The Blueprint

The HIV blueprint at work: two examples

[Example 1] Insite

Vancouver's supervised injection facility -- is an example of the proposed strategic approach in action. This initiative was driven by social justice: the belief that people who use injection drugs have the same rights as others and that a just and caring society had an obligation to help people who inject drugs reduce the risk of overdose deaths and illnesses, such as HIV and hepatitis C. It was based on a sense of shared responsibility among a number of players and involved leadership; a bold, sustained and persistent approach; and grass-roots action.

in the late 1990s, in the wake of an epidemic of overdose deaths among people who use injection drugs, a small group of community activists -- people who use injection drugs, gay men, researchers and a parents' group -- came together to advocate for a legal safe injection site in Vancouver. They saw the site as an effective early intervention that could significantly reduce the harm associated with injecting drugs. Leaders themselves, they inspired others to lead: both the former and current mayor of Vancouver spoke out openly about the need and the city's responsibility and made services for people who inject drugs an election issue.

The process of advocating for the site was largely led by the people most affected -- people who use injection drugs -- who spoke out about their needs and helped ensure that the service would be culturally appropriate. The group carefully built an evidence-based case for the safe injection site by researching similar models in other countries, inviting people from other jurisdictions to talk about the experience, conducting studies to demonstrate that the site would be used and using a persuasive legal analysis prepared by the Canadian HIV/AIDS Legal Network. The group also shared responsibility with other sectors highly affected by the problem, including the police, the public health department and health professionals who served the community of people who use injection drugs, and built effective collaboration around a tangible issue. Members devoted significant time and resources to educating the public about the public health and social benefits of a safe injection site through public fora and the media (members of the group estimate that they were involved in more than 100 media interviews).

After several years of sustained talk, research and advocacy, Insite opened in September 2003 as North America's first supervised injection site scientific research pilot project. Insite provides a clean, safe environment where users can inject their own drugs under the supervision of clinical staff. Nurses and counsellors provide on-site access and referral to addictions treatment services, primary health care and mental health providers, as well as first aid and wound care. The goal of the research project is to assess whether the safe injection site will reduce the harm associated with IDU (e.g., drug overdoses); reduce the costs associated with serious addiction (e.g., health, social, legal and incarceration costs); improve the health of injection drugs users; and lead to more appropriate use of health and social services by people who use injection drugs.

Ongoing monitoring and evaluation are vital, both because they will help further improve, and hopefully expand, the supervised injection facility and other services for people who use injection drugs in Vancouver and because they will provide data that should assist other communities in their efforts to establish such services.

Insite has been successful in terms of utilization: people who use injection drugs adopted the site much more quickly than expected. It has also been effective in reducing overdose deaths -- as of September 2004 (the period for which data are available), no clients of the site had died from an overdose.38 Clinic staff now oversee approximately 550 injections over an 18-hour period each day. The majority of clients are men. The clinic has also resulted in an improvement in public order: during the first 12 weeks the facility was open, the number of people injecting drugs in public dropped, and the number of discarded syringes decreased by 50%.39 The more important and valuable evaluation of whether Insite has had an impact on the spread of blood-borne diseases such as HIV and hepatitis C will take many more months.

[Example 2] Changes to the Patent Act

In August 2003, the World Trade Organization (WTO) decided that under the Agreement on Trade-Related Intellectual Property Rights WTO member countries could manufacture generic drugs under a compulsory licence for export to countries with no or insufficient capacity to manufacture their own generic pharmaceuticals. This ruling opened the door for countries like Canada to help developing countries struggling with the high cost of drugs for HIV/AIDS or other public health problems. for the WTO ruling to have the desired impact, however, individual countries must amend their domestic patent laws to allow generic drug manufacturers to get compulsory licences to produce less expensive medicines for export.

In Canada, the Global Treatment Access Group (GTAG), an affiliation of Canadian civil society organizations committed to health and human rights (e.g., AIDS advocacy groups, humanitarian organizations, development groups, human rights groups, labour unions, student groups, faith organizations), worked to put the issue on the federal government's agenda. Additional support came from Stephen Lewis, UN Special Envoy for HIV/AIDS in Africa, who in a keynote address at the annual general meeting of the Canadian HIV/AIDS Legal Network in September 2003, and again a week later at a conference in Nairobi, Kenya, on AIDS and STIs in Africa, challenged Canada and other wealthy countries to address some of the inequities in AIDS treatment and take action to increase access to cheaper drugs. Then Minister of Industry, Allan Rock, with the support of some Cabinet colleagues, took up the challenge.

But getting the changes implemented required persistence and advocacy. As negotiations proceeded, the civil society organizations were concerned that the proposed changes to the Patent Act would be too narrow and restrictive in terms of the drugs or diseases that it might cover, or that the Government would introduce unnecessary and counter-productive provisions. They continually lobbied the Government to ensure that it would live up to international agreements. At one point, concerned that poor legislation was being pushed through too quickly, they advocated with all parties in the House of Commons to stop the revised bill, arguing that no changes were better than inadequate changes. As a result, the legislation was sent to committee, where some of the major problems were addressed.

The process was a lesson in advocacy and collaboration. The legislative changes involved the work of five different federal departments and agencies -- International Trade Canada, Foreign Affairs Canada, Industry Canada, Health Canada and the Canadian International Development Agency -- non- governmental organizations and industry, who came together to advise Parliament on the best possible approach. The bill was tabled early in 2004 and enacted by Parliament on May 14, 2004. Although no generic drug companies in Canada have yet come forward to test the new law (as of December 2004), the changes to the Patent Act are already having an impact by contributing to the global political momentum to implement the WTO decision.

The same coalition that was successful in advocating for the changes to the Patent Act is now encouraging Canadian generic companies to test the Act. They also continue to advocate for other action that would enhance global health, such as increases in Canada's official development assistance, ensuring that Canadian trade policy does not negatively affect access to health care at home or abroad and working to ensure that the review of Canada's foreign policy takes HIV/AIDS and human rights into account.

Government, non-governmental organizations (NGOs) and industry continue to work together to follow through on making use of the Act to provide greater access to affordable medicines for those in need.

With HIV initiatives like these-- that are based on social justice and a commitment to human rights, involve people living with HIV, acknowledge a shared responsibility, use leadership and evidence, are culturally appropriate and act early and stay the course -- we can get ahead of the epidemic.


BC Centre for Excellence. Evaluation of the Supervised Injection Site. Year One Summary. September 17, 2004.

Wood E, Kerr T, Small W, Li K, Marsh DC, Montaner JSG, Tyndall MW. Changes in public order after the opening of a medically supervised safer injecting facility for illicit injection drug users. CMAJ. Vol. 171, No 7. September 28, 2004.

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