The Actions:
What We Will Do Between Now and 2010

2. Address the social factors/inequities driving the epidemic

Rationale

While the majority of Canadians are aware of how HIV is transmitted, fewer realize the impact of social determinants of health on risk or understand the need for a social justice and human rights approach to HIV. For many communities -- gay men, people who use injection drugs, Aboriginal people, and people from countries where HIV is endemic -- HIV is only one of a number of pressures that threaten their health. Poverty, homelessness, stigma, addiction, violence, untreated mental health problems, lack of employment opportunities, powerlessness, lack of choice, lack of legal status (i.e., undocumented refugees) and lack of social support create an environment in which HIV and other illnesses flourish and spread.

A community that is more knowledgeable about the link between the determinants of health and HIV is more likely to support social-justice-based programs and services. For example, when people understand the potential benefits of needle- and syringe-exchange programs as not only reducing infections but also strengthening social networks, creating an environment for learning and improving access to other services, they are more likely to agree to have them in their communities.

Public policies in many sectors, including housing, taxation, social services, justice, immigration and income stabilization, can have a direct and immediate impact on people living with HIV and communities at risk. For example, a lack of government investment in affordable housing affects people's ability to find and keep shelter. Policy decisions can either limit or increase access to harm reduction measures, such as the distribution of condoms and clean needles. Policies designed to ensure safety and security for prisoners and staff in correctional institutions sometimes conflict with government obligation to preserve and promote prisoners' health and may limit prisoners' ability to practise safer sex or drug use.

The relationship between Canadian criminal law and sex workers' health and safety, including the risk of HIV infection, is multi-faceted. The criminal law reflects and reinforces the stigmatization and marginalization of prostitution and sex workers. The criminal law and its enforcement limit sex workers' life and work choices, thereby placing sex workers in circumstances where they are vulnerable to high levels of violence and exploitation as well as potential exposure to HIV. The preponderance of credible evidence points to the fact that the prostitution-related offences in the Criminal Code both directly and indirectly contribute to sex workers' risk of experiencing violence and other threats to their health and safety.50

People who use injection drugs are particularly vulnerable in this regard because of the policies that shape their environment. Existing drug laws in Canada force drug activity underground, causing people who use injection drugs to avoid prevention and harm reduction programs that could reduce their risk. When people who use injection drugs are arrested, most end up in prison rather than in treatment, which increases their risk of infection. Recent moves to decriminalize the possession of small amounts of marijuana, to provide alternatives to imprisonment and to expand harm reduction programs for people who use injection drugs are examples of policies that attempt to address root causes and reduce risk.

Problematic policies are not limited to government. Rigid workplace policies in the private sector can prevent someone with HIV from returning to work or working part time and gaining the benefits associated with employment (e.g., social support, being integrated into society, contributing to the economy). The impact of these policies is not limited to people with HIV; they affect many people with long-term, debilitating illnesses.

To reduce the social inequities driving the epidemic, we must deal with stigma, both in the general population and in the communities most affected by HIV. Effective anti-stigma programs will require the meaningful participation of people living with HIV. According to research done on schizophrenia, another highly stigmatized disease, the programs that were most successful in changing public attitudes were those that gave people opportunities for one-to-one contact with people with schizophrenia.51

Resources

In 2003, the Canadian HIV/AIDS Legal Network widely circulated for comments and input a draft A Plan of Action for Canada to Reduce HIV/AIDS-related Stigma and Discrimination, which sets out the steps that governments, organizations, advocates, individuals and others should take to fulfil their legal obligations:

  • participation of people living with HIV/AIDS and vulnerable to HIV
  • tackling stigmatizing attitudes
  • advocating for rights
  • improving services
  • strengthening research and evaluation.

Theodore de Bruyn, A Plan of Action for Canada to Reduce HIV/AIDS-related stigma and discrimination, Canadian HIV/AIDS Legal Network, 2004. Available with accompanying booklet in French and English at http://www.aidslaw.ca/Maincontent/
issues/discrimination.htm

In the 1980s, social support for people with HIV/AIDS within the gay community helped people talk openly about the illness, enhance their health and promote and normalize safer sex practices. In recent years, community-based AIDS organizations report significantly less support for gay men who are newly infected and an increase in stigma within the gay community.52 HIV is also a highly stigmatizing disease in Aboriginal communities and among people from countries where HIV is endemic. These attitudes keep people silent and isolated, and the silence allows the virus to spread.

In June 2001, all the member countries of the United Nations, including Canada, made a commitment to develop national plans to confront stigma and to take other measures to eliminate all forms of discrimination and protect human rights. This document is one step in fulfilling that commitment.

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Desired outcomes

  • The dignity and worth of each person is recognized.
  • Individuals and communities at risk have access to the education, income security, housing, social support and employment opportunities they need to maintain and improve their health and reduce their vulnerability to HIV infection.
  • People with HIV live longer in better health, free of stigma and discrimination, and have all their basic needs met.
  • Communities work together to give people living with HIV and communities at risk access to comprehensive health and social services.
  • All jurisdictions have in place supportive policies and laws that promote health and reduce or eliminate the social inequities that fuel the epidemic.

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Targets

For individuals

By 2010:

  • The proportion of people with HIV living in poverty drops.
  • The proportion of people living with HIV dependent on food banks drops.
  • The proportion of people living with HIV who have affordable, appropriate housing increases.
  • The proportion of people living with HIV who report that they have strong social support networks increases.
  • The proportion of people living with HIV who report that they have access to flexible employment opportunities that accommodate HIV increases.
  • The proportion of people living with HIV who have untreated depression drops.
  • The number of reports of incidents of stigma and discrimination in housing, employment, health care settings or other situations drops.
  • The proportion of people with HIV who report feeling stigmatized by their illness drops.
  • Gay men, Aboriginal people and people from countries were HIV is endemic who are living with HIV receive more support within their own ethnic or cultural communities.
  • The proportion of Canadians who are comfortable working with someone who has HIV increases from 70% to 90%.
  • The proportion of Canadian parents who are comfortable having their children attend school with a student who has HIV increases from 57% to 80%.

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For organizations and communities

By 2010:

  • Organizations develop programs to reduce the social inequities driving the epidemic.
  • Communities at risk (e.g.,people who use injection drugs, Aboriginal people, people from countries where HIV is endemic, people in correctional facilities) report measurable improvements in their access to appropriate, comprehensive health and social services, including housing, income and health promotion/harm reduction programs.
  • Organizations that provide services to people with HIV and communities at risk receive support in reducing HIV-related stigma and discrimination experienced by theircommunities.
  • Communities at risk develop and implement strategies to increase social support for their members living with HIV.

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For governments

By 2010:

  • Governments have implemented long-term sustained plans to address HIV-related stigma and discrimination.
  • HIV/AIDS is on the agenda of intergovernmental discussions about health and well-being, particularly those focussed on inner cities.
  • Governments have developed concrete plans to change any policies or laws that hinder efforts to stop the epidemic.
  • Governments have taken significant steps to adopt a health and human rights approach (as opposed to a criminal law approach) to drug use.
  • Governments create opportunities for greater involvement of PHAs in government decisions, organizations and programs.

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Actions

Human rights

2.1 Pursue collaborative initiatives -- locally, provincially, territorially and federally -- to raise awareness of the underlying factors that contribute to the epidemic and to develop support for change.
2.2 Enforce legislation, policies and other measures designed to protect the rights of people with HIV, and use other measures, including communication and education, to make the public aware of human rights issues.
2.3 Fund initiatives that have the potential to reduce social inequities (e.g., domestic violence initiatives, programs designed to reduce physical and sexual abuse, harm reduction programs).
2.4 Provide access to legal assistance for people living with HIV and those at risk who are dealing with discrimination or human rights violations.
2.5 Create a legal and policy environment that supports the health of people who use injection drugs by reviewing and, if necessary, changing current drug legislation to reflect a human rights approach, reduce the burden on the criminal justice system and ensure that people who use injection drugs have the same access to health services as those who do not.
2.6 Create an environment that supports the health of people in correctional facilities by reviewing and, if necessary, changing any policies that have a negative impact on the health of prisoners and their access to HIV-related services that would be available to them in the community.
2.7 Create an environment that supports the health of sex workers by reviewing and, if necessary, changing any local, provincial, territorial and federal policies and laws that have a negative impact on the health of sex workers.
2.8 Review other laws, policies and practices in the public and private sector, and change any that create barriers to HIV prevention, diagnosis, care, treatment and support.

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Income security, housing and employment

2.9 Develop baseline data on the social determinants of health (e.g., the number of people with HIV experiencing problems with poverty, food security, housing, social support, employment, depression, discrimination).
2.10 Review and, if necessary, change social assistance policies and practices -- and insurance laws, policies and practices -- to provide people living with HIV and individuals at risk with greater income security.
2.11 Review and , if necessary, change housing policies and practices -- municipally, provincially, territoriallyand federally -- to give people living with HIV and communities at risk better access to affordable, appropriate housing.
2.12 Review and, if necessary, change employment laws, policies and practices to give all people living with long-term debilitating illnesses greater access to employment opportunities that can accommodate their disability.

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Stigma and discrimination

2.13 Implement communication/education initiatives, including age-appropriate education programs for children and youth, designed to fight all types of discrimination (e.g.,racism, homophobia, sexism), violence and abuse.
2.14 Implement education programs designed to change negative public attitudes toward people who use injection drugs and make people more receptive to harm reduction initiatives in their communities.
2.15 Enhance capacity at all levels -- federal, provincial, territorial and local -- to respond immediately to HIV-related discrimination.
2.16 Implement programs to address HIV-related stigma and discrimination that give people opportunities for one-to-one contact with people living with HIV.
2.17 Create an environment within the gay community, Aboriginal communities and ethnocultural and ethnoracial communities that affirms members who are living with HIV and their place in the community.

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Research/monitoring

2.19 Conduct regular surveys of people living with HIV and communities at risk to assess their access to income, housing, employment and social support, and their experience with stigma and discrimination, with data on vulnerable populations collected in ways that respect their right to confidentiality and privacy.
2.19 Develop a better understanding of the relationships between knowledge, personal contact and social distance to inform programs to reduce stigma and discrimination.

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Footnotes

50
Betteridge G. Sex, Work, Rights: Reforming Canadian Criminal Laws on Prostitution. Montreal. Canadian HIV/AIDS Legal Network. 2005.

51
Stuart H. Stigmatization: Leçons tirées des programmes visant sa diminution. Santé mentale au Québec. Vol. 18, No 1:54-72. 2003

52
Verbal communication. Ontario AIDS Network. 2003.

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