reduce stigma and discrimination experienced by people living with HIV.
- Equipped health professionals with knowledge and tools to provide culturally responsive services in safe environments by:
- Establishing the National Advisory Committee on Sexually Transmitted and Blood-borne Infections (NAC-STBBI) to support PHAC's mandate to prevent and control infectious diseases by providing advice for the development of STBBI guidance for primary care providers and public health professionals;
- Publishing a reference resource and infographic to facilitate conversations between primary healthcare professionals and individuals who should be offered HIV pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP);
- Releasing a resource for health professionals outlining the scientific evidence supporting U=U to facilitate conversations between healthcare providers and their patients and encourage greater HIV treatment adherence; and
- Supporting the expansion of a Women-centred HIV Care (WCHC) Model to address the unique health and social needs of women living with HIV and improve healthcare for this population.
- Supported research initiatives and legislative changes to reduce the adverse impacts of stigma and discrimination and promote inclusion and respect by:
- Introducing Bill C-8: An Act to Amend the Criminal Code (Conversion Therapy) in the House of Commons to criminalize conversion therapy-related conduct in Canada;
- Conducting a systematic review of the scientific evidence that informed the U=U movement and facilitated Canada's endorsement of the campaign, to directly improve the lives of people living with HIV and reduce associated stigmas; and
- Investing in research to address potentially stigmatizing policies. This research contributed to the approval for reducing the deferral period for blood donation for gay, bisexual and other men who have sex with men from one year to three months, a change implemented in June 2019. More research is ongoing to contribute evidence for a future submission by Canadian Blood Services (CBS) to Health Canada. CBS' aim is to use behaviour-based screening for all donors, regardless of gender or sexuality.
- Contributed to efforts to address substance use-related stigmas by:
- Publishing a primer on effective interventions for addressing substance use-related stigmas in the health system, as well as a communications resource on compassionate, non-stigmatizing language on substance use-related topics;
- Expanding the "Know More" tour, which engaged teens and young adults from over 140 high schools and 30 post-secondary schools in 2019 to increase their knowledge of the opioid crisis;
- Developing Preventing Substance-Related Harms among Youth through a Comprehensive School Health Approach: A Blueprint for Action for school communities;
- Investing in community organizations working to reduce substance use-related stigmas and discrimination among health and social systems as well as within communities through the Harm Reduction Fund and the Pathways to Care Program. For example, funding supported AIDS New Brunswick to build service provider capacity in Fredericton to address health issues affecting people who use drugs, in which 85% of participants reported implementing some degree of practices aimed at reducing STBBI-related stigmas in their health and social services; and
- Co-hosting an international technical consultation with the United Nations Office on Drugs and Crime to encourage a public health, rather than punitive, approach to substance use at the global level, and to promote understanding of how stigma negatively affects people who use drugs and substances and creates barriers in implementing and assessing stigma-related interventions.
Priority #3: Community innovation – putting a priority on prevention
The Government of Canada's long-standing support for the community-based response to STBBI is strongly rooted in evidence that frontline organizations are best able to bring awareness to issues, identify solutions most appropriate for local contexts and cultures, increase community capacity, and mobilize for collective impact. To foster a community-led response to STBBI, the Government of Canada:
- Supported communities to design and implement evidence-based front-line projects to prevent new and reoccurring infections, through:
- The LGBTQ2 Community Capacity Fund, a $20 million investment to strengthen the capacity of LGBTQ2 organizations to put them on solid footing so they can continue their critical work in advocating and providing services that improve social, health, and economic outcomes in LGBTQ2 communities; and
- The HIV and Hepatitis C Community Action Fund (CAF), a $26.4 million annual investment that supported 86 projects led by 124 organizations, including:
- The Advance Pan-Canadian Community Alliance, aimed at increasing access to and uptake of health services by gay, bisexual, transgender, Two-Spirit and queer men across Canada; and
- The Dr. Peter AIDS Foundation, which supported capacity-development activities for community organizations and service providers across Canada to operationalize supervised injection services and reduce STBBI transmission.
- Reached over 35,000 people through the Harm Reduction Fund, which aims to reduce HIV and hepatitis C among people who use and share inhalation or injection drug-use equipment:
- Projects funded through the Harm Reduction Fund were reviewed by a committee comprised predominantly of people with lived experience and have reached diverse groups, including LGBTQ2+ and Indigenous communities, health professionals and peer educators; and
- An initial assessment of the Harm Reduction Fund found that 80% of targets set out in project objectives are being met, nearly met or have been exceeded.
- Reduced administrative burdens for supervised consumption site applications and Health Canada increased Departmental support for applicants and operators across Canada. Since 2017, the number of federally approved supervised consumption sites has grown from 1 to 38, which have received close to 2.9 million visits, reversed some 27,000 overdoses without a single death, and provided almost 120,000 referrals to health and social services.
- Facilitated public health webinars that have reached over 1,500 public health professionals across Canada to support knowledge sharing and capacity-building on a range of STBBI-related topics, including promoting safer sex practices, building organizational capacity to provide supervised consumption services, and improving knowledge of STBBI epidemiology in Canada. Nearly all participants (95%) reported the webinar content was useful for their work.
Priority #4: Reaching the undiagnosed – increasing access to STBBI testing
Diagnosis is the gateway to STBBI treatment, care and support as it enables individuals to be directed to information or programming to prevent future infections or onward transmission. To improve access to STBBI testing for Canadians, the Government of Canada:
- Facilitated the availability of new testing technologies on the Canadian market by:
- Working directly with manufacturers to guide them through the application process and holding pre-submission meetings to clarify the requirements expected to be fulfilled;
- Allowing health care professionals to access unlicensed medical devices, including an HIV self-test and rapid tests for syphilis, before they received regulatory approval, thus improving overall patient care related to STBBI; and
- Developing protocols, evaluating STBBI point-of-care testing options, and validating new, innovative diagnostic STBBI methods to contribute to global leadership and acceptance of novel testing technologies.
- Facilitated a national-level discussion among over 100 representatives from different sectors, levels of government, and First Nations, Inuit and Métis organizations to explore the rapidly evolving STBBI testing landscape, gain understanding of research supporting the introduction of new STBBI testing modalities, and identify opportunities, challenges and scenarios that could support the rollout of these testing technologies onto the Canadian market.
- Supported efforts to address gaps in STBBI testing, reaching the undiagnosed, and linkages to care by providing $6 million of funding over five years to the Centre for REACH 3.0—a national hub for intervention research, participatory evaluation, and applied program science. Through this funding, a number of implementation science trials were launched, including projects to facilitate HIV self-testing approval in Canada, STBBI point-of-care testing, and other testing options for STBBI.
- Developed and disseminated a factsheet titled "Responding to syphilis in Canada", highlighting best practices for health care providers to improve their comfort with discussing STBBI and normalize the offering of STBBI screening and testing. As stigma poses a major barrier in seeking STBBI screening and testing services, normalizing the offering of STBBI testing can address associated stigmas, mitigate such barriers, and facilitate testing access.
- Facilitated 15 community-led STBBI training events and 34 testing events in 7 provinces to support northern, remote and isolated communities and other hard-to-reach populations to take ownership of their own responses to STBBI education and health services. A total of 2,593 dried blood spot specimens were collected and used for 7,266 screening tests and 774 viral load tests.
Priority #5: Providing prevention, treatment and care to populations that receive health services or coverage of health care benefits from the federal government
The Government of Canada plays an important role in funding and providing a range of health services or coverage of health care benefits for several populations, including registered First Nations and eligible Inuit, serving members of the Canadian Armed Forces, individuals incarcerated in federal correctional facilities, and certain immigrant populations. To improve the provision and support of STBBI prevention, testing, and treatment, the Government of Canada:
- Increased access to new, highly effective medications (called direct-acting antivirals) for the treatment of chronic hepatitis C for First Nations and Inuit people via the Non-Insured Health Benefits program, along with other public drug plans across Canada. The number of clients receiving these medications for the treatment of chronic hepatitis C increased substantially, by 26.0% from 2015/16, 148.1% from 2016/17, and an additional 14.8% from 2017/18 to 2018/19, with a slight decrease of 2.8% from 2018/19 and 2019/20.
- Initiated an affirmative treatment approach that resulted in a significant increase in the number of people incarcerated in federal correctional facilities who were living with hepatitis C infection beginning treatment, thus contributing to a substantial decline of 75% in the hepatitis C prevalence rate among federally incarcerated individuals: from 18% in 2014 to approximately 4.6% in 2018.
- Updated immigration policies in 2018 to increase the excessive demand cost threshold, which in 2020, was set at $106,020 over 5 years (or $21,204 per year). By tripling the cost threshold, many applicants with conditions that primarily require publicly funded prescription drugs (for example, HIV), would likely become admissible to Canada, as the cost of most of these medications would not typically exceed the new cost threshold.
- Developed a sexual health survey for serving Canadian Armed Forces recruits. The majority of recruits reported that they were not engaging in risky sexual behaviors; however, the study provides a better understanding of how risk propensity can contribute to risky sexual practices, which will inform the Canadian Armed Forces health promotion/education programs.
- Amended the Patented Medicines Regulations to better protect Canadians from excessive prices of patented medicines and improve the affordability of prescription drugs, and to provide Canada's regulator (the Patented Medicine Prices Review Board) with new tools and information. These changes are expected to save public, private and out-of-pocket payers billions over the next decade.
Priority #6: Leveraging existing knowledge and targeting future research
Research is critical for creating new STBBI knowledge that can inform the development and implementation of innovative public health interventions, including STBBI guidance, policy and programming. To ensure public health guidance for STBBI is reflective of constantly evolving research and evidence, the Government of Canada:
- Increased access to user-friendly and updated information for public health professionals to inform patient-centred care approaches through the development and dissemination for new STBBI modules.
- Conducted a needs assessment and identified opportunities to improve the Canadian Guidelines on Sexually Transmitted Infections, leading to the inclusion of culturally appropriate and gender-inclusive language, as well as updates to the structure and layout of the mobile application and web content, which has been downloaded over 26,000 times.
- Updated the Canadian Immunization Guide to ensure hepatitis B and human papillomavirus information was current and accessible for healthcare professionals.
- Engaged over 300 members of the STBBI community to support the development of the Canadian Institutes of Health Research's next five-year Strategic Plan for the HIV/AIDS and STBBI Research Initiative. Community stakeholders provided important input on STBBI research priorities, including advancing health equity and where Canada's research efforts should be directed to accelerate prevention, diagnosis and treatment of STBBI with the aim of reducing the health impacts of these infections in Canada and globally.
- Invested in research to support projects focused on generating and disseminating new knowledge to reduce the incidence and burden of STBBI, especially in key populations; as well as develop the next generation of STBBI researchers via:
- Dedicated funding of $2 million to support community-based research, which included funding for Indigenous community-based research that promotes collaborative capacity-building initiatives relevant to communities affected by STBBI;
- A new strategic initiative to increase the uptake and delivery of the human papilloma virus vaccine to prevent infections and eliminate cervical cancer in Canada; and
- Research to explore the efficacy of HIV pre-exposure prophylaxis (PREP) in preventing HIV and other sexually transmitted infections among gay, bisexual and other men who have sex with men to build the evidence base on the successes and challenges of scaling up publicly-funded prep.
Priority #7: Measuring impact – monitoring and reporting on trends and results
Robust data enables the measurement of progress against the priorities of the Government of Canada Five-Year Action Plan on STBBI. To support regular assessment and public reporting on progress and outcomes, the Government of Canada:
- Began work on the development of domestic STBBI targets and indicators, in collaboration with provincial and territorial public health authorities and other government departments, to map out Canada's progress towards meeting global STBBI targets.
- Coordinated bio-behavioural surveys in 14 sites across Canada (2017-2019) among people who inject drugs to generate public health evidence that can be used to support targeted interventions and activities for this population.
- Participated in the largest, global online survey of gay, bisexual and other men who have sex with men, called the European Men-who-have-sex-with-men Internet Survey (EMIS), with results available in the November 2019 issue of the Canada Communicable Disease Report.
- Worked to improve Canada's national STBBI surveillance systems, which included:
- Expanding surveillance of antimicrobial resistant gonorrhea through the Enhanced Surveillance of Antimicrobial-Resistant Gonorrhea program to include Northwest Territories in addition to the other participating provinces (Nova Scotia, Manitoba and Alberta);
- Improving hepatitis C case-based surveillance to include the monitoring of new diagnoses, initiating revisions to the national hepatitis C case definition, ensuring acute or recent infections are properly classified, and ensuring consistent reporting of hepatitis C cases across the country; and
- Building understanding of HIV transmission and risk of infection by ensuring that the reporting of people who were diagnosed with HIV in another province or country are included in a separate surveillance category, as well as adding new data elements, such as data related to race/ethnicity and CD4 count, which can be used to gauge the robustness of the immune system of a person living with HIV.
- For the first time, collected valuable and nationally-representative information on the experiences of gender-based violence, a contributor to STBBI vulnerability, among transgender and gender diverse persons in Canada;
- Significantly enhanced public health responses to and reporting of infectious syphilis and congenital syphilis cases by:
- Establishing a federal/provincial/territorial committee to provide a forum for national discussion and collaborative work across jurisdictions on syphilis;
- Developing a timely national epidemiological picture of syphilis in Canada;
- Providing approximately $400,000 over two years to support work by the HIV Network of Edmonton Society, OUTSaskatchewan, and the Sexual Health Centre of Saskatoon to reduce the impact and occurrence of syphilis, particularly among women to reduce cases of congenital syphilis;
- Developing and disseminating surveillance products focused on syphilis and sexually transmitted infections, including an infographic, a sexually transmitted infections surveillance report for 2017, a factsheet for healthcare providers, as well as 20,000 copies of a factsheet on the prevention of syphilis, which was disseminated through 431 community-based organizations providing prenatal support to women across Canada; and
- Supporting First Nation communities experiencing syphilis outbreaks by increasing funding to promote nursing capacity at all levels of service in order to increase access to testing, awareness, and prevention, as well as to support intensified case and contact follow-up.
With the release of the Government of Canada Five-Year Action Plan on STBBI in 2019, the federal government committed to a set of seven priorities and actions to enhance its response to STBBI. This is the first Progress Report highlighting key activities undertaken to achieve federal commitments made in the Action Plan.
The ultimate aim of the Action Plan is to improve the life of Canadians by accelerating the Government of Canada's efforts to meet the global STBBI targets, and in doing so, support progress towards the three strategic objectives of the Pan-Canadian STBBI Framework for Action: 1) to reduce the incidence of STBBI in Canada; 2) to improve access to testing, treatment, and ongoing care and support; and, 3) to reduce stigma and discrimination that create vulnerabilities to STBBI.
We have made great strides in addressing the health impacts of STBBI in Canada and progressing towards the new 2025 HIV testing and treatment targets in Canada (called the 95-95-95 targets). We will continue to build on our efforts by expanding options for STBBI testing, promoting the availability of effective and curative treatment, including for those living with chronic hepatitis C in Canada, and continuing to develop and implement targeted approaches to address the rising rates of syphilis, chlamydia and gonorrhea, including the alarming increases in congenital syphilis cases being reported across Canada.
The ongoing, collaborative efforts of the ten federal departments that have jointly committed to the priorities in the Action Plan are critical to contributing to STBBI prevention, improving equitable access to testing, treatment and care, and reducing the adverse impacts of STBBI-associated stigmas and discrimination. This cannot be achieved, however, without intersectoral collaboration, which includes complementary and crucial efforts made by community-based organizations, other governments, researchers, clinicians, public health professionals, and people with lived and living experience of STBBI.
While this 2019-20 Progress Report was prepared during the first year of the global COVID-19 pandemic, it does not reflect its unfolding health impacts. It is therefore critically important that shared Canadian efforts to meet domestic and global STBBI objectives continue despite the challenges posed by the COVID-19 pandemic that have yet to be fully realized or understood.
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