Thank you.
Good morning. My name is Maureen Gans. I am the Senior Director of Client Services at the Parkdale Queen West Community Health Centre. For those who may not be familiar with CHCs, we provide primary care services to clients, including clinical, mental health and health promotion services and activities. Our CHC operates within a harm reduction framework. One could actually argue that we are a harm reduction agency that offers primary health services. We receive funding from the provincial AIDS bureau to conduct point-of-care anonymous HIV testing. If an individual tests positive, we offer a confirmatory blood draw and referral to a specialist for treatment. AIDS bureau funding also supports our considerable outreach efforts.
This past fiscal year, we tested 485 individuals. Of those, nine tested positive. All have disclosed their status, all have access to a primary care provider and all are on antiretrovirals. For those who test negative, they often come back for regular testing. That provides us with an opportunity to develop trusting relationships with individuals, to counsel about pre-exposure prophylaxis, and to provide support and assistance if a test is positive.
ln your invitation, you asked speakers to consider the best ways or practices to address non-disclosure of HIV status. This assumes that non-disclosure, rather than the criminalization of non-disclosure, is the problem. There does not appear to be strong evidence to support non-disclosure as being an issue, given that many of the cases prosecuted to date have involved individuals with a low or negligible risk of transmitting HIV and, in the majority of cases, there was no actual transmission. So why criminalize?
Criminalization is often seen as a response that aims to protect women and provide justice in instances where women have been infected or potentially exposed to HIV by their male sexual partners. However, this can be detrimental. A 2007 study done in AIDS service organizations involving about 40 women living with HIV as well as front-line service providers identifies a range of concerns. There are the added challenges that some women, particularly those in vulnerable relationships, may face when insisting on condom use by their partners, meaning that they then must either disclose or face the possibility of criminal liability. There are the fears that disclosure could trigger the loss of relationships, not only emotional but also financial consequences, or consequences for immigration status if the woman is being sponsored by her husband. There are the fears of abuse and physical violence, as well as the use of criminal law as a weapon, especially in situations where relationships break down and the woman may be subjected to unfounded accusations or threats of criminal charges as a means of seeking revenge or exerting control.
lt is important to note that for any individual with HIV, but particularly those already marginalized and overrepresented in the criminal justice system, disclosure will not necessarily protect from allegations, threats, police investigations or criminal charges. The threat of making a complaint to police is a powerful weapon in the hands of a disgruntled ex-lover or abusive partner. Even if a case does not proceed, the threat or investigation can be extremely damaging.
For racialized communities and black/African communities in particular, what has been experienced in the application of criminalization of non-disclosure is the creation of a pathologizing, criminalizing and profiling of black men as dangerous sexual predators. Cases involving criminal charges against persons living with HIV garner considerable media attention. The profiled face of many media stories has been the face of black men. While black men may not have been charged in greater numbers than white men, studies reveal that public perception exists that black heterosexual men are the perpetrators and are overrepresented among those charged. When the accused in a criminal case was an immigrant, this fact was frequently reported, thus reinforcing the belief that HIV is a problem of outsiders, imported from the Caribbean and Africa by people wanting to take advantage of the Canadian system. Thus, the black communities have seen non-disclosure charges as serving to reinforce anti-immigrant sentiment.
Long before any resolution at trial, as was noted earlier, police media advisories may reveal publicly an accused's identity, including photograph and HIV status, as well as the criminal allegations and details about their personal and sexual life. Criminalization therefore increases stigma. No other infectious disease is viewed with as much fear and repugnance as HIV.
Infectious diseases exist with the capacity to create public health crises, and yet we do not criminalize parents, for example, who do not disclose their refusal to vaccinate their children against measles. Other STIs can result in significant psychological and health impacts, and while there is a requirement for individuals to inform their sexual partner of any STI, only non-disclosure of HIV is met with criminal action.
With many infectious diseases we have treatment for symptoms, but no cure for the disease itself, so why do we choose to exclusively criminalize the non-disclosure of HIV? What is the evidence to suggest that criminalization decreases the likelihood of infected individuals transmitting the disease? I would argue, as many before have, that criminalization can have the effect of preventing individuals from seeking testing. If you don't know your status, you can't be charged with knowingly transmitting.
So let's talk about testing and treatment. The advantage of anonymous testing within a harm reduction agency, especially testing delivered by community testers and not health care professionals, is that we see a significant number of individuals from marginalized communities who will not necessarily go elsewhere for testing: newcomers, including a significant number of racialized individuals; men having sex with men who also use drugs; uninsured individuals; sex workers and folks identifying as trans or non-binary.
I would note that for people who use drugs, the testing world has not always been inclusive or supportive. Perhaps ironically, testers often spend time trying to counsel individuals to stop taking drugs rather than counselling them in safer use.
Individuals who do not engage in treatment once diagnosed with HIV and do not disclose their status are assumed to be deliberately deceptive or even malicious, however there are a number of reasons that people may not receive treatment. There is the lack of access to pre-exposure or post-exposure prophylaxis; even in larger communities, access can be limited to specialized clinics. Regular, run-of-the-mill family physicians may not be familiar with treatment protocols. There is also the lack of access to treatment once diagnosed, a mistrust of the health care system, the lack of awareness of the degree to which an individual does have some right to privacy and the lack of understanding of treatment efficacy.
What women, people who use drugs and racialized communities need is investment in the beneficial impact of HIV testing and other public health initiatives to modify behaviour that risks transmitting HIV. We need to make testing the centrepiece of our strategies and we need treatment to be available to anyone who needs it. We need investment in social and emotional supports for individuals living with HIV to eliminate the fear, isolation and discrimination that exists when people do disclose.
Thank you.