HIV/AIDS and Injection Drug Use: A National Action Plan

Overview

The Action Plan

• Scope
• Philosophy
• Methodology
• Guiding Principles
• Priority Issues
• Policy and Legislation
• Prevention/Intervention
• Treatment
• Population-Specific Action
• Aboriginal Peoples
• Women

This publication was produced by the Canadian Centre on Substance Abuse and the Canadian Public Health Association with funding from Health Canada.

The opinions expressed in this publication are those of the Task Force and do not necessarily reflect the official views of Health Canada.

Acknowledgements

 The Task Force initiative responds directly to recommendations made by the Organizing Committee of the Second National Workshop on HIV, Alcohol and Other Drug Use (Edmonton, 1994). The Task Force thanks participants at that Workshop and members of the Organizing Committee for their role in the development of the National Action Plan.

 The Task Force initiative originated within, and was funded by Health Canada, and was provided ongoing support by Tracey Donaldson of the HIV/AIDS Prevention and Community Action Programs, and Lisa Mattar of the Office of Alcohol, Drugs and Dependency Issues. Betsy MacKenzie, of the HIV/AIDS Policy and Coordination Office, Health Canada, was part of the Planning Committee at the project's inception, and continued her supportive involvement throughout the process.

 The project was coordinated through a partnership between the Canadian Public Health Association (CPHA) and the Canadian Centre on Substance Abuse (CCSA). Ron de Burger and Nora Hammell of CPHA brought the strength of years of involvement in the HIV/AIDS field to the table; Pamela Fralick of CCSA was the principal author for the Task Force, and undertook primary responsibility for coordinating activities throughout the process.

 Development of the National Action Plan involved consultation with some 80 stakeholders. The Task Force thanks all who provided comments and advice. This input strengthened the Task Force's discussions and greatly enhanced the resulting Plan.

 The National Action Plan which follows clearly demonstrates what is possible when partnerships–no matter how diverse–work. All those involved with this initiative hope that similar partnerships can unfold to ensure the Action Plan moves quickly from planning to action.

Call For Action

• Policy and legislative issues must be addressed: enhance governmental and community leadership, change the Criminal Code by adopting laws that favour a medical approach over a criminal one and are applied with consistency, improve conditions in correctional settings, and base all decisions on available and emerging evidence (see page 12 for specific strategies).
• Prevention and intervention efforts must be enhanced: deal with discriminatory attitudes, improve needle exchange and disposal services, and change the nature of, and improve access to, methadone programming (see page 15 for specific strategies).
• Treatment options for substance use and HIV must be improved: expand the continuum of alternatives available, improve the quality of professional training, and research the interactions of treatments for drug use with treatments for HIV and other illnesses (see page 16 for specific strategies).
• Issues specific to Aboriginal populations must receive special and urgent attention: improve data describing the problems, develop culturally appropriate strategies, and ensure better coordination of those involved in the provision of services (see page 19 for specific strategies).
• Issues unique to women must be addressed: direct educational efforts at health care professions and women (through peer support), and conduct appropriate research (see page 21 for specific strategies).

Introduction

 Canada is still in the midst of a public health crisis concerning HIV/AIDS and injection drug use. Despite clear indications of an escalating problem since the mid-1980s and the use of a variety of approaches to address it, the spread of HIV among drug users is increasing, as is the incidence of hepatitis and tuberculosis. Epidemics continue to emerge among new populations. Intersecting issues–HIV and AIDS, substance use, mental health –create multiple problems in an individual for which there is no prescribed course of intervention or treatment. It must also be noted that IDU is not the only connection between HIV, AIDS and substance use–alcohol and other drug use can alter judgment and adversely affect the adoption of safer sex practices, leading to an increased risk of contracting HIV. Continuing marginalization and stigmatization of drug users, especially those who inject, and those who are HIV positive or have AIDS, remain barriers to progress. Leadership is in question, from key community levels up to the federal government.

 With the above needs and urgency in mind, and acting on a key recommendation from the "Second National Workshop on HIV, Alcohol and Other Drug Use" held in Edmonton in 1994, a Task Force was created to develop a "National Action Plan on HIV/AIDS and Injection Drug Use". Funded by Health Canada and coordinated by the Canadian Centre on Substance Abuse (CCSA) and the Canadian Public Health Association (CPHA), this group has built on the discussions from the Edmonton Workshop, identified the most pressing issues of the day and recommended strategies and stakeholders for their implementation. While not claiming to be a comprehensive solution, it is a roadmap for a journey which must be initiated without delay if further spread of this epidemic is to be curtailed.

The Urgency– What We Know

 HIV rates in Canada are still increasing, with the infection spreading in vulnerable populations and showing little respect for geographical boundaries.

Canada is estimated to have had between 19,000 and 20,000 AIDS cases at the end of 1996 (adjusted for reporting delays and underreporting), with 72% of cases reported as having already died. Another 10,000-12,000 cases are expected by the year 2000. In terms of HIV, by the end of 1994 Canada is estimated to have had between 42,500 and 45,000 cumulative cases. Each year adds an additional 2,500 to 3,000 new cases.

 Those becoming infected with HIV are younger.

The median age of new HIV infection has dropped from age 32 years in those infected before 1983, to 23 in the period 1985-1990. It is clear that HIV is increasingly a problem of Canada's youth.

 HIV among injection drug users is increasing dramatically, with Vancouver now having the highest rate in North America.

Although only 8.2% of cumulative AIDS cases reported to date are among injection drug users, the proportion of cases has increased over time, particularly for women - while 6% of cases before 1989 could be attributed to IDU, this figure rose to 15% between 1989 and 1992, and to 24% between 1993 and 1996. For men, the figures rose from 1%, to 2.6% to 5%, for the same time periods.

 HIV data are of even greater concern. In Ontario, prior to 1995, 2.8% of new positive tests were IDUs. This has more than doubled to 6.1% in 1995. In British Columbia, the same figures jumped from 9% prior to 1995, to 38% in 1995.

 In terms of HIV prevalence among IDUs, which gives us a snapshot of the proportion currently infected, Montreal has a rate of 20% and Vancouver is at 25%. New infections are occurring at a rapid rate. Currently in Montreal, it is 8.2 per 100 person-years (Hankins, et al., 1997), and a Vancouver study has documented a rate of 18.6 per 100 person-years. This means that among 100 uninfected individuals on January 1, 1997, who continue injecting, 19 of them will have become infected with HIV by the end of this year. This is the highest reported rate in North America (Strathdee et al, in press, 1997). Although most available data focus on major urban settings, the importance of this issue to other cities and rural areas must not be overlooked, or neglected. In particular, as HIV spreads through the general population, facilitated by injecting drug practices, it is of increasing concern to all Canadians, regardless of geography.

 Incarceration is a risk factor for acquiring HIV, with few innovations being implemented which would improve the situation.

The legal aspects of drug use, and their intersection with HIV/AIDS, have created an emergency situation in our prisons. Many injection drug users spend time in prison settings, either directly, because of drug convictions, or due to other criminal convictions related to that use. Between April, 1994, and August, 1995, the number of known cases of HIV/AIDS in federal correctional institutions rose by 40%. Rates of Hepatitis C range from 28 to 40%. It is a fact of life that inmates will continue to engage in high-risk behaviours. Unfortunately, administrative responses within federal and provincial correctional services aimed at preventing the spread of HIV have thus far been limited (Jürgens, 1996). With the majority of prisoners moving back to the community once their jail terms have been completed, the seriousness of this issue for all Canadians cannot be ignored.

 Despite limited epidemiological information, existing data clearly indicate Aboriginal peoples are over-represented in groups most vulnerable to HIV infection, and the epidemic shows no sign of slowing.

Aboriginal people are over-represented in many of the groups most vulnerable to HIV risk –inner-city populations, sex-trade workers, incarcerated individuals. In a 1995 study, 30% of IDUs who used needle exchange programmes in Vancouver were Aboriginal (Patrick et al, in press, 1997). Within our prison settings, 14% to 40% of inmates are Aboriginal (depending on the province), placing them at increased risk within this confined environment, in which the incidence rate is high (Jürgens, 1996). As well, many Aboriginal people move back and forth between urban settings and reserves, further increasing the potential for spread of HIV. It should also be noted that some Aboriginal populations have higher rates of sexually transmitted diseases, which increases the risk of HIV transmission.

 Women represent an increasing percentage of new HIV cases, many contracting the infection through injection drug use.

The proportion of AIDS cases among adult women, as compared to all adult cases, has increased significantly, from about 5.5% during 1981-1989 to 7.2% during 1993-1996. Injection drug use accounts for 17% of all cases, second only to heterosexual transmission. As of September, 1996, 116 AIDS cases have been attributed to perinatal transmission.

 An increasing percentage of women being tested for HIV are being found to be positive. Prior to 1995, about 8.5% of women tested in Ontario were HIV positive, compared to about 16.4% in 1995. In B.C., this rate changed from 9% to 22.8% for the same time periods. Key risk-factors are injection drug use, and having sexual partners who are at increased risk for HIV.

 The cost of inaction will outweigh the cost of response, in dollars, and in human suffering.

 A recent study attempted to assess the direct and indirect costs associated with the treatment of AIDS and HIV, finding that direct medical costs of treating HIV were $100,000 per individual (Hanvelt and Meagher, 1996). It is expected that treatment costs will increase as new drugs become available, and are used for longer periods of time. By any analysis, the costs of this crisis are enormous, and most are yet to come. This is in addition to the pain and suffering of persons living with HIV and AIDS, and the loss and grief experienced by loved ones.

 New drug-using trends can affect HIV rates significantly.

Attention has typically been focused on the heroin-using population, but new trends indicate an increasing shift toward cocaine use in many cities across the country. In Vancouver, 80% of needle exchange clients inject cocaine (Strathdee et al, in Press, 1997). In Montreal, the figure is 70% (Hankins, 1997) and in Halifax 52% (Grandy, 1995). This raises the spectre of a broader range of networks for HIV transmission, given that there is not perfect overlap between heroin and cocaine-using populations. Combined with the higher injection rate (up to 20 times per day), health and safety concerns are significantly increased.

Why Is This Issue So Important?

 People who inject drugs do not usually continue to do so all their lives. When they successfully stop injecting, society wants them to have years of productive life ahead of them. For this to happen, we must keep them healthy, HIV free, and alive.

 Injection drug users do not live in a vacuum. They are members of our community and, both during and after the periods of their lives which involve the injection of drugs, they form intimate partnerships and have children. Although epidemiologists agree that this epidemic is unlikely to ignite within the broader community to the same extent it has among injection drug users, it will nonetheless touch many lives, infecting and affecting many people who have never used drugs.

 While recognizing the seriousness of our circumstances, it must be acknowledged that there is hope. There are effective strategies that have been documented and can be implemented, and there are new paths to explore. Drug users can and do learn to use safer methods of injecting which can protect them, their partners, and their children from HIV. Some stop using drugs altogether. The right interventions, offered at the right time, do work. It is time to move beyond debating ideological differences and take full advantage of the knowledge and experience already available. It is time to act.

The Action Plan

Scope:

• identifies the most pressing issues, offers strategies with which to address these concerns, and suggests who are in the best positions to implement the recommendations. It recognizes that different issues are of greater or lesser importance to different individuals and organizations, and presents the current recommendations as first steps in addressing priority concerns.
• strongly supports the use of a harm reduction approach, in conjunction with other, complementary approaches
• recognizes the urgent need to make strong recommendations, but not to be prescriptive. Each level of government, each community, each individual must apply the recommendations as is appropriate, developing unique, but complementary responses to a common problem,
• takes a simple, straight-forward approach to increase the likelihood of action, but does not avoid complex issues, in particular, those dealing with drug policy and enforcement issues,
• recognizes that marginalization and stigmatization of drug users in general, and those infected with HIV in particular, are key barriers to progress against the epidemic, and focuses its efforts on reducing these barriers. Placing these individuals at the margins of society reduces access to health-enhancing services, ultimately placing the community-at-large at greater risk from the spread of HIV,
• does not address in detail the long-term prevention measures for young people who may be at risk from using drugs at some point in their lives. The Action Plan focuses on the immediate priority of reducing harm to those who are at risk of initiating injection drug use, or are already doing so.

Philosophy

 Treatment of drug use has been primarily based on an abstinence model, which has a goal of total cessation of use. While recognizing the merits of this approach, the Task Force, in assessing the issues around HIV, AIDS and IDU, recognizes that abstinence is not always a realistic or feasible goal for the individual using currently illegal drugs and that, in the interest of public health, alternative methods must be considered.

 While neither condoning nor condemning drug use, this harm reduction model accepts that drug use continues to occur, and that many initiatives can be undertaken to minimize the harm to all involved. This approach does not exclude abstinence as an eventual goal, should the individual decide to pursue it. However, the focus is on minimizing the harmful outcomes that can be associated with drug use. Examples of harm reduction initiatives include provision of needle exchange, condoms, information on safe-injecting practices, and safe-injecting rooms or shelters. Evidence-based support for these approaches continues to mount, both in Canada (e.g. Hankins, 1997) and elsewhere (Lurie & Drucker, 1997).

Methodology

 Following a 2-day meeting of the Task Force, a draft document was prepared and sent for additional comment to 80 key stakeholders in Canada and internationally. It was also distributed, as an interim document for information only, to key policy and decision makers across the country, including federal and provincial Ministers, Medical Officers of Health and professional Colleges.

 After considering all input, a revised Action Plan was adopted by the Task Force and presented to Health Canada. Dissemination will be as broad as possible, including on the internet, to target key decision-makers, community leaders and mobilizers, and the media.

Guiding Principles

• Effective leadership is required at all levels.
• Community involvement is key to the success of the Action Plan.
• All recommendations are aimed at decreasing the marginalization and stigmatization of injection drug users, and particularly those living with HIV or AIDS.
• Suggested strategies attempt at all times to recognize the diversity among injection drug users and to be aware of the variety of needs when designing programmes and policy.
• Collaboration with a wide base of partners is essential to the successful development and implementation of policies and programmes, drawing from the HIV, AIDS, substance use and mental health fields as well as ensuring all sectors are involved (health, enforcement, legal, and others). New partners should continually be sought.
• Those using the services must be involved in the processes which affect them–policy and programme development.
• Ongoing assessment and evaluation of the efforts and interventions undertaken are the cornerstones of all initiatives.

Priority Issues

Policy and Legislation

Overview

 There are a number of limitations to existing drug policy in Canada which affect our ability to address HIV and AIDS in the injection drug using population, and, in fact, may contribute to the situation or make it worse:

• given the currently illegal status of many drugs, those who inject often opt for the most efficient and fast means of introducing the substance into their bodies–injection drug use–in an attempt to maximize a speedy effect and, at the same time, minimize the likelihood of detection and arrest.
• The illegal status of drugs makes the user afraid to go to health or social services, increasing marginalization
• service providers themselves may shy away from providing essential education on safer use of drugs for fear of being seen to condone use
• the illegal status of drugs fosters emotion-laden anti-drug attitudes toward the user, again adding to marginalization of this population, and directs action toward punishment of the "offender", rather than fostering understanding and assistance.

 Recommendations:

 1. Leadership and commitment to action must be enhanced.

How?

• In view of the seriousness of the problem and the multi-sectoral nature of the solutions required, the federal Minister of Health should take the lead in ensuring a coordinated and integrated response to all recommendations in this National Action Plan.
• Continue or renew national strategies to address HIV/AIDS and substance use with appropriate levels of funding, directed primarily at community-based initiatives.
• Foster formal linkages and permanent mechanisms for consultation and communication among all relevant players, including the criminal justice and health systems, as well as social services.
• Ensure funding exists for alternative programmes in prevention, drug treatment and diversional sentencing to community programmes, including those implemented under Bill C-41 (Alternative Measures). Existing funds should be allocated to these programs and, in addition, funding should be increased through innovative options such as the following:

 2) A 25% surcharge placed on all fines to drug traffickers.

 (Bill C-41, proclaimed in September, 1996, gives courts of law flexibility in responding to a variety of crimes, including drug-related offences, and encourages diversion of the perpetrator away from the criminal justice system to more appropriate consequences. In the case of currently illegal drugs, this could include counselling, treatment, community service, and so on.)

 Use of these funds should be overseen by a partnership of key involved Ministries, federally and provincially.

• Ensure all provinces become signatories to Bill C-41, and develop nationally coordinated implementation strategies.
• Ask that the Health and Enforcement in Partnership (HEP) Steering Committee consider all recommended policy issues and facilitate implementation within their respective departments.

How?

• Provide specific exemptions under the legislation to ensure that physicians may prescribe narcotics (e.g. heroin, cocaine) to drug users in an effort to medicalize drug use and reduce harm associated with obtaining drugs on the street (e.g. English Model). Research to assess the feasibility of this approach should be undertaken on a pilot basis.
• Decriminalize the possession of small amounts of currently illegal drugs for personal use.
• Institute heavy penalties for the commercial trafficking of any drug to minors.
• Initiate discussions among judges, prosecutors and police officers to address the lack of national consistency in the application of laws. For a variety of reasons, these sectors exercise such a high degree of discretion that national legislation no longer has national applicability. This discussion is made necessary by the increasing use of diversion in the justice system and new initiatives by the health service aimed at drug users. The principal goal of these discussions must be to protect the rights of the drug user, within an accepted legal framework.

 (The reader is directed to the document "HIV/AIDS in Prisons: Final Report" by Ralf Jürgens, 1996, for a full examination of correctional issues and accompanying recommendations.)

 How?

• Allow prisoners who have been in a methadone maintenance programme prior to incarceration to continue to receive such treatment in prison.
• Ensure methadone treatment is available to opiate-dependent prisoners who were not receiving it prior to incarceration.
• Institute programmes to evaluate the need for methadone maintenance therapy prior to prison release, and ensure priority transfer to community programming on the outside at release.
• Conduct pilot programmes of needle exchange in federal and provincial correctional settings.

How?

• Involve IDUs in all aspects of research.
• Continue to monitor HIV rates and use this information fully in developing new policies and programmes.
• Investigate local transmission patterns of HIV in IDUs.
• Fund additional research to determine the extent of diversion of prescription opiates to the black market.
• Include quantitative, qualitative and ethnographic methodologies in research designs in order to increase the usefulness of data to policy and programme development.
• Use the "Guidelines on Ethical and Legal Considerations in Research on AIDS and Drug Use at the Community Level" when conducting community-level research.

 Key Partners:

• drug users
• federal, provincial and territorial Ministers of Justice and Corrections
• provincial Attorneys General
• police organizations
• Bureau of Drug Surveillance, Health Canada
• Laboratory Centre for Disease Control, Health Canada
• policy makers
• Colleges of Physicians and Pharmacists
• legislators
• lawyers' associations
• the judiciary
• Health and Enforcement in Partnership Steering Committee
• researchers (universities, Statistics Canada, Medical Research Council, Ministries of Health, Social Services, Justice, etc.)
• Provincial and Territorial Departments of Public Health
• HIV/AIDS and substance use service providers

Overview:

 For long-term impact, and to truly address the issues of marginalization and stigmatization, it is essential that key agencies show leadership in prevention activities. Those providing services in the areas of HIV, AIDS and substance use are, and must continue to be, instrumental in creating an environment which is open to a change of norms. They must work together to achieve these goals. This will be a first step in achieving public awareness and acceptance of the realities in their midst.

 It is critical that more effective prevention and early intervention strategies be developed both for drug use and HIV infection. To protect young people in Canada and future generations, it is essential to have good health promotion programmes suited to communities and cultures across the country. This should include programmes to support strong mental health and self-esteem of individuals, and provide sound education about drugs, healthy sexuality and healthy relationships. It should also include research to help us understand what makes young drug users decide to start injecting and what the appropriate response should be. It does not serve realistic health goals to try to scare children away from the natural developmental tasks of exploring sexuality, taking risks, setting one's own boundaries and establishing an identity. Only truthful information and respectful discussion will serve long term health goals.

 While these long-term public health issues must not be neglected, they are not the focus of this Action Plan. The prevention issues and strategies identified here are aimed at helping Canadians at immediate risk. We need to help those people who are using injection drugs today.

 At the most basic level, attitudes towards injection drug users living with HIV or AIDS must be addressed as a first step in the destigmatization and normalization process. A starting point is the education of the public and professionals, which will lead to increased awareness of the issue. Needle exchange, while a demonstrably effective and essential complement of HIV prevention (Hankins, 1997; Lurie & Drucker, 1997), can work better through decentralization and integration with community-based health services. The overriding goal must be to minimize risk to the individual, the community and society as a whole, through providing care and support to our most vulnerable citizens.

Recommendations:

 1. Discriminatory attitudes toward drug users living with HIV or AIDS must be addressed, with a view to elimination, both in the general public and within professional groups.

How?

• Actively involve drug users in policy development, programme planning and implementation for prevention, care and support, as well as in evaluation.
• Create community-based peer-support and advocacy groups for drug users, and integrate drug users into existing organizations.
• Develop programmatic inter-agency and inter-disciplinary links (mental health, addiction, acute care, community hospitals, HIV treatment).
• Promote awareness, recognition and acceptance in the justice system and in law enforcement that addiction is better dealt with as a health and social issue, than a criminal one.
• Improve diagnostic and treatment capabilities of physicians, nurses, pharmacists, etc. through focused, cross-disciplinary education at the undergraduate level and through continuing education.
• Provide training and information to the judiciary and others in the criminal justice system on the link between HIV and AIDS, and IDU, as a health issue.
• Promote harm reduction as a necessary component of a range of strategies when developing programmes and policies.
• Enhance intersectoral responsibility at all levels of government, recognizing that HIV/IDU encompasses health, social and corrections considerations.
• Examine, and change where necessary, policies and procedures of professional bodies (e.g. physicians, pharmacists) to make sure they facilitate harm reduction and encourage the involvement of members in caring for injection drug users.
• Involve all partners and especially community organizations in promoting needle exchange and disposal as health and safety issues (e.g., availability of needle exchange programmes and appropriate, accessible disposal facilities reduces the likelihood of injury to children, janitorial staff, and others, that can result when needles are improperly discarded in playgrounds and other locations).
• Develop other partnerships to enhance this process (e.g., persons with diabetes and their organizations).

How?

• Provide access to needle exchange in the community, and integrate with a broad range of health services (including health promotion, nutrition, self-esteem training, safe injecting practices) rather than marginalize this one service. Expansion of alternative sites such as hospital Emergency Rooms, Public Health clinics, community-based clinics and pharmacies must be considered in order to achieve decentralization.
• Encourage every pharmacy in the country to sell needles, advertise needle exchange services in the community, and offer disposal services in conjunction with local health authorities.
• Consider giving community awards to pharmacists for their support in order to encourage their continuing involvement, as well as that of their peers.
• Purchase needles for community programming in bulk for an entire city, as in Montreal, or for a whole province, as in B.C. This is a cost-cutting measure which would allow more needles to be made available.
• Offer needles on their own and as part of a package including alcohol swabs, condoms, lubricant, pamphlets, pharmacy addresses, etc.

How?

• Revoke the need for physicians to have authorization from the federal Minister of Health to prescribe methadone. Revoking the need for authorization will allow physicians to prescribe methadone like any other drug, making methadone more accessible.
• Make appropriate training available to physicians to encourage their involvement in providing methadone treatment to injection drug users.
• Dramatically increase the availability of methadone treatment, at a minimum increasing the total number receiving treatment from the current 3,600 to 7,200 within 18 months .
• Reduce and eliminate other barriers to being on methadone, and base decisions regarding methadone carrying privileges on reliable and responsible behaviour of the individual.
• Create a central coordinating agency to link users and doctors at the local level so that users know how to access methadone services.
• Encourage programme planners to undertake study visits to innovative and cost-effective methadone programmes such as those in Vancouver, Halifax and Edmonton, with a view to replication at other sites across the country.
• Add a product monograph for methadone to the Compendium of Pharmaceuticals and Specialties (CPS) for quick physician access.
• Communicate the results of research on the effects of methadone on pregnancy and breast-feeding to practitioners and the general public, especially women (e.g. enter information in the Compendium of Pharmaceuticals and Specialties).
• Investigate other alternative drug therapies, beyond methadone, such as buprenorphine, naltrexone and LAAM (L Alpha Acetylmethadol).
• Set up a low threshold methadone maintenance programme as a pilot project in one or more sites with the explicit goal of reducing injection frequency in heroin users.

How?

• Make pharmacies a focus of disposal efforts. Incentive for this could be built through collaborating with the appropriate governing bodies for pharmacists and pharmacy owners directly.
• Consider installing community disposal containers which are secure from tampering and strategically located for the injecting community.
• Analyse locations where there are more returns than needles distributed to shed light on what information might assist sites with less successful return rates.
• Inform IDUs how to safely dispose of needles in case they are unable or unwilling to bring them back to the available service or other location.

• community agencies
• public health agencies
• community-based AIDS service organizations
• Canadian AIDS Society
• professional Colleges (licensing bodies), especially Pharmacists
• pharmacists associations
• physicians
• Justice, Health Departments
• substance abuse agencies, commissions, services
• needle exchanges and outreach programmes
• consumers
• insurance companies
• private sector
• Researchers

 (The AIDS Care, Treatment and Support Program, Health Canada, national report titled "Care, Treatment and Support for Injection Drug Users Living with HIV/AIDS: A Consultation Report", (March, 1997), provides an overview of the issues and types of care, treatment and support services for injection drug users living with HIV/AIDS.)

 Overview

 Addressing the multiple difficulties in seeking appropriate, accessible treatment for a substance use problem can be overwhelming, as it can also be for HIV infection. Attempting to do this when both conditions are present, and particularly if other issues such as mental illness are also present, can seem insurmountable. Individuals with these conditions may have to confront discriminatory and/or uninformed attitudes on the part of treatment providers, and availability of appropriate treatment spots is frequently limited. Decision-making regarding the best treatment approach is often taken out of the hands of the individual for fear, on the part of the health care providers, that an injection drug user will not comply with treatment regimes. Pain may not be well-managed by physicians unwilling to prescribe adequate medication to someone with a history of substance use, fearing the risk of overdose.

 It must be recognized that injection drug users living with HIV are individuals, suffering in a myriad of ways, and in need of the best possible interventions, tailored to their unique situations. They retain all the rights of every other citizen, and must therefore be given equal access to a continuum of services, as well as the dignity of making their own decisions. If lack of compliance with a drug treatment is feared, then the patient must be supported to ensure adherence to the treatment regime, just as any other individual is, whether diagnosed with diabetes, epilepsy or another condition. Bias against treating IDUs is unjustified and unacceptable.

 (The Portland Hotel in downtown Vancouver is an excellent model of how compliance to drug therapies can be facilitated. 60% of residents are HIV positive. A nurse visits three times a day to ensure proper medication is distributed; needles are available at the front desk.)

 Recommendations:

 1. The continuum of available services and information must be enhanced and expanded.

How?

• Provide treatment options which do not require total abstinence from all drugs. Evidence of drug use should not, alone, be a barrier to drug or HIV treatment. Treatment can be supplemented by incorporating complementary harm reduction approaches to address the ongoing drug use, such as teaching safer injection practices, how to care for abscesses, and improved nutrition.
• Ensure the availability of treatment services where providers are knowledgeable about both substance use and HIV.
• Coordinate services currently addressing only one aspect of the treatment issue (i.e. HIV, AIDS, or substance use).
• Ensure each person seeking treatment is evaluated and offered anti-retroviral drug therapies meeting current standards of care.
• Develop cocaine-specific treatment options.
• Investigate the potential health risks of individuals using combinations of pharmaceutical/therapeutic and recreational drugs. Although there is some information available concerning their interactions (Ciraulo et al., 1989), more research and information are required.
• Conduct clinical trials of prescription morphine, heroin and cocaine as alternative approaches, such as are being done in other countries (United Kingdom, Switzerland).
• Involve all partners in a client-centred, integrated service delivery approach, in order to facilitate higher quality, comprehensive, consistent and cost-effective care.
• Develop alternative delivery systems for drug treatment in comprehensive care clinics, designed with community participation, and licensed by the province (this can be accomplished outside legislative changes, through Statutory Amendments to the Criminal Code). For instance, methadone programmes could be provided at community health clinics rather than only through fee-for-service physicians.
• Enhance continuing education programmes for primary care physician networks of prescribers.
• Ensure a full spectrum of treatment options, including anti-retroviral drugs, are available to those in corrections facilities.
• Educate health care workers in prisons about the side effects of HIV medications and other related issues.

How?

• Encourage each community to develop a "best practice" guideline for physicians, adapted to local community needs and resource availability, and linked to cost-effectiveness (e.g., Halifax has created a Community Methadone Advisory Committee composed of users, health care professionals and methadone clients, which contacts physicians and pharmacists to inform them of the need and value of the Community Methadone Service).
• Establish a mentoring system/programme for physicians, nurses and related professionals.
• Provide regular and ongoing training to those providing services at health centres, substance use programmes, HIV/AIDS programmes, etc.

• substance use programmes and facilities
• HIV treatment facilities, hospices
• community-based AIDS service organizations
• Ministries of Health, Justice, Social Services
• Regional Health Authorities
• public health centres
• professional colleges
• outreach programmes
• research community
• pharmaceutical companies

Population Specific Action:

 While the foregoing recommendations will serve all Canadians, the Task Force sees clearly that more work needs to be done to develop tailored strategies and action plans which are specific to the needs of aboriginal people and women.

Aboriginal Peoples

 As described in the Introduction, available data indicate dramatically increasing rates of HIV among the drug using population of Canada's Aboriginal peoples. The injustices suffered by Aboriginal peoples in Canada have led to the loss of culture and identity of individuals and whole communities. This, and other factors, have led to the present situation in which Aboriginal people are over-represented among urban injection drug users, in correctional institutions and in data on sexually-transmitted diseases, and under-represented in treatment and HIV data. In fact, the lack of available findings is a key gap to understanding the situation and effectively addressing it. Additionally, issues of jurisdiction, governance, culture, racism and homophobia combine to further complicate this situation of overlapping risk-factors. More than in any other group, Aboriginal peoples must play a strong role in addressing their health needs with regard to HIV, AIDS and IDU–quickly, comprehensively and effectively.

 Recommendations:

 1. Data describing the situation must be routinely gathered, and quality must be improved.

How?

• Provide training opportunities to Aboriginal people to ensure that Aboriginal communities can design and undertake research initiatives for their own people.
• Learn from Aboriginal communities and apply teachings in non-Aboriginal agencies, since many Aboriginal people may opt to access these organizations.
• Obtain information concerning Aboriginal origin, and ethnicity, at all data-gathering sites and in all studies.
• Supplement existing AIDS data with HIV prevalence and incidence information.
• Conduct research to address the unique concerns of Aboriginal peoples, such as the younger than average age at which they become infected, the higher incidence of injection drug use as a mode of transmission, steadily increasing HIV rates, and over-representation in correctional settings.

How?

• Convene a meeting of spiritual leaders from different Aboriginal communities, and elders in particular, to address the harms associated with injection drug use and to consider harm reduction approaches.

• Recognize cultural diversity within Aboriginal populations (First Nations, Inuit, Métis) and account for it when developing any policies, programmes and research.
• Recognize that many adults–including current Chiefs and elders - may have been affected by factors such as alcoholism and childhood sexual abuse, which will often affect responsiveness to the current crisis and recommended approaches.
• Encourage communities to use existing cultural practices to mobilize the community and address its problems.
• Provide training to all existing service providers, Aboriginal and non-Aboriginal alike, to heighten cultural sensitivity to, and awareness of, the overlapping risk-factors for this population, such as racism and homophobia.
• Acknowledge the unique needs of Aboriginal women and develop appropriate responses for issues such as their role as caretakers of the culture, the relationship between high rates of sexually-transmitted diseases and HIV, the need for anonymous, confidential HIV testing.
• Promote information sharing about Aboriginal initiatives and AIDS education programmes which are successful.

How?

• Provide support, financial and otherwise, for the Canadian Aboriginal AIDS Network (CAAN).
• Address jurisdictional issues regarding who is entitled to services delivered by different levels of government, as well as the "on versus off reserve" issue. HIV does not respect this arbitrary division of service provision. Access must be facilitated.
• Link native HIV, AIDS and IDU programmes with provincial services to lessen the over- reliance on reserves which has been the trend until the present.

• Canadian Aboriginal AIDS Network (CAAN)
• Assembly of First Nations (AFN)
• Aboriginal addiction treatment programmes
• Nechi Institute
• Ministries of Indian and Northern Affairs, Health, Justice, Social Services, and sections within federal, provincial and territorial ministries responsible for Aboriginal affairs (e.g., Medical Services Branch of Health Canada)

Women

 While still relatively small in Canada, the number of women affected by HIV/AIDS is increasing at an alarming rate, providing an urgent rationale for being proactive in addressing the unique issues women face without delay. Worldwide data indicate that HIV infection is increasing more rapidly among women than in any other group, and it is expected that 13 million women will be infected by the year 2000 (Women and HIV National Workshop, March, 1995). Injection drug use is the second most frequent mode of HIV transmission for women in Canada.

 The report from the "Women and HIV National Workshop" (1995) provides us with an excellent overview of some of the factors, including biological, economic and cultural, which make women more vulnerable to HIV infection than men. Often health providers and women themselves do not consider themselves at risk unless they themselves are engaging in, or have a history of risk behaviour (e.g., IDU, sex work). Lesbian women also are unlikely to consider themselves at risk. These situations result in limited diagnosis, education, prevention and treatment opportunities. As well, emotional and financial dependence on men, and threats of domestic violence, often prevent women from protecting themselves in terms of needle-sharing and sexual relations. Additionally, when women have sexually-transmitted diseases (STDs), they very often have no symptoms. The STDs therefore go untreated. This, combined with the fact that having an STD increases the likelihood of contracting HIV, creates another high-risk situation for women. Finally, the possibility of transmitting HIV during pregnancy and breastfeeding is another uniquely female issue.

Recommendations:

 1. Key players must be educated concerning the unique problems facing women, and how to address them.

How?

• Train health care professionals regarding diagnosis, treatment and prevention of HIV in women IDUs.
• Inform health care professionals of the special risks for young women working in the sex- trade.
• Provide self-esteem training and skill-development for IDU women and non-IDU women who are sexual partners of IDU men.
• Focus on transferring knowledge on reproductive choices to professionals and women (sexuality, conception, pregnancy termination, use of HIV medications in pregnancy).
• Convey information on effects of methadone treatment while breastfeeding.
• Provide resources to assist women IDUs in the care of their children and families while dealing with HIV and/or AIDS, especially outreach programmes.
• Facilitate the development of accessible peer support groups for street-involved women so they can share practical strategies for protecting themselves.

How?

• Include IDU women in the development of policy, programmes and research.
• Include gender-balance as part of all research.
• Conduct research into the relationship between sexual abuse and HIV, as well as the intersection of physical abuse, substance use and HIV.
• Develop and make available women-controlled methods of HIV prevention (e.g. female condom, microbicides).

• women's organizations
• women
• all health professionals and their associations/colleges
• community-based AIDS service organizations
• Canadian AIDS Society (CAS)
• Research Community

Conclusion

APPENDIX A
References

 Cohen, J and Shamroth, A. (1990), The Challenge of Illicit Drug Addiction in General Practice Drug and Alcohol Dependency, 25 (315-318).

 Cook, D.A., Patrick, B.M., Rekart, M.L., Middleton, P.J., Strathdee, S.A., Spencer, D., Rees, T., MacDougall, R. & Marcin, K. (1996) Enhanced surveillance for HIV infection in British Columbia, Canada. Presented at the XI International Conference on AIDS, Vancouver, B.C.

 Fisher, B & Rehm, J. (1997), Personal Communication. The case for a heroin substitution treatment trial in Canada. Submitted to Canadian Journal of Public Health.

 Grandy, T. (1995), New Occupational Hazards of Career Addicts: Main Line Intravenous Needs Assessment (MINA). Document prepared by Main Line Needle Exchange with funding from Health Canada.

 Hankins, C. (1997) Syringe Exchange in Canada: Good but not Enough to Stem the HIV Tide. International Journal of Addictions. In Press.

 Hankins, C., Tran, T. & Desmarais, D. (1997) Moving from surveillance to the measurement of program impact: CACTUS–Montreal Needle Exchange Program. The CACTUS Evaluation Team. 6th Annual Canadian Conference on HIV Research. Ottawa, 22- 25 May, 1997.

 Hanvelt, R. & Meagher, N. (1996). HIV/AIDS Prevention Programmes in Canada: Economic Framework for Evaluation. Paper prepared for the Canadian Policy Research Network .

 Holmberg, S.D. (1996). The estimated prevalence and incidence of HIV in 96 large US metropolitan areas. American Journal of Public Health, 86(5): 642-654.

 Jürgens, R. (1994) HIV/AIDS in Prisons: Final Report of the Expert Committee on AIDS and Prisons. Correctional Services Canada (ECAP).

 Jürgens, R. (1996). HIV/AIDS in Prisons: Final Report. Montreal: Canadian HIV/AIDS Legal Network and Canadian AIDS Society.

 Jürgens, R. (1996). Bill C-8–the Impact of Canada's Drug Laws on the Spread of HIV. A Joint Submission to the Standing Senate Committee on Legal and Constitutional Affairs by the Canadian HIV/AIDS Legal Network and the Canadian AIDS Society. April 15, 1996.

 LCDC (Laboratory Centre for Disease Control) (1996). Epi Update, Bureau of HIV/AIDS and STD, Health Canada.

 Lurie, P. & Drucker, E. (1997). An opportunity lost: HIV infections associated with lack of a national needle-exchange programme in the USA. The Lancet, Vol. 349, No. 9052, 604- 608.

 Patrick, D.M., Strathdee, S.A., Archibald, C.P., Ofner, M., Craib, K.J.P., Cornelisse, P.G.A., Schechter, M.T., Rekart, M.L. & O'Shaughnessy, M.V. (1997) Determinants of HIV seroconversion in injection drug users during a period of rising prevalence in Vancouver. International Journal of AIDS and Sexually Transmitted Diseases (In Press).

 Second National Workshop on HIV, Alcohol and Other Drug Use. Co-hosted by Health Canada, the Canadian Centre on Substance Abuse, the Alberta Alcohol and Drug Abuse Commission, and the Alberta Health AIDS Programme. Funded by the AIDS Education and Prevention Unit and the Alcohol and Other Drugs Unit, Health Canada, Edmonton, Alberta, February 6-9, 1994.

 Strathdee, S.A., Patrick, D.M., Currie, S., Cornelisse, P.G.A., Rekart, M.L., Montaner, J.S.G., Schechter, M.T., & O'Shaughnessy, M. (1997) Needle exchange is not enough: Lessons from the Vancouver Injection Drug Use Study. AIDS (In Press).

 Wilson, P., Watson, R. & Ralston, G.E. (1995). Supporting Problem Drug Users: Improving Methadone Maintenance in General Practice. British Journal of General Practice, 45 (398, 454-455.

 Women and HIV National Workshop (1995). A National Workshop to Enhance Networking and Collaboration between the Affected Community, Educators, Health and Social Service Professionals, and Researchers. McGill AIDS Centre, Montreal.

APPENDIX B
Terms of Reference

 to develop a clear, action-oriented, targeted National Action Plan on HIV, AIDS and Injection Drug Use, focusing on the most urgent priorities which can be implemented rapidly. The underlying philosophy of the Action Plan reflects a commitment to harm reduction in the interest of achieving the lowest possible incidence of HIV associated with injection drug use.

 the Task Force represents the collective experience and expertise of individuals from various backgrounds including drug users, police, addictions, HIV/AIDS, First Nations, public health, pharmacy, governments, law, and includes broad geographical representation as well as representation by gender and sexual orientation.

 to address strategic policy and programme issues in order to produce an action plan that includes principles and values, barriers, gaps, goals and strategic actions to be used by all responsible agencies and relevant jurisdictions in Canada to coordinate resources, act in partnership and advocate for necessary changes to reduce the harm associated with injection drug use

 to identify the most effective strategies for packaging and disseminating the action plan so as to encourage implementation and engender ownership of the Action Plan at all levels.

APPENDIX C
National Task Force on HIV, AIDS and Injection Drug Use

 Kevin Barlow
Atlantic First Nations Task Force on AIDS

 Shaun Black
Nova Scotia Drug Dependency Services

 Valerie Cartledge
Advocate, Ex-User

 Claire Dineen
Canadian AIDS Society

 Doug Elliott
Canadian Bar Association

 Ken Higgins
Canadian Association of Chiefs of Police

 Brian Kearns
Alberta Alcohol and Drug Abuse Commission

 Perry Kendall
Addiction Research Foundation of Ontario

 Pat Matusko
Manitoba Health

 Michael O'Shaughnessy
B.C.Centre for Excellence in AIDS

APPENDIX D
Recommendations

Policy and Legislation:

• In view of the seriousness of the problem and the multi-sectoral nature of the solutions required, the federal Minister of Health should take the lead in ensuring a coordinated and integrated response to all recommendations in this National Action Plan.
• Continue or renew national strategies to address HIV/AIDS and substance use with appropriate levels of funding, directed primarily at community-based initiatives.
• Foster formal linkages and permanent mechanisms for consultation and communication among all relevant players, including the criminal justice and health systems, as well as social services.
• Ensure funding exists for alternative programmes in prevention, drug treatment and diversional sentencing to community programmes, including those implemented under Bill C-41 (Alternative Measures).

• In the case of currently illegal drugs, this could include counselling, treatment, community service, and so onExisting funds should be allocated to these programs and, in addition, funding should be increased through innovative options such as the following:
1. 50% of the revenues produced through Anti-Drug Profiteering/Proceeds of Crime cases,
2. A 25% surcharge placed on all fines to drug traffickers,
3. A 10% surcharge added to the cost of bringing an action to the courts.

• Ensure all provinces become signatories to Bill C-41, and develop nationally coordinated implementation strategies.
• Ask that the Health and Enforcement in Partnership (HEP) Steering Committee consider all recommended policy issues and facilitate implementation within their respective departments.

• Provide specific exemptions under the legislation to ensure that physicians may prescribe narcotics (e.g., heroin, cocaine) to drug users in an effort to medicalize drug use and reduce harm associated with obtaining drugs on the street (e.g. English Model). Research to assess the feasibility of this approach should be undertaken on a pilot basis.
• Decriminalize the possession of small amounts of currently illegal drugs for personal use.
• Institute heavy penalties for the commercial trafficking of any drug to minors.
• Initiate discussions among judges, prosecutors and police officers to address the lack of national consistency in the application of laws. For a variety of reasons, but not the same reasons, these sectors are now exercising the maximum of discretion to the point that, while the use of currently illegal drugs is intended to be addressed by statute laws, the existing national laws no longer deal with the reality of a nationwide problem. (This discussion is made all the more necessary by the increasing use of diversion in the justice system and new initiatives by the health service aimed at drug users.)

 (The reader is directed to the document "HIV/AIDS in Prisons: Final Report" by Ralf Jürgens, 1996, for a full examination of correctional issues and accompanying recommendations.)

• Allow prisoners who have been in a methadone maintenance programme prior to incarceration to continue to receive such treatment in prison.
• Ensure methadone treatment is available to opiate-dependent prisoners who were not receiving it prior to incarceration.
• Institute programmes to evaluate the need for methadone maintenance therapy prior to prison release, and ensure priority transfer to community programming on the outside at release.
• Conduct pilot programmes of needle exchange in federal and provincial correctional settings.

• Involve IDUs in all aspects of research.
• Continue to monitor HIV rates and use this information fully in developing new policies and programmes.
• Investigate local transmission patterns of HIV in IDUs.
• Fund additional research to determine the extent of diversion of prescription opiates to the black market.
• Include quantitative, qualitative and ethnographic methodologies in research designs in order to increase the usefulness of data to policy and programme development.

Prevention/Intervention:

• Actively involve drug users in policy development, programme planning and implementation for prevention, care and support, as well as in evaluation.
• Create community-based peer-support and advocacy groups for drug users, and integrate drug users into existing organizations.
• Develop programmatic inter-agency and inter-disciplinary links (mental health, addiction, acute care, community hospitals, HIV treatment).
• Promote awareness, recognition and acceptance in the justice system and in law enforcement that addiction is better dealt with as a health and social issue than a criminal one.
• Improve diagnostic and treatment capabilities of physicians, nurses, pharmacists, etc., through focused, cross-disciplinary education at the undergraduate level and through continuing education.
• Provide training and information to the judiciary and others in the criminal justice system on the link between HIV and AIDS, and IDU, as a health issue.
• Promote harm reduction as a necessary component of a range of strategies when developing programmes and policies.
• Enhance intersectoral responsibility at all levels of government, recognizing that HIV/IDU encompasses health, social and corrections considerations.
• Examine, and change where necessary, policies and procedures of professional bodies (e.g. physicians, pharmacists) to make sure they facilitate harm reduction and encourage the involvement of members in caring for injection drug users.
• Involve all partners and especially community organizations in promoting needle exchange and disposal as health and safety issues (e.g., availability of needle exchange programmes and appropriate, accessible disposal facilities reduces the likelihood of injury to children, janitorial staff, and others, that can result when needles are improperly discarded in playgrounds and other locations).
• Develop other partnerships to enhance this process (e.g., persons with diabetes and their organizations).

• Provide access to needle exchange in the community, and integrate with a broad range of health services (including health promotion, nutrition, self-esteem training, safe injecting practices) rather than marginalize this one service. Expansion of alternative sites such as hospital Emergency Rooms, Public Health clinics, community-based clinics and pharmacies must be considered in order to achieve decentralization.
• Encourage every pharmacy in the country to sell needles, advertise needle exchange services in the community, and offer disposal services in conjunction with local health authorities.
• Consider giving community awards to pharmacists for their support in order to encourage their continuing involvement, as well as that of their peers.
• Purchase needles for community programming in bulk for an entire city, as in Montreal, or for a whole province, as in B.C. This is a cost-cutting measure which would allow more needles to be made available.
• Offer needles on their own and as part of a package including alcohol swabs, condoms, lubricant, pamphlets, pharmacy addresses, etc.

• Revoke the need for physicians to have authorization from the federal minister of Health to prescribe methadone. Revoking the need for authorization will allow physicians to prescribe methadone like any other drug, making methadone more accessible.
• Dramatically increase the availability of methadone treatment, at a minimum increasing the total number receiving treatment from the current 3,600 to 7,200 within 18 months.

• Reduce and eliminate other barriers to being on methadone, and base decisions regarding methadone carrying privileges on reliable and responsible behaviour of the individual.
• Create a central coordinating agency to link users and doctors at the local level so that users know how to access methadone services.
• Make appropriate training available to physicians to encourage their involvement in providing methadone treatment to injection drug users, now that administrative limitations have been removed (Bureau of Drug Surveillance, April 1, 1996).
• Encourage programme planners to undertake study visits to innovative and cost-effective methadone programmes such as those in Vancouver, Halifax and Edmonton, with a view to replication at other sites across the country.
• Add a product monograph for methadone to the Compendium of Pharmaceuticals and Specialties (CPS) for quick physician access.
• Communicate the results of research on the effects of methadone on pregnancy and breast-feeding to practitioners and the general public, especially women (e.g. enter information in the Compendium of Pharmaceuticals and Specialties).
• Investigate other alternative drug therapies, beyond methadone, such as buprenorphine, naltrexone and LAAM (L Alpha Acetylmethadol).
• Set up a low threshold maintenance programme as a pilot project in one or more sites with the explicit goal of reducing injection frequency in heroin users.

• Make pharmacies a focus of disposal efforts. Incentive for this could be built through collaborating with the appropriate governing bodies for pharmacists and pharmacy owners directly.
• Consider installing community disposal containers which are secure from tampering and strategically located for the injecting community.
• Analyse locations where there are more returns than needles distributed to shed light on what information might assist sites with less successful return rates.
• Inform IDUs how to safely dispose of needles in case they are unable or unwilling to bring them back to the available service or other location.

Treatment:

• Provide treatment options which do not require total abstinence from all drugs. Evidence of drug use should not, alone, be a barrier to drug or HIV treatment. Treatment can be supplemented by incorporating complementary harm reduction approaches to address the ongoing drug use, such as teaching safer injection practices, how to care for abscesses, and improved nutrition.
• Ensure the availability of treatment services where providers are knowledgeable about both substance use and HIV.
• Coordinate services currently addressing only one aspect of the treatment issue (i.e., HIV, AIDS, or substance use).
• Ensure each person seeking treatment is evaluated and offered anti-retroviral drug therapies meeting current standards of care.
• Develop cocaine-specific treatment options.
• Investigate the potential health risks of individuals using combinations of pharmaceutical/therapeutic and recreational drugs. Although there is some information available concerning their interactions (Ciraulo et al., 1989), more research and information is required.
• Conduct clinical trials of prescription morphine, heroin and cocaine as alternative approaches, such as are being done in other countries (United Kingdom, Switzerland).
• Involve all partners in a client-centred, integrated service delivery approach, in order to facilitate higher quality, comprehensive, consistent and cost-effective care.
• Develop alternative delivery systems for drug treatment in comprehensive care clinics, designed with community participation, and licensed by the province (this can be accomplished outside legislative changes, through Statutory Amendments to the Criminal Code). For instance, methadone programmes could be provided at community health clinics rather than only through fee-for-service physicians.
• Enhance continuing education programmes for primary care physician networks of prescribers.
• Ensure a full spectrum of treatment options, including anti-retroviral drugs, are available to those in corrections facilities.
• Educate health care workers in prisons about the side effects of HIV medications and other related issues.

• Encourage each community to develop a "best practice" guideline for physicians, adapted to local community needs and resource availability, and linked to cost-effectiveness (e.g. Halifax has created a Community Methadone Advisory Committee composed of users, health care professionals and methadone clients, which contacts physicians and pharmacists to inform them of the need and value of the Community Methadone Service).
• Establish a mentoring system/programme for physicians, nurses and related professionals.
• Provide regular and ongoing training to those providing services at health centres, substance use programmes, HIV/AIDS programmes, etc.

Aboriginal Peoples:

• Provide training opportunities to Aboriginal people to ensure that Aboriginal communities can design and undertake research initiatives for themselves.
• Learn from Aboriginal communities and apply teachings in non-Aboriginal agencies, since many Aboriginal people may opt to access these organizations.
• Obtain information concerning Aboriginal origin, and ethnicity, at all data-gathering sites and in all studies.
• Supplement existing AIDS data with HIV prevalence and incidence information.
• Conduct research to address the unique concerns of Aboriginal peoples, such as the younger than average age at which they become infected, the higher incidence of injection drug use as a mode of transmission, steadily increasing HIV rates, and over-representation in correctional settings.

• Convene a meeting of spiritual leaders from different Aboriginal communities, and elders in particular, to address the harms associated with injection drug use and to consider harm reduction approaches.

• Recognize cultural diversity within Aboriginal populations (First Nations, Inuit, Métis) and account for it when developing any policies, programmes and research.
• Recognize that many adults - including current Chiefs and elders–may have been affected by factors such as alcoholism and childhood sexual abuse, which will often affect responsiveness to the current crisis and recommended approaches.
• Encourage communities to use existing cultural practices to mobilize the community and address its problems.
• Provide training to all existing service providers, Aboriginal and non-Aboriginal alike, to heighten cultural sensitivity to, and awareness of, the overlapping risk-factors for this population, such as racism and homophobia.
• Acknowledge the unique needs of Aboriginal women and develop appropriate responses for issues such as their role as caretakers of the culture, the relationship between high rates of sexually-transmitted diseases and HIV, the need for anonymous, confidential HIV testing.
• Promote information sharing about Aboriginal initiatives and AIDS education programmes which are successful.

• Provide support, financial and otherwise, for the Canadian Aboriginal AIDS Network (CAAN).
• Address jurisdictional issues regarding who is entitled to services delivered by different levels of government, as well as the "on versus off reserve" issue. HIV does not respect this arbitrary division of service provision. Access must be facilitated.
• Link native HIV, AIDS and IDU programmes with provincial services to lessen the over- reliance on reserves which has been the trend until the present.

Women:

• Train health care professionals regarding diagnosis, treatment and prevention of HIV in women IDUs.
• Inform health care professionals of the special risks for young women working in the sex- trade.
• Provide self-esteem training and skill-development for IDU women and non-IDU women who are sexual partners of IDU men.
• Focus on transferring knowledge on reproductive choices to professionals and women (sexuality, conception, pregnancy termination, use of HIV medications in pregnancy).
• Convey information on effects of methadone treatment while breastfeeding.
• Provide resources to assist women IDUs in the care of their children and families while dealing with HIV and/or AIDS, especially outreach programmes.
• Facilitate the development of accessible peer support groups for street-involved women so they can share practical strategies for protecting themselves.

• Include IDU women in the development of policy, programmes and research.
• Include gender-balance as part of all research.
• Conduct research into the relationship between sexual abuse and HIV, as well as the intersection of physical abuse, substance use and HIV.
• Develop and make available women-controlled methods of HIV prevention (e.g. female condom, microbicides).