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According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), the number of people living with HIV reached its highest level ever in 2004.1 Almost 5 million people became newly infected making the total number of people living with HIV/AIDS worldwide nearly 40 million.
Although HIV/AIDS in Canada does not show the same increases, the domestic epidemic continues to be serious. Updated surveillance data released by the Public Health Agency of Canada (PHAC) in April 2005 show that a total of 57,674 positive HIV tests were reported to PHAC between November 1985, when reporting began in Canada, and December 31, 2004.2 The number of positive HIV test reports has increased by 20 per cent over the past five years, from 2,111 in 2000 to 2,529 in 2004. The new surveillance data also reveal that a total of 19,828 AIDS diagnoses in Canada had been reported to the end of 2004 (however, data were not available from Quebec for 2004).
Significant changes in the Canadian HIV epidemic were noted in the surveillance report including a rise in the proportion of positive HIV reports from females from 10% in 1985-1994 to 25% in 2004. The epidemic among different ethnic groups is also changing with an increasing proportion of AIDS cases attributed to Aboriginal persons (2.3% in 1994 to 14.8% in 2004) and Black Canadians (8.3% in 1994 to 15.5% in 2004). Although the epidemic is changing, men who have sex with men and injection drug users remain high risk populations.
It is clear that despite efforts, there is not enough being done to significantly impact the epidemic.
The Federal Initiative to Address HIV/AIDS in Canada (FI-HIV/AIDS) - was announced by the Minister of Health on January 13, 2005. The Federal Initiative is an evolution from the previous Canadian Strategy on HIV/AIDS (CSHA). It builds on recommendations from the Standing Committee on Health, lessons learned from past federal HIV/AIDS strategies, and consultations with stakeholders, provinces and territories.
The initiative provides a doubling of funds by 2008/09 for a renewed and strengthened federal role in the Canadian response to HIV/AIDS. It encompasses elements of the human rights, social justice and determinants of health approaches to HIV/AIDS, and is an important step towards a fully integrated Government of Canada response to HIV/AIDS. The FI-HIV/AIDS is a partnership of PHAC, Health Canada, the Canadian Institutes of Health Research (CIHR) and Correctional Service Canada (CSC).
One component of a comprehensive federal response to HIV/AIDS is a strong and productive research program. Through research into the physical, psychological and societal impacts of this devastating disease, Canada continues to make important contributions to the global situation. Through efforts in basic biomedical research, Canada is also helping to improve understanding of the evolving virus.
As one of the four funded partners in the FI-HIV/AIDS, CIHR, led by the Institute of Infection and Immunity, has the responsibility of identifying research priorities for and administering the extramural research program. Approximately 25% of the funding made available to the FI-HIV/AIDS is reserved for CIHR for research. The CIHR-HIV/AIDS Research Initiative accomplishes its goals by developing strategic funding opportunities and providing funding for research projects and training and salary awards, which support researchers throughout their careers. In this way, CIHR is seeking to do its part to eradicate the disease.
In addition to establishing priorities and developing strategic research programs for extramural CIHR-funded HIV/AIDS research, CIHR will also partner with the Pubic Health Agency of Canada in the coming years on the development of a comprehensive national HIV/AIDS Research Plan. This national HIV/AIDS Research Plan will bring together many funders of HIV/AIDS research in Canada, research programs conducted in federal, provincial and territorial laboratories, users of research knowledge and other stakeholders in developing a shared vision for the future of HIV/AIDS research in Canada.
The CIHR HIV/AIDS Research Initiative is advised by the CIHR HIV/AIDS Research Advisory Committee (CHARAC). CHARAC is struck as a sub-committee of the Institute of Infection and Immunity Advisory Board and is chaired by a member of that Board. To ensure the appropriate expertise and knowledge is available to the Committee, its members represent multiple CIHR Institutes, HIV/AIDS researchers, the Ministerial Council for HIV/AIDS, the Public Health Agency of Canada and broader community organizations. This composition allows for in depth knowledge of all aspects of Canadian HIV/AIDS research, an understanding of the complex dynamics of the HIV/AIDS community and an ability to make recommendations on research policies and programs that would be supported by all of CIHR. Such membership also enables the Committee to be a voice for HIV/AIDS researchers within CIHR, and encourages communication between stakeholders interested in HIV/AIDS research.
CHARAC reports, via the CIHR Institute of Infection and Immunity Advisory Board and Scientific Director, to the CIHR Research Priorities and Planning Committee (RPPC) which is composed of 13 institute Scientific Directors, 4 CIHR Vice-Presidents and is chaired by the President. This reporting ensures that the work of CHARAC has an impact which spans all 13 CIHR institutes.
CHARAC met on October 7, 2005 to undertake the exercise of identifying draft priorities for CIHR-funded extramural HIV/AIDS research to be conducted under the FI-HIV/AIDS over the next few years. These priorities will be used to guide the development of CIHR's strategic research funding opportunities in HIV/AIDS.
This priority setting exercise was facilitated by an external contractor to ensure objectivity and progress. Prior to the meeting, CHARAC members were provided with a synthesis of priorities and objectives offered in previous direction setting meetings, transformative documents and researcher meetings (Appendix A) to stimulate thinking of potential discussion points. Sources include the Standing Committee on Health Report on HIV/AIDS, Leading Together and the Federal Initiative to Address HIV/AIDS in Canada.
Before the deliberations on potential priorities began, a preliminary report of an environmental scan being undertaken on the state of HIV/AIDS research in Canada was presented. This report gives broad information about Canadian HIV/AIDS research funding from across provincial and federal sources as well as key non-governmental organizations. The final report will further refine such information to attempt to identify strengths and weaknesses in the Canadian research environment.
During the priority setting exercise participants were asked to discuss and deliberate around the previously suggested theme areas presented in Appendix A and to identify gaps where more emphasis was required. Decisions were made by mapping suggested themes against previously identified criteria for establishing research priorities (Appendix B). From the initial extensive list of potential priorities, a list of seven important areas was created. This list was then prioritized by having CHARAC members identify the priorities they deemed most important according to their knowledge and role in the HIV/AIDS environment. The remaining seven priorities are listed below in order of suggested priority. The top four priorities were identified as those that will receive initial attention and development.
The list of proposed priorities for the CIHR extramural research program is driven by the need to take into account the complex and diverse range of issues contributing to transmission, treatment and care. The proposed priorities are responsive to all aspects of HIV/AIDS from the behavioural basis of risk and acquisition, population specific factors affecting access to care, testing and treatment (gender, age, ethnicity, etc.) and the basic biomedical advances in understanding the virus and developing new therapies.
The priorities reflect areas which currently need addressing through strategic initiatives such as targeted requests for applications. The priorities are not intended to lessen the importance of other areas of HIV/AIDS research which will remain eligible for funding through regular CIHR open competitions.
Access to testing, care, treatment and prevention services are fundamental to our ability to get ahead of the disease. Understanding the barriers to accessing care and the factors that promote or impede access is important to ensuring sound decision making and policy direction in the health care setting. Ensuring a strong and vibrant community of human health resources must also be considered.
Along with increased access to care and services comes an associated increase in the economic draw on the health care budget. As prevention research progresses and new strategies and technologies are proven effective, types and standards of care change. The impact of greater access to HIV/AIDS programs and services must be understood to better anticipate and predict shifts in trends and to redirect related policy.
Key areas of research
In populations with known risk factors, difference in prevalence in some communities may provide clues and offer insight into resistance. Resilience, as opposed to vulnerability, assists in defining the determinants of health which lead to differences in infection rates.
Key areas of research
HIV/AIDS has an impact which reaches further than that of an individual to the greater society. Significant disparities exist between populations with factors ranging from race to poverty to cultural beliefs. Research which contributes to understanding the consequences of infection on communities as well as the individual is required.
Key areas of research
The most effective way of addressing the increasing transmission rates and reducing the spread of HIV/AIDS remains prevention. Both behavioural, social and medical interventions contribute to the overall prevention of HIV/AIDS. Basic biomedical research in prevention interventions such as vaccines and microbicides as well as culturally sensitive behavioural and social interventions will be supported.
Key research areas
The development of new and more effective drug therapies, including combination and salvage therapies, for combating HIV infection is required. Although current treatments are effective in extending life for those infected with HIV there are serious complications associated with these treatments including drug toxicities and drug resistance. The identification of new less toxic regimens continues to be of great importance to those infected by HIV.
Key areas of research
Key areas of research
It is not unusual for individuals who become HIV infected to have, or remain vulnerable to, a host of conditions. This is in part due to the situations responsible for the initial infection such as substance abuse, mental illness, and homelessness. Both the risks and the consequences of HIV infection for these individuals must be evaluated and addressed in the context of these other conditions as well as developing treatments specific to the needs of co-infected individuals.
Key areas of research
HIV/AIDS as a research discipline is very broad; it encompasses all pillars of health research and affects many different populations. It is a discipline which is of interest and concern to many of CIHR's 13 Institutes. To ensure that all CIHR Institutes are informed of the priorities for extramural HIV/AIDS research, and to explore potential collaborations, the list of priorities identified by CHARAC was presented to the CIHR Research Priorities and Planning Committee (RPPC) in December 2005.
Involvement of stakeholders in decision making is a fundamental principle of the Federal Initiative to Address HIV/AIDS in Canada and CIHR strategic planning. To gain important insight from stakeholders this report on priorities for CIHR-funded extramural HIV/AIDS research is being circulated broadly for feedback. The results of this consultation will be consolidated and integrated into the research priorities by CHARAC .
Once the list of current priorities is finalized, CIHR and CHARAC will establish working groups, as required, to work on each of the priority areas. The working groups will contribute to the further refinement of the priorities and the development of a process to address the needs in each area including identification of targets for future requests for applications. The working groups will provide the opportunity for involvement of individuals and organizations, beyond the current CHARAC membership, with expertise in specific areas to make important contributions to the development of HIV/AIDS research initiatives.
HIV/AIDS research extends beyond the scope of CIHR-funded research as there are other national and provincial agencies supporting HIV/AIDS research and research and surveillance is being conducted by governments at the federal, provincial and territorial level. Therefore, CIHR and the Public Health Agency of Canada have committed to work together to develop a comprehensive national HIV/AIDS research plan. The expertise and work of CHARAC will provide very valuable information for the development of the national plan and once the plan is developed it may provide guidance for future refinement of priorities for CIHR-funded extramural HIV/AIDS research.
Over the past years, there have been gatherings, formal consultations, strategies and guidelines and scheduled meetings such as CHARAC meetings where research priority theme areas have been discussed and considered. As expected, there are common themes throughout these sources. In an effort to facilitate the discussion, these commonalities have been clustered and are presented here. This list was intended to stimulate discussion.
Health of populations and population specific research 3,5
- Virology such as clade identification and monitoring, transmission issues
- Immunology including innate immunity and correlates of immunity
- Pathogenesis for example mucosal transmission, long term non-progressors and role of T cell-mediated immunity (CD4, CD8s).
To best define relevant and appropriate HIV/AIDS research priorities, a list of criteria for applying these priorities was outlined. Priorities identified during the discussion were mapped against these criteria.
These criteria are guided by the CIHR principles of multidisciplinarity, scientific excellence and need to support research that has the potential for impact in improving the health of Canadians. In addition, the CIHR mandate includes knowledge translation which is accepted here as a fundamental portion of all research conducted under the HIV/AIDS Research Initiative.
CIHR Mandate
"To excel, according to internationally accepted standards of scientific excellence, in the creation of new knowledge and its translation into improved health for Canadians, more effective health services and products and a strengthened Canadian health care system."
In addition to the principles defined within the CIHR mandate, research priorities for the HIV/AIDS Research Initiative, a component of the Federal Initiative to Address HIV/AIDS in Canada, will strive to meet the following criteria:
Chair
C. Power - CIHR Institute of Infection and Immunity Advisory Board
Members
CIHR
E. Nowgesic - CIHR Institute of Aboriginal Peoples' Health
D. Weaver - CIHR Institute of Neurosciences, Mental Health and Addiction
M. Schechter - CIHR Institute of Health Services and Policy Research
C. Hankins - CIHR Institute of Population and Public Health
FI-HIV/AIDS Partners
N. Arron - Public Health Agency of Canada
A. Rachlis - Ministerial Council on HIV/AIDS
Reseachers
J. Angel, L. Calzavara, M. Wainberg, A. Anis
Community Representatives
R. Travers, S. Hosein
Ex-Officio
B. Singh - Scientific Director, CIHR Institute of Infection and Immunity
