Evidence to Policy to Practice in Gay Men’s HIV Prevention in Ontario Presentation to OHTN 2009

1. Evidence to Policy to Practice in Gay Men’s HIV Prevention in Ontario Presentation to OHTN 2009 Summer Learning Institute James Murray, Senior Program Consultant, AIDS Bureau Ontario Ministry of Health and Long-Term Care http://www.health.gov.on.ca/english/public/program/hivaids/aids_mn.html July 14, 2009

2. Your questions… • How do I get research off the shelf and informing policies and programs? • What are some examples of successful knowledge-transfer and exchange activities?

3. …in the context of two recent Ontario examples of research linked to policy and programs What constitutes policy development in the context of HIV prevention policy and programs targeted to gay and bisexual men? And, where do we KTE? What constitutes evidence in the context of government HIV prevention policy for gay men in Ontario? What are some possible insights for researchers interested in producing knowledge that gets integrated into policy and practice?

4. What do we mean by the policy development process? I might be wrong, you might be right, and together by an effort we may get closer to the truth. - Sir Karl Popper

5. What constitutes ‘evidence’? • Research • Broader community survey’s (Toronto Pride Survey 2005; Ontario Men’s Survey; M-track) • Population-specific studies (Mabwana Black Men’s Study; Gay, Bi, Queer Trans Men’s Needs Assessment) • Intervention research (GPS: POZ Prevention Intervention Study; Towel Talk) • Other community research (Toronto Crystal Meth Study; ACAS focus groups with HIV positive gay men) • Trends in research over time or a body of evidence

6. What constitutes ‘evidence’? • Professional experiences of people working in HIV/AIDS • Anecdotal experiences of people living with HIV and people at real risk of acquiring HIV • knowledge or understanding produced through a multi-stakeholder dialogue that integrates research, professional knowledge, and anecdotal experience

7. Story #1: Harm Reduction in Ottawa • In 2007, Ottawa City Council made political decision to discontinue funding to Ottawa Public Health in support of the distribution of safer crack use materials • Much community advocacy began, media attention focused on the issue, and it became something that quickly moved to the radar of the minister • As part of the process, Hepatitis C Task Force and Ontario Advisory Committee on HIV/AIDS wrote a joint letter to minister outlining research evidence in support of the harm reduction measures to assist people who smoke crack to avoid infectious disease

8. How did research inform this process? • The letter is initially written by civil servants and vetted by key stakeholders (experts within our multi-stakeholder advisory committee’s) • We were able to quickly gather supporting research by contacting Lynne Leonard, a researcher for whom we have a pre-existing and ongoing relationship • Had we not had the pre-existing relationship with Lynne, stakeholders on our advisory committee’s would have known key contacts to gather the evidence

9. Research connected to policy “An evaluation of Ottawa’s Safer Crack Use Initiative in 2006 by Lynne Leonard and her team at the University of Ottawa indicated the following positive benefits: • A reduction in the sharing of drug use equipment. The proportion of people sharing pipes ‘every time’ declined from 37% in the six months before the program began to 31% in the first, one-month follow-up post-implementation evaluation, to 12% at six-months and 13% in the twelve month post-implementation assessment. • A marginal decline in the proportion of participants reporting the presence of oral sores. • Evidence of change in drug use behavior, with some people reporting transitioning from injecting to smoking. Prior to implementation, 96% of injection drug users reported injecting in the month prior to the initiative compared with 84% at one-month into implementation and 78% at six months and twelve months into implementation. At the same time, there was a significant increase in the prevalence of crack smoking among people who inject drugs, from 77% of injection drug users reporting crack smoking pre-implementation, to 86% at one-month into the program, 89% at six months, and 93% at twelve months post-implementation.”

10. Outcome • The program was funded by the ministry of health and is being delivered through a community agency in Ottawa • Political advocacy and agitation and media attention brought import to the issue politically • The research evidence was available to the minister as he made his decision; we (civil service) were able to access relevant, local evidence quickly because of our relationship to researchers and knowledge of their work, and because of an infrastructure that creates a network of key stakeholders, including researchers, to inform the process • People in Ottawa who smoke crack have a means of obtaining materials to assist them in avoiding infectious disease, reducing their likelihood of injecting (an activity with potentially greater health harms) and connecting them to service providers

11. Story #2: The Gay Men’s Sexual Health Alliance is a provincial coalition of gay men and their allies from community-based AIDS service organizations, public health, HIV researchers, policy makers and other community members.

12. GMSH Mission To foster a systematic, evidence-informed, skilled, consistent and effective response to the sexual health needs of Ontario’s diverse communities of gay, bisexual and other men who have sex with men. To reduce the transmission of HIV and other sexually transmitted infections and improve our overall health and well-being.

13. Support front-line work: • Build capacity over-time and keep it (research, best-practice in serving gay/MSM) • reduce isolation; support each other through networking and collaboration • Provide a framework to support multi-stakeholder collaboration in prevention policy/program planning and delivery • Support longer-term thinking and planning

14. KTE Strategies of the GMSH • Ontario Gay Men’s Sexual Health Summit • Internal GMSH website • E-blasts • Working Groups • Collaboration and partnership

15. KTE Strategies of the GMSH • Commissioned by GMSH to provide baseline knowledge of literature • Been shared widely • Used as part of information to set priorities for GMSH work

16. Research informing policy: GMSH Strategic PlanExample: POZ Prevention • Maintain a POZ Prevention Working Group • Define ‘Poz prevention’ • Develop a poz prevention service provider manual • Develop a sexual health guide for HIV positive gay men • Develop a legal guidebook for HIV positive gay men • Address HIV stigma

17. Research to policy to practice: Campaigns

19. How did we get to the campaign? Provincial Advisory Body, Campaign Working Group, POZ Prevention Working Group Environmental scan POZ Prevention values and principles ‘Be Real’ evaluation Situation Report informed priorities in our logic model Research looking at sexual/social networks shared/silent assumptions, and the social environment 19

20. Ontario Gay Men’s HIV Prevention Interventions/Campaign – Logic Model Goal On an annual or as needed basis and within the framework of the strategic plan ofthe Ontario Gay Men’s HIV Prevention Strategy,translate evidence and knowledge collected from the inputs into HIV prevention interventions and campaigns and develop and advise on dissemination strategies of those to the PAB. Inputs PAB Strategic Plan, Gay Summit KTE activities and evaluation, OChart and Logic Model data, Be Real, ACCHO and Assumptions Campaigns Evaluation, Provincial Epi-data, Front-line evidence and experiences, Ontario Gay Men’s Situational Report, Pride, Lamda (MTrack), Male Call Canada, M’Bwana, Trans Men’s Needs Assessment and other research on HIV risk including CBR and the views of intended participants and a community capacity assessment. Priority Setting: Based on an environmental scan of what other work is being done provincially and nationally on HIV prevention for gay men (Assumptions 3, ACT’s Tina, CAMH Rainbow services, local and regional CBR, Poz prevention, anti-homophobia campaigns and other resources), evaluations of other work with decisions made annually. Key Objectives: Empower Gay men to assist them to become aware of and take action on the factors that contribute to better sexual health outcomes and HIV risk Such as: Social isolation and mental health issues such as depression UAI in the context of sophisticated sero-sorting and conflicting assumptions about risk factors Erectile difficulties and other issues around problematic condom use Substance use Environments and social networks • Resources developed and distributed, increased knowledge for risk reduction in the priority areas • Resources developed and distributed, increased knowledge around communication, relationships, attitudes and assumptions • Intervention design, implementation and promotion, Knowledge transfer and exchange, Annual Summit and Conferences, Education and • training on skills and tools development, Community based research on risk behaviours and risk factors, organizational capacity assessment and increased capacity • of ASO’s and other orgs addressing HIV prevention, Best Practice Reviews, Research and Literature Review • 4. Partnerships with Public Health and private business, Campaigns, Community Forums, Media Strategies • 5. Advocacy on the Social and Systemic Factors affecting gay men such as homophobia, AIDS stigma and discrimination • Outputs on: • Personal • Interpersonal • Organizational • Community • Society UAI in the context of sophisticated sero-sorting and conflicting assumptions about risk factors on their sexual health erectile difficulties and other issues around problematic condom use on their sexual health Short Term Outcomes (1 to 3 years) Gay men have access to and awareness of tools and resources to address the impact of : Substance use on their sexual health Social isolation and mental health issues such as depression on their sexual health Environments and social networks on their sexual health Increased Practice of Healthy Behaviours; Improved Access to HIV/AIDS Prevention Tools, Knowledge, Skills, Treatment and Support Improved Health Status of Gay Men with or Vulnerable to HIV; and improved and increased skills and responses available to people working in HIV Prevention and Support Intermediate Outcomes (3 to 7 years) Long Term Outcomes (7 to 10 years) Strategy contributes to the yearly decline in new HIV infections in Ontario and improved HIV Prevention and Support systems and healthier communities, environments and society for gay men.

21. Campaign roll-out process as KTE • Information developed that articulates the issues, rooted in the knowledge produced for the campaign (integrates research with anecdote/professional experience) • Planning day with front-line workers who deliver the campaign to discuss the knowledge in greater depth • Campaign presentations at KTE events; allows for further articulation and discussion of knowledge • Other research presented and discussed in context of HIV stigma and health

22. GMSH Process Evaluation • Heard from 52 of 64 participants • Sought feedback on strategy communication, inclusion and decision-making • sought feedback on value of participation for front-line work What we learned • >80% feel participation is very or quite worthwhile • >80% feel input reflected very much or somewhat in outcomes and decisions; >90% feel outcomes and decisions reflect meeting discussions

23. GMSH Process Evaluation Top three benefits to participating • Strengthen connection between research and communities • Connecting policy to what is going on in communities • Exchanging ideas and learning from experiences of others/networking

24. So, how do I get my research into policy, into programs? • Build a relationship with the communities for which you do your research work • Be a critical community-based researcher • Multi-stakeholder partnerships in research (ie. from the beginning, with meaningful sharing of authority over the work) • View KTE as a necessary and vital component of the research process • Advocate within research institutions for models of research training, funding, and research oversight that recognize the importance of an integrated approach to research • Challenge the myth that quality, publishable research cannot be done in collaboration with communities, with shared power • Participate in KTE events in the community

25. So, how do I get my research into policy, into programs? • Understand/value the vital contributions of people living with HIV, people living with the real risk of HIV infection, and people working with these communities every day to improve their health and well-being in research and in policy • Publish, present your work at conferences and in communities • Build a relationship with civil servants charged with facilitating policy development work • Invite them to be on your multi-stakeholder research team or advisory committee • Participate in committee work and other policy development processes • Send them your work and invite them to dialogue with you about your research

26. James Murray, Senior Program Consultant AIDS Bureau Ontario Ministry of Health and Long-Term Care 416-327-8816 james.murray@ontario.ca http://www.health.gov.on.ca/english/public/program/hivaids/aids_mn.html