Five-year federal action plan for sexually transmitted and blood-borne infections

Abstract

Sexually transmitted and blood-borne infections (STBBI)—which include HIV, hepatitis B and C, chlamydia, gonorrhea, syphilis and human papillomavirus—remain significant public health issues both nationally and globally. In 2018, a Pan-Canadian STBBI Framework for Action (the Framework) was released by federal, provincial and territorial governments to provide an overarching and comprehensive approach to addressing STBBI for all those involved. This includes all levels of government, First Nations, Inuit and Métis communities and leadership, frontline service providers, clinicians, public health practitioners, non-governmental organizations and researchers. The Framework includes strategic goals, guiding principles and pillars for action to address STBBI in Canada. In response, the Government of Canada released its own action plan in July 2019: Accelerating Our Response – Government of Canada Five-Year Action Plan on Sexually Transmitted and Blood-Borne Infections (the Action Plan). This document identifies seven priority areas for federal action on STBBI over the next five years: 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. The Government of Canada is currently working with provincial and territorial governments, First Nations, Inuit and Métis partners, and other stakeholders to develop STBBI indicators and targets for the Canadian context that are appropriate, feasible and measurable against the shared strategic goals of the Framework and the Action Plan. In addition, the Government of Canada has also committed to reporting annually on its progress in implementing the priority areas laid out in the Action Plan.

Introduction

Sexually transmitted and blood-borne infections (STBBI)—which include HIV, hepatitis B and C, chlamydia, gonorrhea, syphilis and human papillomavirus—remain significant public health concerns in Canada. Rates of sexually transmitted infections in Canada rose dramatically between 2008 and 2017: chlamydia rose by 39%, gonorrhea by 109% and syphilis by 167%^{Footnote 1}. Over the past several years, a number of jurisdictions have declared syphilis outbreaks, and cases of congenital syphilis have also increased^{Footnote 2Footnote 3Footnote 4}. Although HIV-related deaths and rates of reported hepatitis C cases have decreased substantially since the 1990s, new infections continue to occur^{Footnote 5Footnote 6}. Globally, there is momentum to eliminate STBBI as a public health concern, and Canada has endorsed the World Health Organization’s global targets for HIV, viral hepatitis and sexually transmitted infections. These infections share common transmission routes and risk factors, and the populations most affected or likely to be exposed often overlap.

Improving the prevention, testing, treatment and care of STBBI is complex and involves a number of actors, including all levels of government, First Nations, Inuit and Métis communities and leadership (Text box), frontline service providers, clinicians, public health practitioners, non-governmental organizations and researchers. In 2018, the Public Health Agency of Canada released a Pan-Canadian STBBI Framework for Action (hereafter called the Framework)^{Footnote 7}, which was endorsed by federal, provincial and territorial ministers of health. The Framework provides an overarching and comprehensive approach to addressing STBBI for all those involved. It identifies strategic goals, guiding principles and pillars for action spanning the STBBI continuum of care and highlights the role of enabling environments—social, cultural, physical, structural and legal conditions—that support the prevention of STBBI transmission and promote access to services. The Framework was summarized in a previous Canada Communicable Disease Report article^{Footnote 8}.

In July 2019, the Government of Canada (GoC) released its own plan outlining key federal priorities to reduce the public health impacts of STBBI in Canada and advance the work of the Framework from 2019 to 2024. This plan, entitled Accelerating Our Response: Government of Canada Five-Year Action Plan on Sexually Transmitted and Blood-Borne Infections (hereafter called the Action Plan)^{Footnote 9} takes a whole-of-government approach and involves ten federal departments whose mandates and activities address aspects of STBBI and/or who are responsible for providing prevention, treatment and care or coverage of health care benefits to specific populations.

This plan shares the strategic goals of the Framework. These goals are to 1) reduce the incidence of STBBI in Canada, 2) improve access to testing, treatment, care and support and 3) reduce the stigma and discrimination that create vulnerabilities to STBBI. The following article summarizes the Action Plan and briefly describes its seven priority areas.

Renewing the federal response to STBBI: Overview of the Action Plan

The Action Plan includes seven priority areas.

The Action Plan’s commitment to moving toward truth and reconciliation with First Nations, Inuit and Métis Peoples reflects the broader GoC commitment to reconciliation. The GoC will take an approach to STBBI policy, programs and services that address the priorities identified by First Nations, Inuit and Métis communities. Under this priority area, the GoC will support First Nations, Inuit and Métis Peoples’ priorities in relation to STBBI, improve availability and accessibility of community level data on STBBI outcomes, and invest in culturally safe and responsive initiatives for STBBI prevention, education, awareness, and ongoing care and support.

Stigma and discrimination remain key obstacles to effective STBBI prevention, care, treatment and support. Disproportionate rates of STBBI affect populations that face various types of stigma and discrimination, including sexism, racism and homophobia. Stigma and discrimination also impede access to appropriate prevention, care, treatment and support services for STBBI. The GoC will promote the important message of undetectable=untransmittable (U=U), which is based on the substantial body of scientific evidence indicating that, for people living with HIV who have achieved a sustained undetectable viral load, there is effectively no risk of sexual transmission. Under this priority area, the GoC will also work to:

• Address stigma and discrimination (including racism and sexism), gender-based violence, transphobia, biphobia and homophobia
• Equip professionals with skills to provide culturally safe and responsive services in safe environments
• Reduce the over-criminalization of HIV non-disclosure in Canada

The GoC will continue its long-standing support for community-based organizations that work to prevent STBBI with programs and interventions tailored to the particular contexts and priorities of specific communities. This includes federal grants and contributions programs including the Harm Reduction Fund^{Footnote 10} and the HIV and Hepatitis C Community Action Fund^{Footnote 11}. Under this priority area, the GoC will support frontline, community-based projects to prevent new and recurring infections, reach the undiagnosed and link them to testing, treatment and care, and support efforts to bring high impact interventions, such as HIV preexposure prophylaxis, to scale so more people can benefit from them.

Testing for STBBI enables people to access care, treatment and support, and can ultimately reduce onward transmission of infections. However, current approaches to STBBI testing are not reaching everyone who could benefit. For this reason, under this priority area, the GoC will prioritize efforts to increase access to culturally-safe and responsive testing models and expand the range of testing options available to people in Canada, including point-of-care testing, self-testing and the use of dried blood spot technology.

The GoC funds and provides health services or coverage of health care benefits for a number of specific populations, including members of the Canadian Armed Forces, certain immigrant populations, incarcerated individuals in federal correctional facilities and eligible First Nations and Inuit. Under this priority area, the GoC will ensure that eligible individuals receive effective and culturally safe and responsive prevention, including harm reduction, care and treatment services, and facilitate linkage to care for those transitioning from federal to provincial and territorial health systems.

Scientific research continues to advance and improve knowledge about STBBI, the conditions that promote vulnerability to infection, the development of new prevention and testing modalities and treatments and knowledge about the physical, mental and social impacts of living with chronic infection. Under this priority area, the GoC will invest in the following areas: research on basic, translational and clinical research; research supporting STBBI prevention, testing and diagnosis, treatment and care; and support for the development of First Nations, Inuit and Métis health research capacity.

Global targets for HIV, hepatitis and sexually transmitted infections are part of the momentum driving Canada’s efforts to reduce the health impacts of STBBI. However, global targets are not sufficient to unify efforts, drive change and measure Canada’s progress. Under this priority area, the GoC will lead a process to develop indicators and targets for STBBI that are appropriate for the Canadian context. It will also prioritize efforts to strengthen Canada’s STBBI surveillance system to ensure that the GoC has the data that is needed to focus efforts and monitor trends and changes over time. In addition, the GoC has committed to reporting on the results from this Action Plan on an annual basis.

Conclusion and next steps

The Action Plan outlines the seven priority areas for federal efforts to implement the Framework and support Canada’s contribution to meeting the global targets for HIV, hepatitis and sexually transmitted infections by 2030 (Table 1). The GoC is currently working with provincial and territorial governments, First Nations, Inuit and Métis partners, and other stakeholders to develop STBBI indicators and targets within the Canadian context that are appropriate, feasible and measurable. This work will include a community consultation process over the coming months. The GoC has also committed to reporting annually on its progress in implementing the priority areas laid out in the Action Plan. Full implementation of the Framework, however, will require the ongoing and unified efforts of governments, stakeholders and affected communities to ensure that culturally- safe and responsive STBBI prevention, testing, care, treatment and support are available to those who need it.

Table 1: Global Targets for Sexually Transmitted and Blood-Borne Infections (STBBI)

STBBI	Target year	Global targets
HIV	2020	90% of people living with HIV know their status 90% of people living with HIV who know their status are receiving treatment 90% of people on treatment have suppressed viral loads Fewer than 500,000 new HIV infections Elimination of HIV-related discrimination
	2030	Zero new HIV infections Zero AIDS-related deaths Zero discrimination
Hepatitis	2020	30% reduction in new cases of chronic viral hepatitis B and C infections 10% reduction in hepatitis B and C deaths 30% of viral hepatitis B and C infections are diagnosed Five million people receiving hepatitis B treatment, and three million people receiving hepatitis C treatment Achieve and maintain up-to-date 90% coverage for vaccination of hepatitis B vaccine (three doses)
	2030	90% reduction in new cases of chronic viral hepatitis B and C infections 65% reduction in hepatitis B and C deaths 90% of viral hepatitis B and C infections are diagnosed 80% of eligible people receiving hepatitis B and C treatment
Sexually transmitted infections	2030	90% reduction of syphilis incidence globally 90% reduction in gonorrhea incidence globally 50 or fewer cases of congenital syphilis per 100,000 live births in 80% of countries Sustain 90% national coverage and at least 80% in every district (or equivalent administrative unit) in countries with the human papillomavirus vaccine in their national immunization programme

The success of these efforts lies in partnerships. The GoC is committed to implementing the Truth and Reconciliation Commission’s Calls to Action^{Footnote 12} and will continue to engage closely with First Nations, Inuit and Métis communities and leadership. The GoC is also committed to continuing to work with people with lived experience as programs and policies are developed. In addition, the GoC’s collaborative work with provinces, territories and community-based organizations remains critical to achieving the shared strategic goals for STBBI. With the Action Plan, the federal government will continue to drive progress on HIV, viral hepatitis and sexually transmitted infections within the context of the Framework.

Authors’ statement

• CJ — Writing and editing
• GT — Writing and editing

Conflict of interest

None.

Acknowledgements

The Public Health Agency of Canada would like to thank all those who contributed their time and expertise to the development of the Action Plan.