That's fine. Thank you.
Good morning, everyone.
Thank you very much for having me as a witness in your study on the criminalization of the non-disclosure of HIV status.
I have organized my testimony around the four questions that were sent to us by Mr. Girard, the clerk of this committee. I also thank him very much for his support as I prepared for this meeting.
Essentially, your first question deals with the relevance and content of the federal directive. As a public health physician and an officer of Montréal sans sida, the issue of the criminalization of the non-disclosure of HIV-positive status has often been brought to my attention.
Without doubt, the directive is relevant. In Canada, there have been around 200 prosecutions of persons living with HIV for non-disclosure of their HIV status. Internationally, if we judge by the texts that address these problems, Canada was perceived as a country with quite a debatable interpretation, given the reality of possible HIV transmission. So the directive comes at a good time, because it provides a much more up-to-date interpretation of the decision handed down by the Supreme Court in 2012. It is much more in step with the scientific advances on living with and transmitting HIV.
We know that criminalizing the non-disclosure of HIV-positive status is generally not recommended by public health authorities. It really does not reduce the risk of transmission. Nor does it lead to lasting changes in people's behaviour. It can even have an adverse effect on public health prevention efforts because criminalization can lead to those living with HIV being stigmatized. It can, in a way, harm the relationship between patients and their treatment teams. In certain cases, it can even lead to those at risk of contracting HIV being less willing to seek HIV screening.
The directive is being received with a lot of relief in the HIV-prevention field. Our impression is that it will reduce the use of criminal law in cases of non-disclosure of HIV. We are pleased that, finally, there is a better understanding of life with, and transmission of, HIV.
Without doubt, the directive is relevant, mainly because it is public. That goes a long way in reducing the stigma. The fact that it was made public and that there was media coverage sends a very clear and helpful message.
I will not spend a lot of time on the content, because the directive was preceded by a very substantial report on the state of the science. Essentially, we are pleased to see that the directive covers two advances that are very interesting from a medical point of view. First, there is the fact that HIV is now seen as a chronic disease that is managed medically, which greatly improves people's quality of life and life expectancy. The second very relevant medical consideration is that HIV is transmitted much less easily than was thought in the past. Scientific advances show us that, when people have access to effective prevention strategies, there is little or no risk of sexual transmission. This is the case when people have a suppressed viral load, when they use condoms consistently and engage in lower-risk sexual activity. These are all part of the directive's content and they are very helpful.
The directive has another relevant item, which provides an answer to your second question about best practices in the non-disclosure of HIV status. First and foremost, the directive recognizes that non-disclosure is really a public health problem, not a criminal justice problem. This is written right into the directive and we find it very helpful.
In fact, the actions that have proved effective in changing behaviour and preventing HIV in a lasting way, are those based on a public health approach generally referred to as a graduated intensity approach. In public health terms, this means that the actions that will be put to a person, with the intent of changing behaviour and reducing the likelihood of transmitting HIV, are based on the real risk of transmission and on an approach that is as voluntary as possible. That is the way to make lasting changes in behaviour that will reduce the risk of transmission.
In the great majority of cases, we determine the factors that lead a person to not take the precautions necessary to prevent the transmission of HIV. There is often a host of factors; they may be medical, social or cultural, and they are better dealt with by a public health approach than by a criminalization approach.
In the very rare cases where an approach of that kind does not result in voluntary changes in behaviour, there is legislation, the Public Health Act in Quebec, for example, that allows us to choose a little more coercive approach, such as disclosing HIV status without a person’s consent. However, it is extremely rare that we have to go that far. In public health, we never really need to use criminal justice to achieve our ends in terms of preventing the transmission of HIV, when the health of the general public is threatened, for example.
In our view, the best practices are those based on a public health approach.
I would not like to talk about best practises in non-disclosure of HIV without going into a more general discussion about best practises in HIV prevention. Those best practices are based first of all on reducing the stigmatization of those living with HIV and communities at risk of contracting HIV, and also on better access to services to prevent and treat HIV. That is really how we are going to achieve our public health objectives in terms of HIV.
In Canada, the vast majority of new HIV diagnoses can be attributed to those who do not know their HIV-positive status, not to those who know that they are carrying HIV, are living with HIV, and do not take the precautions necessary to avoid transmission. Those cases are really very rare when you consider all those living with HIV.
That leads us to address your third question, about the best ways for the criminal justice system and public health authorities to work together. Certainly, closer work of that kind allows us to achieve our public health objectives to a greater extent.
Beyond the important matter of criminalizing the non-disclosure of HIV status, other aspects of criminalization can adversely affect public health efforts. Montréal sans sida has gathered comments from communities. A number have told us, among other things, that everything to do with the criminalization of sex work, drug use and drug possession is a factor that leads to the increased stigmatization of communities at risk of contracting HIV and that distances them from HIV prevention services. In public health terms, that really distances us from our objectives of eliminating local transmission of HIV.
Therefore, each step that the justice system takes to move closer to public health authorities and the communities most affected by the enforcement of criminal law helps us to achieve our public health objectives.
The Department of Justice's directive and report are excellent examples of effective collaboration between the justice system and public health authorities. The justice system called on the epidemiological and methodological expertise of public health authorities in seeking a detailed knowledge of the science and how to translate it into effective legal tools. Can we not imagine that kind of collaboration for other aspects of criminal law, such as those I mentioned earlier?
I will not say more on that point, but I am very open to your questions. I really want to keep some time so that I can talk to you about some other things.
Your final question asked about the role that the federal government could play—