Vancouver HIV/AIDS
Care Co-ordinating Committee
Public Sections
Documents: Environment Report 1999-2002
This is a companion document to the Strategic Plan and a work in progress; this version March 31, 2000
BEST PRACTICES
In the absence of a cure or effective vaccine for HIV infection, preventing the spread of HIV through public health mechanisms is the primary option for controlling the epidemic. HIV exploits human behaviour to spread from infected people to vulnerable populations. Governments can achieve the greatest impact on the spread of HIV by creating individual and group incentives to adopt safer behaviours. The effectiveness of these initiatives depends on harm reduction by those most likely to spread or to be exposed to HIV.
Harm reduction is a philosophy and a practice that minimizes harm and increases the health and quality of life of the individual. It recognizes that each individual is the expert on his or her life. Harm reduction respects the individual’s decisions regarding their personal health and endeavours to minimize any harm resulting from those decisions to the individual, their family and/or, caregivers and the larger community.
For injection drug users, harm reduction can mean use of less harmful drugs, safer drug use or practices, reduced amount of drug use or cessation of use. In Britain and Europe, where comprehensive harm reduction strategies have been implemented for some years, there is less needle sharing, less drug use, fewer deaths from drug overdose, decreased crime rates and less HIV transmission.
Harm reduction can also be applied at the broad societal level to bring about change in public policies and laws. For example, the federal Controlled Drugs and Substances Act (section 56) allows the Minister of Health to exempt any person or class of persons from the Act and to make regulations to that effect (section 55). These provisions can be used by the Crown to protect facilities or caregivers from criminal charges in connection with drug-related activities by their clients or patients.
In Vancouver, HIV prevalence among injection drug users is highly concentrated among those who have the least advantage in society. While injection drug use and HIV are found in most neighborhoods in Vancouver, the Downtown Eastside, which is the poorest urban neighborhood in Canada, has the highest incidence of HIV among injection drug users in North America. It is not injection drug use itself that is causing these alarming rates, but the circumstances in which these drugs are used.
The Canada Health Act provides for universal access to health care. Persons living with HIV, like others confronted with serious chronic illnesses are entitled to care, treatment and support. It is entirely appropriate to extend the principles of the Act to preventable diseases and illnesses and to invest equal attention and financial support in preventing the spread of HIV infection to vulnerable populations.
Research based evidence shows that people will respond to primary prevention programs and modify their behaviours. The stages to achieving safer behaviours begins with information and awareness about HIV and the available methods to prevent spreading HIV. Individuals and groups provided with information about prevalence and incidence of HIV are better able to assess their risks. In addition to general information about HIV, the availability of confidential HIV testing can provide information to people, communities and public health authorities that encourages and justifies preventive actions by individuals and groups.
While knowledge will induce some to adopt safer behaviour, in many cases there is an immediate burden to these changes with uncertain future benefits. Consequently, additional steps to achieve effective prevention include measures to reduce these burdens for both the infected and vulnerable populations and in some cases to create immediate incentives (or benefits) to adopt safer behaviour.
Measures to improve the availability and distribution of condoms and clean needles have been adopted to permit safer behaviours at an accessible cost. Additional measures such as making medically controlled doses of pure drugs available to addicts not in "detox" programs are being considered. Lowering the barriers and reducing costs for practicing safer sex or injecting behaviours will also improve the effectiveness of prevention programs.
The development of community resources is complementary to changing risk behaviours and supporting individuals to promote health. HIV/AIDS service organizations complement other community agencies by providing community space for social interactions in addition to information, education, condoms, sterilized needles and other resources to meet the specific needs of populations at risk. In addition to society's recognition of the need for broad supports to arrest the spread of HIV, we need to focus on those at risk and to address the broader social and economic reasons why some people are at greater risk.
The effectiveness of prevention through behaviourial change has not been directly demonstrated because of ethical and financial limitations on research. Consequently, investigators have applied mathematical models informed by research findings and calibrated by previously reported diagnosed AIDS case and HIV surveillance data to explore the options for prevention interventions.
One of the more significant findings in this work is that infections averted today have a cumulative effect in the future by disrupting the chain of viral transmission. Unlike medical treatments, the benefits of expenditures on prevention are not limited to the person directly involved in the program. The cost of averting an infection declines with time as this cumulative effect builds from the initial expenditure.
Prevention should be viewed as an investment that generates benefits in the future and spreads these benefits to those who might have been at risk. This is in marked contrast to an expenditure on treatment for an immediate health effect for a particular person.
In the light of limited government resources and the cumulative future benefits of prevention, governments need to ensure that effective prevention programs are not under-funded today. Effective programs must address the broad needs of those people who are most likely to contract or transmit the virus. Prevention programs among those most at risk can be controversial; nonetheless, primary prevention can preserve health, save lives and reduce the avoidable human and financial burden of HIV disease in the future.
