A current record of standing for ACT on issues impacting the health and well-being of people living with HIV and AIDS and those at increased risk of HIV.
ACT position statements
Below are ACT’s position statements. These tackle a single issue and articulates ACT’s viewpoint around it. Position papers exist around issues that impacts and/or is related to the agency’s programs, services, strategic goals, mandate and/or mission.
A growing body of evidence demonstrates that people living with HIV who are able to attain and maintain an undetectable viral load will not pass the virus on during sex, regardless of whether condoms were used. Given this breakthrough, ACT is confident in the use of effective HIV treatment as a reliable form of HIV prevention.
ACT’s position rests upon evidence from two scientifically and statistically sound, large-scale research studies. Together, they have demonstrated the effectiveness of HIV treatment and undetectable viral loads at preventing HIV transmission.
The HPTN 052 study first reported interim results in 2011 and final results in 2015.1HPTN 052 compared the rates of HIV transmission between serodiscordant (mixed HIV status) couples. In one group, the HIV-positive partner waited to start HIV treatment after being diagnosed. In the other group, the HIV-positive partner began HIV treatment upon learning of their diagnosis.
Takeaways from HPTN 052:
- beginning HIV treatment upon learning of a diagnosis reduced the risk of onwards transmission by 96% compared to people who were HIV-positive but not on treatment
- the study was interested in the effects of antiretroviral treatment more broadly on HIV transmission risk, not just people who attained an undetectable viral load
- the study looked only at heterosexual transmission risk; it did not investigate HIV transmission risk through anal sex among serodiscordant (mixed HIV status) MSM couples (men who have sex with men)
The PARTNER study reported interim results in 2014 and published final results in 2016.2 PARTNER looked at the risk of HIV transmission when a person’s viral load had been rendered undetectable. The criteria used to qualify as undetectable was a viral load below 200 copies/ml of blood.3 Participants included serodiscordant heterosexual and MSM couples having condomless anal and vaginal sex. With a combined but approximate 58,000 sex acts reported, there was no linked HIV transmission between couples.
Takeaways from PARTNER:
- effective HIV treatment lowers the viral load in many people living with HIV to undetectable levels, and an undetectable viral load renders the risk of transmitting HIV to effectively zero
- some participants were removed from the study because their viral load ceased to be undetectable and did not return to being undetectable
- some participants’ viral load briefly rose but then returned to undetectable levels. They were kept in the study and did not transmit HIV despite a temporary rise in their viral load4
- the presence of an STI did not impact the risk of transmission for a person living with HIV when accompanied by an undetectable viral load5
What These Results Mean:
The results of these studies attest to the truth and power of treatment as prevention. A Canadian-born strategy, it improves the health of people living with HIV, reduces the stigma surrounding HIV, and dramatically reduces the risk of HIV transmission.6 This new research should be embraced and celebrated. It should also serve as further motivation to ensure all people living with HIV in Canada and around the world have access to HIV treatment and the supports to remain adherent.
The results of these studies are definitive but that does not mean there are not considerations. The authors of the PARTNER study report a 95% confidence limit to its data and explain that “with eligible couple-years accrued so far, appreciable levels of risk cannot be excluded, particularly for anal sex and when considered from the perspective of a cumulative risk over several years.”7 If concerned about STIs or pregnancy, an undetectable viral load is not applicable and other safer sex methods should be used.
ACT also recognizes that for some people living with HIV, attaining and maintaining an undetectable viral load may not be possible. Reasons for this are complex and relate to both treatment access, treatment effectiveness and personal health challenges. As a result, we understand the benefits of an undetectable viral load to be absolute but further work is required to extend the benefits to as many people living with HIV as possible. While HIV treatment will not always yield an undetectable viral load, it can consistently lower viral loads and generate a host of benefits to the overall health and well-being of people living with HIV.
ACT is dedicated to strengthening the health and well-being of the communities it works with, and recognizes its role in communicating the benefits and limitations of emerging HIV treatment and prevention technologies. We will continue our tradition of challenging HIV-related stigma and commit to achieving our vision of a Toronto with zero AIDS-related deaths and zero new HIV infections. Treatment as prevention and undetectable viral loads are crucial to securing this optimistic future.
1. Cohen MS; Chen YQ; McCauley M; et al. (August 2011). "Prevention of HIV-1 infection with early antiretroviral therapy". N. Engl. J. Med. 365 (6): 493–505.
2. Rodger AJ, Cambiano V, Bruun T, et al. Sexual Activity Without Condoms and Risk of HIV Transmission in Serodifferent Couples When the HIV-Positive Partner Is Using Suppressive Antiretroviral Therapy. JAMA. 2016;316(2):171-181.
3. This is a significantly higher threshold than in Canada, which defined undetectable as a viral load below 50 copies/ml of blood.
4. Rodger, Cambiano, Bruun et al, “Sexual Activity Without Condoms,” 177.
5. Rodger, Cambiano, Bruun et al, “Sexual Activity Without Condoms,” 179.
6. Montaner JS, Hogg R, Wood E, Kerr T, Tyndall M, Levy AR, Harrigan PR. The case for expanding access to highly active antiretroviral therapy to curb the growth of the HIV epidemic. Lancet. 2006 Aug 5; 368(9534):531-6.
7. Rodger, Cambiano, Bruun et al, “Sexual Activity Without Condoms,” 179.
Introduction to issue:
People who inject drugs are more vulnerable of acquiring hepatitis C and HIV. In Toronto, people who inject drugs have also been dying from overdoses at an increasing rate. Distributing unused injection drug gear and establishing integrated supervised injection services are effective public health tools for reducing the spread of HIV and hepatitis C, and preventing unnecessary deaths from overdoses. For these reasons, ACT fully supports Toronto establishing comprehensive harm reduction services that protect people who inject drugs and affirms their right to healthcare services.
Background + context:
In 1989, and in the face of ardent opposition from the police, Toronto Public Health began offering unused injection drug gear as part of a new needle distribution program called the Works. The program was initially set up in direct response to high rates of HIV and AIDS among people who inject drugs.
Toronto Public Health’s needle exchange program has since expanded to cover many areas of the city and has been highly effective at preventing HIV from spreading. It has been found that the prevalence of HIV among people who inject drugs is approximately 3%, one of the lowest among major North American cities. However, upwards of 70% of people who inject drugs in Toronto were living with hepatitis C.1
In 2012, St. Michael’s Hospital and the University of Toronto published the results of a feasibility study into supervised consumption sites in Toronto. The authors recommended that Toronto “would benefit from implementation of supervised injection facilities” and that “the optimal model” for such sites are a “fixed facility that is integrated within an existing organization.”2
Between 2004 and 2013 (the most recent figures available), deaths resulting from overdoses increased by 41%, 146 to 206. When looking specifically at deaths from accidental overdose, the numbers have jumped by more than 80%, going from 82 in 2004 to 149 fatalities in 2013. The reasons for such a rise are understood to be an increase in the prevalence of narcotics such as fentanyl and heroine. This increase has not been met with an increased awareness regarding the risks of using specifically fentanyl.
In response to an explosion in the reported number of overdose deaths over the past several years, in March, 2016, the City of Toronto indicated that it was moving forward with the process by which three supervised injection sites would open. Located at the Works building, South Riverdale and Queen West Community Health Centres, the three sites would provide a much needed, overdue, and crucial intervention into protecting the health of people who inject drugs.
The applications are backed by Toronto’s chief medical officer of health, Dr. David McKeown, but first require approval by city council before going through an onerous application process to qualify for a federal exemption. Although the current federal government has indicated it will not reject applications for anything outside of merit, there exists a clear need for the federal government of Canada to pass legislation that protects the rights of people who use drugs to safety and healthcare. Rather than rely on ad hoc decisions, leadership in this area is needed to fully legalize and protect comprehensive harm reduction measures in Canada.
ACT supports equitable access to life-saving health services for all people living with and affected by HIV and AIDS, including people who inject drugs. We acknowledge that some people who inject may not be ready, willing or able to begin treatment to reduce their use. For this, we encourage all proposed and future supervised injection sites to offer a range of supports to help care for people who use drugs who struggle with addiction, HIV and AIDS, hepatitis C, mental health challenges, and other physical sickness.
ACT believes in the benefit of comprehensive harm reduction strategies for all groups living at increased risk for HIV and hepatitis C, including safer sex tools, safer injection drug gear distribution and safe injection sites.
This paper was originally published in October, 2012. To ensure its accuracy, updates have been made as new data surrounding the efficacy of and access to PrEP emerge.
The AIDS Committee of Toronto (ACT) supports the introduction of innovative strategies that help to reduce the transmission of HIV, including Pre-Exposure Prophylaxis (PrEP).
ACT believes that PrEP should be a part of a comprehensive approach to HIV prevention that includes access to condoms and lubricants, risk reduction counselling, information provision, the scale-up of social and behavioural interventions, access to regular and voluntary HIV and STI testing, community development activities, as well as the development of other biomedical interventions such as mircobicides.
While PrEP is not licensed for use in Canada as an HIV prevention method, it is being prescribed "off label" for these purposes. ACT encourages the implementation of PrEP in Canada and welcomes further research to inform individuals, communities and health care providers regarding its use as an HIV prevention technique. ACT is concerned about the costs associated with accessing PrEP off-label in Canada and encourages its coverage under both private and public drug plans.
In July 2012, the US Food and Drug Administration (FDA) approved the licensing of the anti-HIV medication Truvada for PrEP, and have developed guidelines for PrEP eligibility and implementation1. Truvada’s safety and efficacy for PrEP were demonstrated in two large, randomized, double-blind, placebo-controlled clinical trials: The iPrEx trial evaluated Truvada in 2,499 HIV-negative gay men or transgender women who have sex with men with evidence of high risk behaviour for HIV infection, such as inconsistent or no condom use during sex with a partner of positive or unknown HIV status, a high number of sex partners, and exchange of sex for commodities. Results showed Truvada was effective in reducing the risk of HIV infection by 44 percent compared with placebo in this population. Efficacy was strongly correlated with drug adherence in this trial: in a sub-study that measured Truvada drug levels in participants, comparing those with drug measured in their blood (i.e. those that were adherent with their medications) to those with no drug measured in their blood (i.e. those that were non-adherent), the effectiveness of reducing the risk of HIV infection rose to 92 percent.
The Partners PrEP trial was conducted in 4,758 heterosexual couples where one partner was living with HIV and the other was not (serodiscordant couples). The trial evaluated the efficacy and safety of Truvada and Tenofovir versus placebo in preventing HIV infection in the uninfected male or female partner. Results showed Truvada reduced the risk of becoming infected by 75 percent compared with placebo.
As these large-scale trials continue to develop, the efficacy of PrEP, when taken daily, is being shown to reduce the transmission of HIV by over 90% and as high as 99%.
PrEP was also endorsed by the World Health Organization (WHO) for use among men who have sex with men that may be at higher risk for HIV infection in July 2014 2.
According to the FDA, “Truvada for PrEP is meant to be used as part of a comprehensive HIV prevention plan that includes the following:
- HIV risk reduction counselling
- consistent and correct use of condoms
- regular HIV testing (at least every three months)
- screening and treatment for sexually transmitted infections (STIs)."
Truvada will not prevent the transmission of other STIs including syphilis, gonorrhea and chlamydia. Some STIs increase the likelihood of HIV infection. Regular STI testing and treatment is therefore integral to the use of PrEP.
When used as PrEP, Truvada should be taken every day in people who are confirmed to be HIV negative. The FDA warns that when used as PrEP, Truvada must not be prescribed to patients whose HIV status is ‘unknown’ (ie. they have not been tested for HIV) or who are HIV-positive (as this could lead to the development of drug resistance as Truvada is always prescribed in combination with other anti-HIV medications for those who are HIV-positive). The FDA encourages physicians to test their patients who use PrEP for HIV at least every three months.
Truvada is not approved in Canada or other countries for use as PrEP; it is however, approved for HIV treatment and is therefore available with a prescription. Truvada manufacturer Gilead Sciences has yet to seek approval for Truvada as PrEP in Canada, Western Europe and Australia. In Canada, a month’s supply of Truvada (for HIV treatment) costs between $800 - $1,100 per month.
Concerns exists as to whether public and private drug plans in the US will cover the costs associated with Truvada as PrEP, thus reducing access to PrEP for those who might benefit the most from it.
ACT is dedicated to strengthening the health and well-being of the communities it serves and recognizes its role in communicating the benefits and limitations of emerging HIV prevention technologies. ACT is optimistic about the implementation of PrEP in Canada, but is concerned about the costs associated with accessing PrEP off-label in Canada. To that end, we encourage its coverage under both private and public drug plans, and support efforts to achieve such access.
1 Interim Guidance: Preexposure Prophylaxis for the Prevention of HIV Infection in Men Who Have Sex with Men:
2. WHO: People most at risk of HIV are not getting the health services they need
Post-exposure prophylaxis (PEP) is a four-week daily dose of anti-HIV medications in pill form that can possibly stop HIV infection if taken within 72 hours of potential exposure. (ii, iii, iv, v, vi)
In Ontario, access to PEP is subject to a healthcare provider’s discretion. It can be argued that people who are exposed in the workplace to body fluids that may contain HIV (e.g. a healthcare worker who accidentally suffers a needle-stick injury) or in emergency circumstances, such as a sexual assault, elicits one response, while those people whose exposure to HIV is through unprotected sex, a condom break during sex or shared needles elicits another. ACT believes that PEP be prescribed to individuals regardless of method of exposure.
Barriers to accessing PEP include incorrect assessments, the cost of PEP medication and a lack of information regarding prioritization or awareness of PEP among health care providers. These barriers can reduce the timeliness in which people receive treatment or the prescription of anti-HIV medications with difficult side effects.
It is estimated that 646 people were infected with HIV in Toronto in 2012. Each HIV infection prevented in Canada is estimated to save our health care system between $242,686 and $376,785.(vii)
While PEP is offered free of charge in a sexual assault situation and in many occupational exposure situations, the cost of a month’s supply of PEP for an individual in Ontario can cost between $900 - $1300 depending on the medications prescribed and requires private health insurance to cover it.(viii)
ACT believes money should not be a barrier for an individual’s access to PEP and that a provincial standard of care for non-occupational PEP is long overdue.
This disparity between Ontario and other provinces and jurisdictions’ standards leaves Ontarians at a greater risk of a potentially preventable disease.
It is imperative that the government of Ontario extend treatment coverage of PEP to all Ontarians and establish provincial standards of care for all types of HIV exposures; and to ensure that all health care providers are informed and equipped to provide service to people who have been potentially exposed to HIV in a timely and respectful manner.
After potential exposure to HIV in the workplace and in sexual assault circumstances the cost of PEP is covered through Ontario’s health care system. ACT believes that other circumstances of exposure such as consensual sex or drug use also merits the same, consistent coverage.
Affordability, stigma and a lack of access should not be a detriment to an individual accessing medication. ACT believes that prevention is a more sustainable and considerate allocation of resources than a lifetime of treatment.
ACT believes that all Ontarians deserve access to PEP if they have been exposed to HIV, regardless of method of exposure. People who are at risk in community settings (i.e. human bites, accidental contact through discarded needles, or those that result from consensual sex or sharing of injection equipment) should be eligible for coverage. The current two-tier approach adopted by the Ministry of Health and Long-Term Care discriminates against those who have had sexual exposure. Moral judgements about people who engage in sex have no place dictating public health policy.
There is currently no standard of care for non-occupational exposure in Ontario. The decision to provide PEP lies with the healthcare provider and is made on a case-by-case basis. Many healthcare providers in Ontario are unaware of non-occupational PEP, are not trained to provide PEP, or may be unwilling to prescribe it. This means that people may be assessed differently, kept waiting longer, or prescribed older anti-HIV drugs with more severe side effects that impact people’s ability to adhere to the treatment.
PEP for non-occupational exposures is an accepted clinical practice in many jurisdictions. In Canada, Alberta, Quebec, Manitoba, Saskatchewan, Prince Edward Island and British Columbia have standard of care protocols in place. Internationally, the US, UK, Australia, Netherlands, France, Switzerland, Spain and Denmark, among others have protocols.
The present funding position of the Ministry of Health and Long-Term Care represents a contradiction. The science and efficacy of PEP treatment is not in question. We know that it works and the government recognizes this by providing access and coverage for occupational and sexual assault exposure. ACT believes coverage of PEP should be provided as part of a comprehensive HIV prevention strategy.
i. CDC. 2005. Antiretroviral Post-Exposure Prophylaxis After Sexual, Injection-Drug Use, or Other Non-occupational Exposure to HIV in the United States: Recommendations from the U.S. Department of Health and Human Services. MMWR. 54(RR-2): 1-20
ii. Tsai CC, Emau P, Follis KE, Beck TW, Benveniste RE, Bischofeberger N, Lifson JD, Morton WR. 1998. Effectiveness of postinoculation (R)-9-(2-phosphonylmethoxypropyl) adenine treatment for prevention of persistent simian immunodeficiency virus SIVmne infection depends critically on timing of initiation and duration of treatment. Journal of Virology. 72: 4265–73.
iii. Otten RA, Smith DK, Adams DR, Pullium JK, Jackson E, Kim CN, Jaffe H, Janssen R, Butera S, Folks TM. 2000. Efficacy of postexposure prophylaxis after intravaginal exposure of pig-tailed macaques to a human-derived retrovirus (human immunodeficiency virus type 2). Journal of Virology. 74: 9771–5.
iv. Cardo DM, Culver DH, Ciesielski CA, Srivastava PU, Marcus R, Abiteboul D, Heptonstall J, Ippolito G, Lot F, McKibben PS, Bell DM. 1997. A casecontrol study of HIV seroconversion in health care workers after percutaneous exposure. New England Journal of Medicine. 337(21): 1485-90.
v. Tsai CC, Emau P, Follis KE, Beck TW, Benveniste RE, Bischofeberger N, Lifson JD, Morton WR. 1998. Effectiveness of postinoculation (R)-9-(2-phosphonylmethoxypropyl) adenine treatment for prevention of persistent simian immunodeficiency virus SIVmne infection depends critically on timing of initiation and duration of treatment. Journal of Virology. 72: 4265–73.
vi. Otten RA, Smith DK, Adams DR, Pullium JK, Jackson E, Kim CN, Jaffe H, Janssen R, Butera S, Folks TM. 2000. Efficacy of post-exposure prophylaxis after intravaginal exposure of pig-tailed macaques to a human-derived retrovirus (human immunodeficiency virus type 2). Journal of Virology. 74: 9771–5.
vii. Toronto Public Health. 2012. Sexually Transmitted and Bloodborne Infections: Communicable Diseases in Toronto 2012.
viii. Shoppers Drug Mart via Toronto Public Health, September 16, 2013.
On October 24, 2012, the Commission for the Review of Social Assistance in Ontario released its final report and recommendations.
In the past year since the release of the report, several of its recommendations made have been implemented, including:
- Creating a $200 monthly earning exemption for people who receive benefits from Ontario Works (OW) and Ontario Disability Support Program (ODSP).
- Improving financial independence for OW clients by increasing the amount of assets they are able to keep before they can get help, such as a car they may need for employment.
- Encouraging businesses to improve job opportunities for people with disabilities by establishing a Partnership Council on Employment Opportunities for People with Disabilities.1
ACT supports and commends the Government of Ontario for these positive changes to social assistance and welcomes the implementation of any recommendations that will improve the lives of people on social assistance and improve models of service delivery.
How will proposed and recent changes to social assistance affect people living with HIV/AIDS?
Many of ACT’s service users rely on ODSP or other forms of social assistance to meet their basic needs including housing, food, transportation and health care. A number of the reviews recommendations directly impact people Living with HIV/AIDS. ACT also receives funding for its employment services program (Employment ACTion) from the Ministry of Community and Social Services through ODSP, and any changes to the funding model will affect program and service delivery.
Of the 108 proposals made regarding social assistance in the review, ACT is taking a position on the following recommendations from the implementation priorities laid out in year one of the proposed provincial strategy.2 These are recommendations that may have a direct or indirect impact on ACT programs and services, and the well-being of ACT service users and members of the community.
Early Priorities identified in Brighter Prospects: Transforming Social Assistance in Ontario:
- Moving forward on employment for people with disabilities
We strongly encourage the Ministry to modify the eligibility requirements for ODSP Employment Supports, so that once an individual is deemed eligible for ODSP Income Support they become automatically eligible for employment supports. This will eliminate the need for employment service agencies to get additional approvals prior to assisting these individuals to find employment.
ACT also supports the Ontario Disability Education Network (ODEN) position to streamline the approval process for people who have a disability who are not in receipt of ODSP Income Supports. At the same time, people with disabilities who are not able to work should not be forced to look for work.
In addition, the government should eliminate the punitive approach to people who make mistakes in income reporting and/or other documents required by ODSP.
- Transfer ODSP delivery to municipalities
ACT does not support the downloading of social assistance, including affiliated employment service delivery, to the municipal level. There is a concern that if services are downloaded, individual municipalities may not prioritize ODSP recipients in the same way and may not dedicate the appropriate level of resources to service delivery, thereby increasing the vulnerability of this already vulnerable population. The current provincial delivery of ODSP Income and Employment Supports ensures a level playing field for delivery of services because those services are managed and delivered through one provincial body as opposed to many different municipal bodies. As the Government of Ontario is a champion of the Accessibility for Ontarians with Disabilities Act (AODA), by maintaining ODSP supports at the provincial level, the government can demonstrate its commitment to action as well as legislation.
People with disabilities (including people living with HIV/AIDS) must be viewed as a distinct group for employment services and such services must take into account the specific disability. The stigma of HIV/AIDS remains pervasive in the workplace. People living with HIV/AIDS need to have continued access to specialized employment services and supports which they need to help achieve successful employment outcomes. This requires contracting out the delivery of direct services to third party delivery agents who are specialized in providing employment services for specific disabilities.
- Implement new performance-based funding arrangements with third-party service deliverers
The current ODSP funding model for third-party service deliverers needs to include funding for service providers for intake/assessment, skills upgrading, preparing for job readiness, job placement and retention supports follow-up while recognizing the unique needs for people living with disabilities. We understand this model is currently in place for Employment Ontario and under review with ODSP.
ACT’s Employment ACTion program experiences many clients who need a second, third or more replacement jobs due to a labour market that increasingly relies on contract work or part-time work. Helping service users to find work after their initial contracts expire requires additional employment supports which are not covered under current ODSP funding model.
- Earnings exemption of $200/month
We applaud the government for taking this first step in increasing the earnings exemption, but feel it does not go far enough. We advocate for an exemption of up to $500 a month in earnings and/or to reduce the claw back on earnings from the current 50% to 25%.
People with disabilities should be provided with an incentive to find and keep work. As well, housing-geared-to-income should be taken into account when considering earning exemptions, as the majority of people on disability are also in subsidized housing.
- Examine the impact of benefit withdrawal rates on the financial incentive to work to provide a better basis on which to establish the rate of withdrawal of social assistance benefits.
In today’s labour market which relies on contract or part-time work, often without benefits, people living with HIV/AIDS engaged in employment often need continuance of these benefits if they are not provided for by the employer.
- Accelerate the implementation of the adult phase of the comprehensive mental health and addictions strategy with a focus on employment as a key outcome.
In addition to health status, some people living with HIV/AIDS often experience mental health and substance use challenges as barriers to employment and personal well being. This population needs increased supports to access high-quality services including early identification and intervention.
- Partner with corporate leaders to champion the hiring of people with disabilities
We encourage the government to support and encourage the corporate sector to hire more people with disabilities. There are many small and large businesses who have been proactive and successful in hiring and integrating people with disabilities into the workforce. These models should be explored using a business-to-business educational approach and emphasizing the AODA. Service providers, particularly service providers with an expertise in episodic disabilities, should also be consulted and included in this process.
1. News Release: “Ontario Government Helping People Find Jobs, Improve Their Financial Security”, Ministry of Community and Social Services May 22, 2013
2. Lankin, Frances and Munir Sheik, Commissioners. Brighter Prospects: Transforming Social Assistance in Ontario. A Report to the Minister of Community and Social Services, 2012. Toronto, Ontario. P124-125.
The AIDS Committee of Toronto (ACT) believes that universal access to free, voluntary HIV testing should be available to all, and that HIV testing should be accompanied with professional, in-person pre (before) and post (after) test counselling. While ACT encourages those at risk for HIV infection to access HIV testing in order to find out about their HIV status, we believe that the existing free services available through anonymous HIV testing clinics in Ontario are the best method to do so. Unlike costly at-home test kits (which are not licensed for use in Canada), Ontario’s HIV testing clinic staff are able to provide one-on-one, in person pre and post test counselling, sexual health information, links to medical care and referrals to community supports for those who test HIV-positive. Furthermore, with the expansion of ‘rapid’, point-of-care HIV testing in Ontario, those who want to receive their HIV test results are able to do so within minutes.
The United States’ Food and Drug Administration (FDA) has approved The OraQuick In-Home HIV Test. This self administered testing kit is used to detect the presence of antibodies found in the Human Immunodeficiency Virus type one (HIV-1) and type two (HIV-2). It is important to note that Health Canada has not authorized HIV kits for home use in Canada.1 ACT is concerned that at-home testing does not allow for appropriate pre test counselling, post test counselling, education about HIV transmission, nor does it provide immediate support and referrals for those who test HIV-positive. Not having those resources available in person, at the time of receiving a test result, can cause emotional and psychological distress and could result in those who test positive for HIV not being linked to proper care and support.
ACT is also concerned about the price of at-home test kits, which sell for approximately $30.00 (USD) in the United States. The cost limits access to those with limited financial resources, often those who are most vulnerable to HIV. ACT recognizes that stigma related to HIV may make it difficult for some people to seek testing services. ACT believes the expansion of anonymous HIV testing sites that provide accessible and culturally appropriate supports and referrals is the best way to encourage people to seek HIV testing regularly, as well as providing them with a clear understanding of what an HIV test is and what the results
mean. This allows individuals to achieve self-determination, informed decision-making, independence and control of their overall health and well-being.
ACT believes that criminal law is an ineffective and inappropriate tool with which to address HIV non-disclosure. HIV/AIDS is an individual and public health issue first and foremost, and should be addressed as such.
ACT opposes mandatory minimum sentencing for drug crimes.
For several years, Canada’s Parliament has debated bills on mandatory minimum sentencing, with the latest focus on drug crimes. The latest omnibus crime bill proposed by the federal government would remove judicial discretion and force courts to implement minimum sentence lengths for drug-related crimes.
Research and expertise in other jurisdictions has shown that this punitive approach is ineffective at curbing drug use or crime, is harmful to public health, hampers efforts to prevent HIV transmission, and will be unnecessarily expensive.
- Jurisdictions that have implemented mandatory minimum sentencing for drug crimes have not shown success at reducing drug use or crime. Many of these jurisdictions are now moving away from this failed approach.
- There is an HIV epidemic in Canada’s prisons, and the federal government is failing to address it. Putting more drug users in prisons – already a vulnerable group for HIV – will result in more HIV infections. The direct cost of every HIV infection in Canada is more than $370,000 over a lifetime 1.
- Forcing courts to lengthen sentences, even when unwarranted, will require a massive expansion of prisons. Canada’s Parliamentary Budget Officer has estimated that the federal government’s new crime legislation will add 4,000 prisoners to the federal system, costing the correctional system an additional $1 billion every year.
ACT opposes the excessive use of the criminal law to address public health issues, and believes that everyone – including drug users – deserves access to health care and harm reduction information and programs.
Mandatory minimum sentences restrict the ability of courts to address drug crimes properly by applying a one-size-fits-all approach to all drug use and all drug users. We encourage the federal government and Members of Parliament to join other jurisdictions in abandoning this failed approach.
1. Lima, Hogg, and Montaner, 2010. Expanding HAART Treatment to All Currently Eligible Individuals Under the 2008 IAS-USA Guidelines in British Columbia, Canada.
ACT supports expanding access to the HPV vaccine, regardless of sex or gender, to reduce transmission of the cancer-causing virus and to save long-term health care costs. Allowing males to access the vaccine for free would allow men and women to take equal responsibility for preventing HPV, and also provide protection for gay men.
This could be implemented through a combination of the following strategies:
- Expanding Ontario’s school-based HPV vaccination program to allow all students to participate, regardless of sex or gender.
- Providing the HPV vaccine for free to males, females and trans people up to the age of 26, via public health units, sexual health clinics, HIV clinics and primary care physicians.
In July 2006, Health Canada approved a new vaccine to provide protection against four types of human papillomavirus (HPV), which can cause cancer and genital warts. Due to the limited research studies available at the time, Health Canada only licensed the vaccine for use in females aged 9 to 26 years. In 2007, the Government of Ontario rolled out a free province-wide school-based vaccination program for female students.
After studies demonstrated the effectiveness of the vaccine in preventing pre-cancerous anal lesions and genital warts in men, Health Canada approved its use on males aged 9 to 26 years in February 2010. However, Ontario’s school-based HPV vaccination program has not yet been extended to male students.
HPV is of particular concern to gay, bisexual, and other men who have sex with men, who are 17 times more likely to develop anal cancer than heterosexual men. Among HIV-positive gay men, the likelihood is even higher. The HPV vaccine prevents 77.5% of pre-cursor lesions to anal cancer in gay and bisexual men. Yet gay men do not benefit from the current vaccination program, and they must pay for the vaccine out of pocket, costing each individual hundreds of dollars.
Limiting the HPV vaccine to females also limits the effectiveness of the program in a heterosexual context, by reducing the number of eligible participants. Providing the vaccine for free to all eligible males would allow everyone – regardless of their sex or gender – to share responsibility for preventing HPV.
HPV vaccination not only benefits the health of the individual and our communities, but also reduces long-term costs in the health care system by preventing illnesses. In one modeling study by the Harvard School of Public Health (The Lancet Infectious Diseases. 10(12):845-52, 2010 Dec.), vaccination of gay, bisexual and other men who have sex with men would provide a cost effectiveness ratio of up to $15,290. The study found that vaccination was cost effective for this population even up to the age of 26, pointing to the benefit of expanding free access beyond school-based programs.
The health and economic benefits of HPV vaccination demonstrate the need to eliminate barriers by expanding coverage beyond the existing school-based vaccination program.
Recent research has resulted in confusion about whether lubricants increase, reduce or have no effect on the risk of infection from HIV and other sexually transmitted infections (STIs) during anal sex.
The AIDS Committee of Toronto (ACT) continues to recommend the use of water-based or silicone-based lubricant with condoms for anal sex, and calls for more research into the effects of lube on rectal tissue.
Lubricant that is compatible for use with condoms (water-based or silicone-based) has been proven to decrease the risk of condoms breaking or slipping off. When condoms are used correctly and consistently, they provide the most effective protection against HIV and other STIs during anal sex.
Some studies have tested the effects of lubricants on rectal tissue – some in the laboratory and one on humans – and have concluded that certain types of lubricant can cause damage to rectal tissue. The reasons are not yet clear. Damage to the rectal tissue could increase vulnerability to STIs (including HIV) if a condom is not used.
The AIDS Committee of Toronto (ACT) believes that HIV testing and treatment should be offered to all people living with HIV, but no one should be forced to undergo either. No response to HIV can work without the engagement and voluntary participation of people living with and at increased risk of HIV.
ACT supports universal access to anti-retroviral (anti-HIV) drug therapy and other treatments for HIV/AIDS, in Canada and around the world. ACT believes that access to HIV treatment is a right of all people living with HIV/AIDS.
Recently, discussion has emerged regarding the potential of anti-retroviral treatment to be used as an HIV prevention tool. Some researchers have projected that universal application of anti-retroviral treatment could stop the global HIV epidemic in its tracks, by reducing viral load and infectiousness among those living with HIV.1
ACT supports a comprehensive approach to HIV prevention and treatment. Universal access to HIV treatment is a part of the HIV prevention response. However, any response must respect the health and human rights of people living with and at risk of HIV, and be delivered in combination with other HIV prevention methods, including:
- access to condoms (male and female/receptive) and other barriers;
- the development of microbicides (for both vaginal and anal use);
- pre- and post-exposure prophylaxis;
- voluntary, confidential and anonymous testing for HIV and other sexually transmitted infections; and,
- needle exchanges and other harm reduction initiatives.
While ACT supports the laudable goal of increasing access to HIV treatment, and the concurrent role it can play in HIV prevention, we remain concerned about:
- Treatment in settings without adequate viral load testing to identify cases of treatment failure, which could result in undetected viral rebound;2
- Treatment in settings without access to second-line (ie newere) anti-HIV drug regimens which could result in increased transmission of drug-resistant HIV;2
- The application of drug treatments that lower infectiousness, but are not medically necessary, which may have negative health impacts on those living with HIV/AIDS;3 and,
- Universal application of treatment which violates the human rights of people with HIV/AIDS by removing the choice of when to begin anti-retroviral therapy.
1. Montaner JSG et al. The case for expanding access to highly active antiretroviral therapy to curb the growth of the HIV epidemic. The Lancet 368: 531-536, 2006.
2. Alcorn, Keith. Treatment as prevention tool: enough evidence to say it works, says IAS president.<http://www.aidsmap.com/en/news/30D49BD7-41FC-4E0D-AEBD-A210794D0533.asp>
3. O’Neal, Reilly. Is HIV treatment HIV prevention? <http://www.thebody.com/content/art54536.html>
In order to create universal access to HIV/AIDS treatment, the AIDS Committee of Toronto (ACT) supports:
- The creation of a federal program to provide catastrophic drug coverage1 in Canada, as advocated by the Canadian Treatment Action Council and the Best Medicines Coalition.2
- Legislative amendments to Canada's Access to Medicines Regime, as proposed by the Canadian HIV/AIDS Legal Network,3 to reduce red tape and encourage its use by Canadian generic drug manufacturers, non-governmental organisations and developing countries.
Since the introduction of highly active antiretroviral therapy (HAART) to treat HIV/AIDS, access to treatment has been unequal and often impossible, based on income and geography.
People living with HIV/AIDS in Canada face unequal access to treatment through the lack of a federal government program to cover the high cost of treatment for chronic or life-threatening diseases and conditions for Canadians who are working but have limited or no private insurance. Today, Canada remains one of the few industrialised countries without a nationally supported catastrophic program to assist with the out-of-pocket costs of prescription drugs.
While some Canadians are reimbursed for the cost of prescription drugs through an inconsistent patchwork of private and public drug plans depending on the province or territory where they live, many Canadians have no prescription drug coverage at all.
For people living with HIV/AIDS in the Global South, unequal access to treatment stems from the fact that developing and least developed countries have no capacity to produce pharmaceuticals, and the cost of importing patented drugs from industrialised countries is prohibitive.
Canada's Access to Medicines Regime (CAMR), established in 2004, created a legislative framework to allow Canadian manufacturers to produce generic pharmaceutical products for export to developing countries.
However, unnecessary red tape and bureaucratic hurdles within the Regime have prevented both Canadian generic manufacturers and importing countries from using the program. As of October 2008, only one shipment of generic drugs has been made under CAMR to a developing country.
The AIDS Committee of Toronto believes that a world without AIDS can only be achieved when all barriers to treatment are eliminated, regardless of an individual's income or geography.
1 According to the Canadian Treatment Action Council (CTAC), a catastrophic drug plan is "a publicly-mandated and funded health insurance plan which covers prescription drug costs for chronic, life-threatening diseases and conditions for individuals who do not have private health insurance or whose private insurance is insufficient to cover their prescription drug costs."
2 Best Medicines Coalition, "National Pharmaceuticals Strategy: An Urgent, Emerging Issue", Canadian Treatment Action Council Newsletter. Summer 2006.
3 Canadian HIV/AIDS Legal Network, Review of Canada's Access to Medicines Regime - Legal Network Submission to the Government of Canada. January 24, 2007.
In late March 2007, UNAIDS and the World Health Organization endorsed circumcision as a way of reducing heterosexual men’s vulnerability to HIV infection. Their endorsement was based in part on the findings of three recent studies which indicate that circumcised men are up to 60 per cent less likely to contract HIV from vaginal intercourse than uncircumcised men.
The studies looked at the vulnerability of heterosexual men in three high-prevalence, or HIV-endemic, countries: South Africa, Kenya, and Uganda.
The AIDS Committee of Toronto (ACT) recognizes the significance of these studies. Given, however, that the studies took place in social and epidemiological contexts different from those here in Toronto, ACT would like to clarify what the studies do and do not tell us.
What the current research tell us:
- Uncircumcised men are more vulnerable to acquiring HIV during vaginal sex than circumcised men are. The foreskin is susceptible to nicks and tears during intercourse, which can act as entry points for the HIV virus. Compounding this vulnerability is the fact that the foreskin is rich in Langerhans cells, a target for the HIV virus.
- While circumcision can reduce men’s vulnerability to getting HIV, it does not eliminate it.
What the current research does not tell us:
- It is not clear whether uncircumcised men are more likely to pass on the HIV virus than circumcised men.
- It is not clear whether circumcision significantly reduces the risk of HIV transmission to the insertive male partner (the ‘top’) during anal sex. It is possible to infer that the same factors that make uncircumcised men vulnerable to acquiring HIV during vaginal sex would make them vulnerable to HIV transmission during anal sex. However, the studies themselves did not look at this.
ACT would like to stress that while circumcision may reduce some men’s risk of HIV infection, it does not eliminate that risk.
Condoms are the most effective way to protect yourself and your partner from HIV transmission during sexual intercourse, whether you’re circumcised or uncircumcised, straight, gay, or bisexual.
Circumcision is a personal decision that may be made on religious, cultural or other grounds. As preventative measure against HIV, however, ACT cannot endorse circumcision based on the current research.
Feedback or comments on where ACT stands? Get in touch with ACT’s Communications Coordinator at firstname.lastname@example.org.