Amidst all the good news that Insite, Canada's first and only safe injection site, has effectively been legalized in BC after years of court battles and harassment by the drug-hating Harper Government, there is one small cloud. You could almost overlook it, in fact, in the jubilation.

The cloud? The responsibility for approving safe injection sites like Insite now becomes a matter of provincial jurisdiction. That is as it should be – provinces are responsible for most health matters.

That’s good news if you live in an NDP or Liberal-led Province. Not so good news if your province has a conservative government in power. And with a provincial election looming in Ontario which could see the Liberals toppled, that’s potentailly not good for Canada’s largest city, Toronto.  So whether a safe injection site - or two - appears in our neck of woods anytime soon, despite the need, despite the demonstrated benefits, is very much up in the air.

So I suspect we'll see the battles we've followed from afar in BC mirror themselves in Ontario, as the need for safe injection sites here becomes the advocacy issue du jour.

Still, the Supreme Court ruling IS cause for rejoicing, because the Canadian social justice/public health agenda has just taken a giant step forward.

There have been few proponents of Insite more vocal than the Hon Libby Davies, the outspoken NDP MP for Vancouver East and long-time friend of the HIV/AIDS community, who is quoted in the Globe and Mail article below. I was there to hear Libby talking on the subject at the North America Housing and HIV/AIDS Research Summit in New Orleans last week. As soon as she started talking about Insite, I whipped out my camera and set it on video.  While the video footage is strictly amateur, Libby is wonderful.  That video is at the end of this post.

By the way, while there, I interviewed Libby on camera for the PositiveLite/Ontario HIV Treatment Network (OHTN) collaborative project to provide video content for both websites, and I’m sure that interview will be polished, edited and ready soon. So consider this a stop-gap solution to bring something to you fast.

Anyway, here’s the Globe and Mail breaking the Insite story this morning. This is an abridged version; the actual story itself is lengthy but well worth reading. It’s here.  

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The Supreme Court of Canada has opened the door to supervised drug injection clinics across the country in a landmark decision on Friday that ordered the federal government to stop interfering with Vancouver’s controversial Insite clinic.

The Court was persuaded by evidence that drug addicts are considerably safer administering their own injections under medical surveillance rather than obtaining and injecting hard drugs on the streets of the city’s troubled Downtown Eastside.

Supreme Court decision to keep drug injection clinic met with rants, raves In its 9-0 decision, it said the federal government has the jurisdictional right to use criminal law to restrict illicit-drug use – but that the concerns it cited in an attempt to close Insite were “grossly disproportionate” to the benefits for drug users and the community.

“During its eight years of operation, Insite has been proven to save lives with no discernible negative impact on the public safety and health objectives of Canada,” the Court said. “The effect of denying the services of Insite to the population it serves and the correlative increase in the risk of death and disease to injection drug users is grossly disproportionate to any benefit that Canada might derive from presenting a uniform stance on the possession of narcotics.”

In ordering the Harper government to exempt the clinic from prosecution for its activities, the Court said that the government cannot simply close down clinics based on its own distaste for legally sanctioned drug injections.

It said that the consequences of interrupting the work of the clinic could have such “grave consequences” that only a direct court order can be assured that the spirit of the judgment would not be circumvented.

Leona Aglukkaq, the federal Health Minister, said her Conservative government is taking a close look at the ruling.

"Although we are disappointed with the Supreme Court of Canada’s decision today, we will comply," Ms. Aglukkaq told the House of Commons.

"As part of our strategy, we have made significant investments to strengthen existing treatment efforts through the treatment action plan. "We will do our part and do the due diligence and review the Supreme Court decision."

Libby Davies, the New Democrat MP who represents Vancouver’s downtown eastside, applauded the Supreme Court. “It has validated all of these years of struggle and work to show that Insite is a very important resource and service and it saves lives," she said.

The federal Conservative government has consistently failed to pay attention to evidence and the real experience in the community, Ms. Davies said. “So I really hope that today’s decision is a moment of opportunity and reflection and for Mr. Harper and his government to think about the importance of this service and to say to themselves that when something is working so well locally, they should not be a barrier; they should not be standing in the way of something that is proven to be a very important medical intervention to help save lives," she said.

Hundreds of people gathered outside the Insite clinic to watch the decision on a live video stream. Cheers broke out, some people hugged, others cried, when Liz Evans of the Portland Hotel Society yelled, “We won!”

Dr. Julio Montaner, who has conducted research into the Insite facility, said the court decision was “a victory for public health.”

“It is a very clear message to Stephen Harper that the time has come for him to abandon his ideology regarding addiction, HIV and other related matters and move on with the evidence,” he said.

In her judgment, Chief Justice McLachlin referred specifically to federal fears that the continued existence of Insite “raises the spectre of a host of exempt sites, where the country’s drug laws would be flouted with impunity.” On the contrary, she said, clinics will only exist without fear of prosecution if they are provably capable of reducing the risk of death and disease.

She said that the purpose underlying drug laws is to register societal disapproval of drug use, deter drug use and to prevent harm, yet the federal government's actions in withdrawing Insite's exemption contradicted those underlying purposes.

Insite was launched in 2003 under a special exemption from prosecution. Chief Justice McLachlin described its creation as a clear instance of cooperative federalism.

“Local, provincial and federal authorities combined their efforts to create it,” she said. “It was launched as an experiment. The experiment has proven successful. Insite has saved lives and improved health. And it did those things without increasing the incidence of drug use and crime in the surrounding area. The Vancouver police support Insite. The city and provincial government want it to stay open.”

In 2008, however, the Harper government became disenchanted with the notion of providing addicts with legally sanctioned hard drugs and ended the exemptions.

The move forged an immediate alliance between drug users, the medical community and across the province’s political spectrum. A coalition of groups wasted little time in asking the Courts to clear the way for Insite to continue operating, and the dispute became a major source of tension between B.C. and the federal government.

Supported by the B.C. attorney-general, the coalition was successful in persuading the B.C. Supreme Court and the British Columbia Court of Appeal to find Insite immune from the criminal prosecution under the doctrine of “inter-jurisdictional immunity.” But the Supreme Court overruled the lower courts on the finding of immunity, saying Ottawa has a clear right to administer the criminal law where it sees fit, provided it does not violate an individual’s Charter rights.

Still, by allowing the province to override federal anti-drug concerns, the judgment constitutes a slap in the face to the Harper government in a case had evolved into a major constitutional brawl between the two levels of government.

“It is a classic battle between the federal and provincial governments over the limits of two powers – criminal law and health care – which are mutually exclusive but have obviously conflicted in this case,” said Prof. Mathen.

The Chief Justice noted that supervised injection sites are being operated successfully in many other countries, including 70 cities in six European countries and in Australia.

“These sites are evidence that health authorities are increasingly recognizing that health care for injection drug users cannot amount to a stark choice between abstinence and forgoing health services,” she said. “Successful treatment requires acknowledgment of the difficulties of reaching a marginalized population with complex mental, physical, and emotional health issues.

The B.C. Health Ministry, which funds the facility, has cited numerous studies that showed Insite’s effectiveness in connecting vulnerable, at-risk injection drug users with health services. Vancouver Police also report no risk to the public from the site’s operation in the heart of the Downtown Eastside.

September 15, 2008 found me feeling rather lost and out of place in a dull-looking buidling, at least from the exterior, but which housed an impressively professional looking movie studio.  We were in an industrial area of East York (Toronto). I was there to film an interview for Top Drawer Creative, the ad agency GMSH (Gay Men’s Sexual Health Alliance) had engaged to produce the campaign for us.

It was an intimidating set-up. Real lights, drapes, BIG cameras, sound booms, a crew of half a dozen or more, a make-up studio. You can see the set-up in two of the pictures below.

Myself and the other interview subjects destined to appear on the campaign website, talking and blogging about stigma, weren’t even exactly sure what we were going to be asked. The decision had been made that spontaneous answers were the key. But James Murray, a colleague from GMSH who I trusted implicitly, was to be the interviewer, so that helped dampen the nerves.

There were eight of us in that campaign – four negative and four positive gay guys. I think there were four of us scheduled to be filmed that day.   I knew them to varying degrees. One of them was Brian Finch. We’d met briefly before; when I came in to the make-up room, it being almost time to go on, he was being worked on.

The rest is history. We did the interviews: you’ll see two of them below including Brian’s and the one from Murray Jose, the talented ED of PWA, both of whom did a great job. The Top Drawer people made us all look good in fact. I loved the edgy look they brought to the campaign that you’ll get a taste of in the interviews.

The stigma campaign (unfortunately the campaign website is no longer up) turned out to be an unexpectedly intense experience for all us, blogging for a full and sometimes exhausting six months about HIV stigma and its impact on HIV transmission. The campaign was web-based and designed to create a dialogue, using the slogan “If you were rejected every time you disclosed, would you?”  Those words, intentionally provocative,  came out of the sense that gay men don’t talk enough about their status – positive or negative – which leads to assumptions being made about status - and risk taking. Creating a dialogue around stigma was seen as a way to contribute to reduced risk taking, in fact. That dialogue was to be largely by way of blogging – a somewhat innovative approach at the time.

As the evaluation indicates – it’s referred to in the article below - that dialogue was especially rich. For this blogger at least, it was also transformative. The responsibility of fronting such a high-profile, province-wide campaign weighed heavily; we watched our words a lot, and often engaged in lengthy discussions about individual responses. (PositiveLite blogger Stephen Lincoln was our amazing coordinator/confidante in that process.)  In short we became immersed in all things HIV stigma for the length of the campaign, and even afterwards when some of us took it on the road.

I don't think many of us realized initially how big everything would become.  There was an enormous print and outdoor advertizing campaign aimed at directing people to the site.  Wellesley subway, the TTC (Toronto Transport Commission) station that serves Toronto's gay neighbourhood, was virtually taken over, for instance. You can see photos of this massive advertizing campaign throughout this post.  We were kind of in awe of it all at the time.

But it was all good. Particularly, the evaluation which indicated we did in fact make a measurable difference. You can read about that in the article which follows.

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(This article by Roger Pebody first appeared in aidsmap September 21, 2011.

Media campaign on disclosure and stigma changes gay men’s attitudes

A Canadian campaign which asked gay men “If you were rejected every time you disclosed, would you?” appears to have raised men’s understanding of the dilemmas which men with HIV face. The campaign also succeeded in reducing the number of men who try to avoid infection by relying on men with HIV disclosing their status, researchers report in the October issue of Health Education Research.

The campaign was not intended to broadcast a ‘message’ or give instructions, but to stimulate dialogue within local communities. Moreover the authors suggest that the extensive community consultation which went into its development contributed to the campaign’s success.

Staff from frontline HIV prevention work, public health, government and academia participated in the consultation which identified HIV-related stigma as a priority issue. Moreover they focused on stigma within gay communities as it is manifested in the attitudes of some HIV-negative men towards potential sexual partners who have HIV. The campaign developers believe that there are links between the problems of stigma, disclosure, conflicting assumptions and risk taking.

In particular, some of those involved in this project have previously researched gay men’s sexual interactions in which “potential partners interpret risk by bringing sometimes conflicting and inaccurate assumptions to bear in making decisions about safe sex”. For example, men may make different assumptions about a partner’s willingness to have unprotected sex, with some HIV-positive men assuming that only another positive man would do so, and some HIV-negative men thinking the opposite.

To further complicate the expectations and understandings of men seeking sexual partners, the Canadian judiciary has also asserted that disclosure of HIV status is an obligation for people with HIV before any sex in which there is a significant risk of HIV transmission.

Given the incompatibility of these different assumptions, the campaign was intended to allow men to move beyond the conversations they had within their own social circles and engage in “a more broad based community discussion” about stigma, disclosure and sexual decision making.

The campaign drew attention to itself through press advertising, outdoor advertising, online promotion and community outreach activities.

It was centred on the question “If you were rejected every time you disclosed, would you?”. This question was intended to be sufficiently provocative that it would encourage public reflection and conversation.

Moreover a key part of the campaign was its website. Blogs on the website written by eight different HIV-negative and HIV-positive men invited men visiting the site to respond to the issues raised and to post comments.

Over five months, the web site had 20,844 unique visitors (80% from Ontario), who stayed an average of six minutes per visit. Some 4,384 visitors came back to the site ten times or more.

The researchers describe the blog discussions as “lengthy and lively”. Topics included the sources, forms and consequences of HIV stigma; how to separate rejection of the virus from rejection of men who have the virus; the ethics and practicalities of disclosure of status; challenging stigma; and responsibility and consent in HIV transmission.

Evaluation

Despite the central role of behaviour change media campaigns in many countries’ HIV-prevention programming, careful evaluation of their impact remains rare.

The evaluation described here is not a randomised control trial (which provides the most reliable form of evidence), but assessed the impact of the campaign by means of cross-sectional surveys before and after the intervention. The campaign was promoted throughout the province of Ontario (including Toronto, a major gay centre) and was largely delivered via the internet, so it would have been difficult to identify a control group of gay men who were not exposed to the campaign and who had similar characteristics to those in Ontario.

Recruitment to the before and after web-based surveys was by identical means (an e-mail to local subscribers of a cruising website, www.squirt.org), and this was separate from delivery of the media campaign. A total of 1942 and 1791 men took part in the first and second survey, respectively. The characteristics of those taking part were broadly similar on each occasion.

Of those completing the second survey, 42% were aware of the campaign. Awareness was higher in gay-identified men, residents of big cities, men under the age of 45, better-educated men and men who reported unprotected sex with casual partners. Awareness did not vary by ethnic group or income. But far more HIV-positive men (68%) than HIV-negative men (42%) or men of unknown HIV status (31%) recalled the campaign, perhaps suggesting that its themes were particularly salient for men with HIV.

In terms of attitudes towards disclosure, the men who completed the pre-campaign survey had similar responses to the men who completed the second survey but weren’t aware of the campaign.

Moreover, comparing respondents of the second survey who were aware of the campaign with those who were not, there are statistically significant differences in their attitudes, even after controlling for confounding factors such as age, HIV status and sexual risk behaviour. The researchers believe that this shows the impact of the campaign on those who saw it.

Men who were aware of the campaign were more likely to agree that “gay men with HIV face stigma and discrimination within the gay community” (odds ratio 1.82) and that “gay men with HIV are reluctant to disclose their HIV status to their sexual partners because they do not want to be rejected” (odds ratio 1.48).

They were less likely to use terms like ‘clean’ or ‘disease-free’ when cruising for sex on-line (odds ratio 0.64) or to seek sexual partners with the same HIV status as a way to prevent HIV transmission (odds ratio 0.67).

They were also less likely to agree with the following statement: “If a gay man has HIV, there is no excuse for him not to talk about his HIV status before having sex with a new partner” (odds ratio 0.63). Nonetheless a large majority of respondents did agree with this statement – 85% of those unaware of the campaign, and 73% of those aware of it.

The authors believe that these results, along with the extensive activity and postings on the campaign website, “indicate that the site struck a chord with many community members and stimulated dialogues that likely spilled over into other contexts of daily life… Those who were aware of the campaign were significantly more aware of stigma and its role in HIV transmission at the conclusion of the intervention.”

Reference

Adam BD et al. hivstigma.com, an innovative web-supported stigma reduction intervention for gay and bisexual men. Health Education Research 26: 795-807, 2011. Click here for the free abstract.