HIV/AIDS: a public health perspective
HIV and AIDS: A Public Health Perspective is the result of the cumulative efforts of hundreds of public health professionals across Canada who engaged in an open, interactive and consensus-building consultation on the many complex, often confounding issues of HIV and AIDS. Public health professionals met in regional workshops, responded to draft reports and examined their own policies and practices in light of what their colleagues were doing in the field.
AIDS is the first major epidemic in this age of vaccines, pills, human rights legislation and activism. It raises questions such as how well traditional communicable disease control methods and public health law and practice work. The discussions in the workshops often centred on the dichotomy of policy and day-by-day practice. HIV and AIDS: A Public Health Perspective is a consensus document based on the advice of over 400 public health participants in the two national and four regional sessions held in 1991-92 and on the feedback from key informants and the broader AIDS-affected community. It provides an excellent framework for public health policy and practice for the future. It is the intent of the Canadian Public Health Association, its affiliated associations/branches and divisions and particularly its national AIDS Education and Awareness Program to promote the report and its recommendations.
A process such as this has required substantial time, energy and resources and would have been impossible without the support of the Federal, Provincial and Territorial Governments, CPHA Provincial/Territorial Branches and Associations and Divisions, the Planning Committee and Program staff. To all who participated, many thanks. Collectively we shall have a significant impact on public health practice in Canada.
Background to this Report
During the 1991 Annual Conference of the CPHA, a well-attended debate on the role of public health in HIV infection and AIDS was held. That forum demonstrated some of the strong feelings and divergent opinions that existed in the public health community on issues such as testing, partner notification and reporting practices.
As a follow-up to that debate, the CPHA AIDS Education and Awareness Program developed a 16-month process for gathering input from the public health community and its partners, to clarify the public health perspective on issues in HIV infection and AIDS.
The Discussion Process
The process of arriving at the publication of this document included the following steps:
- A workshop planning committee, made up of public health professionals active in the field of HIV and AIDS and representatives of the CPHA AIDS Education and Awareness Program, structured a flexible workshop design that invited participants to identify and explore the public health issues in HIV and AIDS.
- Over 400 people from the public health community participated in the national forums and regional workshops: in Calgary (October, 1991), Halifax (March, 1992), Toronto (April, 1992) and Montreal (June, 1992). The four workshops were designed to:
- provide a forum for discussion, exchange and debate about AIDS and HIV issues within the professional public health community;
- further a national discussion process;
- explore the key issues in detail; and
- develop principles and recommendations for policy and program action in each issue area.
- A report that compiled the ideas and recommendations of the four regional workshops was then discussed at a National Forum on HIV and AIDS Issues in Public Health, held at the CPHA Annual Conference in Yellowknife on July 6, 1992. Participants in that workshop confirmed the legitimate role of public health in HIV and AIDS education, supportive environments, counselling, prevention, testing and disease surveillance. They called for a consistent public health response to the HIV and AIDS pandemic that emphasizes prevention and collaboration at all levels.
- Comments from the Yellowknife workshop were incorporated into a draft document that was circulated to CPHA's major partners in the field, as well as to selected experts and the participants from each workshop.
- Comments from external reviewers fell into two categories:
- editorial or explanatory comments that improved and enriched the text (these were added); and
- substantive content comments that expressed differing or additional views from what was said during the workshop process. These are noted in Section IV of this report. To be true to the discussion process and the degree of consensus reached, they could not be fully integrated into the text.
In total, approximately 500 people participated in the process.
Organization of this Report
The first section of this report briefly introduces the public health community with reference to the role of public health in HIV and AIDS.
The next four sections are organized around four broad public health goals in HIV and AIDS. These goals fall out of the common themes that arose in the regional workshops.
Goal 1. Emphasize prevention and education
Goal 2. Create and ensure supportive environments
Goal 3. Ensure effective management of HIV cases
Goal 4. Clarify and promote the role of public health in dealing with HIV and AIDS
The opening text within each goal reflects the discussion process. Participants in the workshops identified principles for each issue and examined the implications of those principles for public health practice. They then went on to make recommendations for action to the various stakeholders in the field of HIV and AIDS.
A principle was defined as a lofty and idealistic idea or belief (what we should do); the implications examine what a principle means in practice (how we are going to do it). The idea of "sticking to principle instead of position" was helpful in resolving areas of non-agreement. Areas that evoked the greatest debate included reportability of HIV seropositivity, proposals to advocate the legalization of prostitution and the decriminalization of drug use, the efficacy and appropriateness of partner notification and the handling of difficult cases. In each of these areas, most participants were in agreement with the lofty principles of public health. Areas of disagreement tended to focus on operationalizing the principles. The substantive comments in the final review that could not be incorporated within the text are provided in Section IV.
The recommendations for action (Section V), which are summarized in a chart on pages 26-30, suggest the main groups that need to take action on each recommendation. The recommendations are listed under five strategic headings: advocacy and policy, education and awareness, legislation, professional education and training, and research and evaluation. In framing these recommendations, participants identified two important factors:
- While the chart suggests lead agencies, effective action in the field of HIV and AIDS requires that all the stakeholders work collaboratively.
- The recommendations fall out of idealistic principles of best practice. They only become realistic when the required resources are available, and when there are consistent, long-term efforts to support the work of all partners in the field.
- This report will form the basis of a position paper on HIV and AIDS to be prepared by the Sexual Health Division of CPHA and forwarded to the membership for consideration and ratification at the 1993 annual meeting of CPHA. Resolutions and motions will arise out of the position paper.
- The AIDS Education and Awareness Program will bring those recommendations that identify CPHA as a lead agency to the attention of the CPHA Board of Directors, the CPHA AIDS Advisory Committee and appropriate Divisions, with a proposal for appropriate follow-up, in collaboration with our partners.
- This paper will be distributed to all the major stakeholders. CPHA will urge its partners and governments at all levels to consider the recommendations that affect them and to take action as appropriate.