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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

 

    

THE EXPERIENCE OF
SPECIFIC POPULATIONS

http://www.aidslaw.ca/

The patterns and effects of stigma and discrimination vary among the diverse populations affected by HIV/AIDS. While there are similarities in the experiences of different populations (as discussed above), there are also features that are specific to particular populations. These features either are not encountered by other populations or are experienced differently.

This section of the Paper aims to describe stigma and discrimination as experienced by specific populations affected by the HIV epidemic in Canada. The differentiation of populations affected by HIV/AIDS is a social and cultural construction. Such differentiation may itself contribute to discrimination,133 as when drug users or sex workers are vilified as "vectors of disease." On the other hand, the failure to recognize and acknowledge publicly the experiences of a particular population in the course of the HIV/AIDS epidemic has also led to neglect and avoidance of that population's needs, as gay men have found in the "de-gaying" of AIDS.134 In the judgment of the author, the dangers of neglecting the experiences of people exceed the dangers of stereotyping the experiences of people. Accordingly, this section of the discussion paper proceeds by populations, however imperfectly described or designated.

Gay and Bisexual Men

Anyone who believes a gay man can explore the experience of being at risk for HIV disease without considering the experience of being gay is hopelessly mistaken.135

The family of a gay man living with HIV/AIDS in a smaller Canadian province wanted nothing to do with him. When he was ill, they were told he was dying of cancer. His mother was aware that he was dying of AIDS and arranged for billeting in a larger city in that province with the help of an AIDS service organization. She paid for the services in cash, and also made a cash donation after his death, because she did not want her credit union to know that she was making contributions to an AIDS service organization.

Two men applied to rent an apartment. One of them gave the name of an organization of people with HIV/AIDS as a reference. He also had to indicate that he was on social assistance. The landlord called the organization to find out if he could catch AIDS. He was worried that they would come all over the carpet, and that he would become infected if he had to clean the apartment after they left. The two men were denied the apartment.

The education co-ordinator [in an AIDS service organization] is not comfortable with gay and lesbian issues. ... [The executive director of an AIDS service organization] puts a damper on any initiatives that come out of [the men who have sex with men program]. He wants us to work within a certain framework - visible but not too visible.136

Epidemiology

Health Canada reports that "[t]he HIV/AIDS epidemic in Canada is no longer as concentrated among men who have sex with men as it was in the early-to-mid 1980s, but this group is still a significant part of the epidemic": 137

• 72.5 percent (10,943) of the total number of AIDS cases (15,101) reported to Health Canada were attributed to men who have sex with men, and an additional 4.3 percent (655) were attributed to the combined category of men who have sex with men and use injection drugs;

• the annual number of AIDS cases attributed to men who have sex with men leveled off from 1992 to 1994 and has decreased since then, but the proportion of AIDS cases attributed to the combined category of men who have sex with men and use injection drugs has steadily increased (4.9 percent in 1996).

• the number of new cases of HIV infection among men who have sex with men as a proportion of the total number of new cases has been decreasing since the mid 1980s. However, at the end of the 1980s there appears to have been a resurgence of HIV infection among younger men who have sex with men.138 The rate of infection in a cohort of gay and bisexual men in Vancouver between the ages of 18 and 30 was 3.1 percent as of December 1996, twice as high as the authors of the study expected;139 and

• a significant proportion of men who have sex with men continue to have unprotected anal sex with both regular and casual partners.

Patterns of Stigma and Discrimination

As the Final Report on gay and lesbian legal issues and HIV/AIDS documents, prejudice against homosexuality has resulted in a predominantly negative legal, social, and cultural environment for gay men, lesbians, and bisexuals:140

• gay and lesbian adolescents have little support within their family, among their peers, and at school in recognizing and affirming their sexual orientation and in developing relationships with other gays and lesbians.

• an overwhelming majority of gay men and lesbians have been verbally abused, and many gay men and lesbians have been threatened, chased or followed, assaulted, or otherwise abused.

• same-sex sexual activity was until recently considered a crime, and the Criminal Code still includes provisions that discriminate on the basis of sexual orientation, including legal age of consent for anal intercourse.

• literature and information about same-sex relationships have been censored by schools and libraries, and literature and information about same-sex sexual activities (including safe-sex educational materials) have been seized by Canada Customs.

• sexual orientation was only recently made a prohibited ground of discrimination in the Canadian Human Rights Act (after almost two decades of struggle to realize this basic protection), and has not yet been made a prohibited ground of discrimination in the human rights legislation of Alberta, Prince Edward Island, and the Northwest Territories.

• gay men and lesbians in a same-sex relationship are not assured of the right or access to employment benefits, may experience discrimination based on sexual orientation in obtaining custody of or access to children or in other parenting arrangements, cannot sponsor their partners for immigration under the family class, and are vulnerable to exclusion in the event of the illness or death of their partner.

The early prevalence of HIV/AIDS among gay men in North America has resulted in an enduring association between HIV/AIDS and homosexuality. The predominantly negative attitudes toward homosexuality have influenced people's attitudes and behaviour toward people with HIV/AIDS in general, and gay and bisexual men in particular.141 As a result:

• people have a more negative attitude toward people with HIV/AIDS than they do toward people with other diseases, regardless of the sexual orientation or presumed cause of infection of the person living with HIV/AIDS;

• people have a more negative attitude toward gay men with HIV/AIDS than toward other people with HIV/AIDS, are more likely to blame gay men for being HIV-positive, and are less inclined to help gay men with HIV/AIDS;

• people with HIV/AIDS may be stigmatized and discriminated against because they are assumed to be homosexual; and

• gay and bisexual men are stigmatized and discriminated against because they are assumed to be HIV-positive or the cause of the HIV epidemic.

Research has shown that people who support the rights of same-sex couples to marry, adopt or have children, and enjoy the same employment benefits as heterosexual couples, have less fear of AIDS.142

It is important to note that men who have sex with men may not identify as gay or bisexual and may have a very loose association with the "gay community."143 The categories "men who have sex with men," "bisexual," and "gay" comprise a diversity of identities, cultures and behaviours. The degrees to which men considered under these categories may have appropriated the negative stereotypes and stigmas associated with homosexual activity or identity in their surrounding culture will vary.144

Impact of Stigma and Discrimination

Vulnerability to Infection

A comparison of two cohorts of gay men in Vancouver - one recruited between 1982 and 1984 (the Vancouver Lymphodenopathy AIDS Study), the other recruited since 1995 (the Vanguard Project) - shows that there has been a decline in the frequency of high-risk sexual behaviours among gay and bisexual men over the decade.145 At the same time, a significant proportion of gay men and bisexual men (particularly young men) continue to engage in risky sexual behaviour.146

As the section on gay, lesbian and bisexual youth (below) discusses more fully, growing up and coming out in an unsupportive or hostile environment contributes to risk of HIV infection and other risks to health and well-being. The Vanguard Project found that, among 147 young gay and bisexual men, 18 percent had experienced domestic violence, 11 percent had experienced gay bashing, 25 percent had experienced sexual abuse, 55 percent had seriously considered suicide, and 33 percent had attempted suicide. Twenty-two percent had been diagnosed with a mental disability or mood disorder, most commonly depression.147 The authors conclude:

A disturbing proportion of young [men who have sex with men] report having considered suicide or made suicide attempts, which is consistent with high levels of depression. Various other forms of violence appear to be common for young [men who have sex with men]. The relationship between violence and HIV requires further investigation. Along with other forms of psychologic distress - including depression, substance abuse and homophobia - violent life experiences likely impact negatively on self-esteem and negotiating skills, which could in turn lead to heightened vulnerability to HIV infection.148

Testing and Confidentiality

For men who have sex with men, whether or not they identify as gay or bisexual, taking an HIV- antibody test has both personal and social consequences. The decision to take the test may involve overcoming a number of fears, including the fear of being infected with HIV, of having infected others, of illness or death resulting from HIV infection, of disclosure as a gay or bisexual man or as a person with HIV, or of stigma or discrimination based on HIV status or sexual orientation.

Toward the end of the 1980s, as the prospects for treatment improved, gay and bisexual men were encouraged to be tested. At the same time, AIDS organizations pressed for wider access to anonymous testing in order to assure people of complete confidentiality. Even so, a national survey of gay and bisexual men in Canada in 1991-92 found that the probability of expressing an intention to take an HIV-antibody test varied between 2 percent and 94 percent, and that an individual's personal evaluation of the consequences of taking the test was the most important variable in determining the probability of expressing an intention to take it.149 The authors describe the significance of their findings as follows:

The intention to take the test is mainly affected by attitudes. According to the theoretical framework adopted for this study, "attitude" is defined as a personal evaluation of the consequences of adopting a given behaviour. Such factors as the possibility of having one's name on a government list or having one's career or insurance affected define one's attitude to taking the test. Perceived lack of anonymity seems to be a dominant attitudinal determinant.150

Numerous studies suggest that availability of anonymous testing encourages people to come forward to be tested, particularly those who are at greatest risk for HIV infection.151 Of particular significance for gay and bisexual men is the finding of a study on the effect of a decision to discontinue anonymous testing in 82 of 100 counties in North Carolina in 1991. There was a 12.4 percent decrease in testing of gay men in counties that ended anonymous testing; gay and bisexual men accounted for 10 percent of all tests in counties that retained anonymous testing, but 4 percent of all tests in counties that discontinued it.152 As long as the social environment is hostile to gay and bisexual men, HIV testing programs must take into account the risks - perceived as well as actual - that an HIV test entails for gay and bisexual men.

Disclosure and Concealment

I have always hidden my homosexual tendencies from my family and friends. To now come out and say I am gay and I have AIDS, it's a double stigma. Unfortunately, the stigma attached is attached to you at the time you need support, you are afraid of dying, and you are hurting pretty badly. I am better off passing as normal.153

This observation from a gay man living in Newfoundland is a reminder that for gay and bisexual men, disclosure of HIV status is a double-edged sword. As the authors of a study of disclosure among gay men observe:

It may open up the opportunity to receive social support. However, it may also lead to added stress, due to stigmatization, discrimination and disruption of social relationships. Conversely, concealing one's HIV status from significant others can be stressful in itself and can interfere with obtaining and adhering to potentially critical medical treatments. Concealment can also have negative effects on significant others' well-being, since they may experience guilt, confusion or anger when they find out about the individual's illness (especially if this occurs after the individual is very sick or has died).154

Gay men with HIV/AIDS are more likely to disclose their HIV status to their lover or their closest friends, whom they perceive to be more helpful and supportive, and less likely to disclose to their family, coworkers or employer.155 The reasons for not disclosing include fear of discrimination (particularly at work) and the desire to conceal one's homosexuality. As one man put it, "My parents don't know I'm gay."156 Disclosure of HIV-status and sexual orientation to one's family often occur at the same time:

The level of denial and crisis in families who were not aware of a son's homosexuality until a diagnosis of AIDS may be fairly high. Among men who have already revealed their sexual orientation to their families, the stigma of a diagnosis of AIDS may reopen old wounds as family members are forced by the crisis of the illness to once again confront and express their feelings regarding sexual orientation. Disclosure of homosexuality to parents is often more difficult than disclosure to others because parental reaction is usually negative and the family perceives the disclosure as a crisis. Depending on their value system, parents may apply stereotypes about homosexuality to their son, perceiving him as a potential child molester or a sinner condemned to everlasting punishment. Also, parents may fear that others in their social network will apply similar negative values to the whole family, leading to isolation and ostracism.157

Disclosure may be particularly problematic for bisexual or heterosexual men if they are divulging previous same-sex activity for the first time:

At the time I told my wife, my fiancée, I told her about me having experienced being with a man before and so this was the first time this subject had even come into the light. She didn't have any suspicion or inclination so it was kind of hard to deal with.158

Not all families, however, respond negatively.159 It is significant that one gay man gauged his family's likely response to his HIV status according to their prior response to his sexual orientation:

I didn't really have that much fear they wouldn't accept me because they knew from a very young age that, you know, from thirteen that I was gay. ... They were very, very supportive right from the very beginning.160

Caregivers of gay or bisexual men with HIV/AIDS are also adversely affected by the stigma of HIV/AIDS and homosexuality. As one study found, going public as a caregiver can mean harassment, rejection, and the loss of jobs, friends and housing.161 The authors report that "[g]ay caregivers who were less open about their sexual orientation usually were very cautious about going public, especially outside of the gay community," while parents "often perceived themselves failures as parents, or were accused of poor parenting by others."162

Employment

As noted above, gay and bisexual men are less likely to disclose their HIV status to co-workers and employers than to lovers and friends.163 The association between fear of AIDS and aversion to homosexuality means that disclosing HIV status may mean encountering homophobic attitudes.164 As one gay man recounted:

One day on the floor where we were discussing this whole issue of AIDS and homosexuality and that kind of thing, one person said, they should all be isolated in a commune or shot. Now this is a nurse I worked with for a year and a half, shoulder to shoulder....165

AIDS may be used to harass gay men:

I heard they caught wind that I was gay. I had a pop or coffee sitting there. "Don't forget that he has AIDS."166

People may incorrectly assume that a gay man has HIV:

A gay man was laid off from his job as a caretaker for a large condominium when his employer concluded, incorrectly, that he was HIV-positive because he had been ill.

Gay men may be fired or may resign for fear of discrimination once it becomes known that they or their lover are HIV-positive.167

The report of a recent survey of people with HIV/AIDS in Québec notes that there are three types of "silence" at work - silence about sexual orientation, silence about HIV status, and silence about HIV medications.168 People who are currently not working would rather not return to their previous employer because of the level of stress and discrimination and the attitude of their employer. They would prefer to work in a context that is more open to sexual orientation, HIV seropositivity, and combination therapy. Gay and bisexual men are more likely to disclose their HIV status when their employer is aware of their sexual orientation and when their employer is gay or bisexual.169

Discrimination and harassment in the workplace on the basis of sexual orientation is prohibited by human rights legislation in all jurisdictions except Alberta, Prince Edward Island, and the Northwest Territories. However, as the Final Report on gay and lesbian legal issues and HIV/AIDS observes, the difficulty in a human rights complaint is that discriminatory attitudes are often subtle, and that it is not always easy to prove that a particular decision was based on sexual orientation, disability, or indeed any specific prohibited ground of discrimination.170 In addition, the complaints procedure is time-consuming, slow in providing redress, and emotionally draining, thereby discouraging individuals from lodging or pursuing their complaints.

Health Care

In order to recognize the risk of HIV infection, provide appropriate counselling and testing, and early treatment, it is important that physicians in general be knowledgeable about and comfortable with men who have sex with men. This involves such things as taking a history of sexual orientation and sexual activity, assessing risks of transmitting or acquiring HIV, and taking a history of sexually transmitted diseases - practices that are not routine for all physicians.

A study of 300 physicians attending AIDS-related continuing education courses in Ohio between 1987 and 1989 found that only 42.4 percent routinely took a history of sexually transmitted diseases, only 24.7 percent routinely assessed the risk of transmitting or acquiring HIV, and only 17.6 percent routinely took a history of sexual orientation. Parallel studies were conducted at the same time among gay men. Less than half (41.6 percent of 573 men) had discussed their sexual orientation with their personal physician. When asked why they had not, 74 percent responded that they were never asked.171 Thus, an opportunity to establish an open relationship between physicians and men who have sex with men, as well as to provide education about HIV/AIDS and early testing for HIV, was lost.

There is evidence that these problems continue today. A study of the experiences of gays, lesbians, bisexuals, and transsexuals with physicians in Ontario found that 41 percent of physicians do not discuss safe sex with their clients.172 Twenty-eight percent of clients also experienced discrimination because of HIV. It is possible that the practices of physicians who specialize in HIV/AIDS care are more appropriate.173 Nevertheless, two individuals consulted in the preparation of this Paper reported that physicians in two smaller cities were known to hold positions or make remarks that gay men found objectionable. In one case, the physicians was the only specialist for a large northern region. Conversely, an AIDS support worker stressed how hanging a rainbow flag in the emergency room in a hospital in a large metropolitan area was an important symbol of acceptance for the large gay, lesbian and bisexual population served by the hospital.

End-of-Life Decisions

Lack of acceptance of the sexual orientation of a gay man with HIV/AIDS can, together with the stigma of HIV/AIDS, create conflict within his family of origin or between his family of origin and his lover or partner.174 In the event of a crisis (such as decisions about health care for a person who is incapacitated) or death, the law privileges the family of origin. As the Final Report on gay and lesbian legal issues and HIV/AIDS notes:

If a person living with HIV or AIDS has not planned in advance of his/her death or incapacity, his/her same-sex partner will have almost no recourse for making decisions about that person's health care, administering finances and property, or claiming a share in the deceased partner's estate. The partner of the deceased may have a claim based on common law remedies (such as resulting or constructive trusts) or a claim for compensation for having cared for the deceased, but there is no statutory right to a share of the estate or to be appointed to administer the estate.175

Same-sex partners can take steps to protect their position, and laws in Newfoundland, Nova Scotia, Québec, Ontario, Manitoba, and British Columbia specifically permit individuals to designate who can make health-care decisions when they become incapacitated.176 But the law still substantially privileges biological families over same-sex partners.

Transgendered People

Like many of my sisters and brothers I have felt like a freak of nature, and had a sense of not belonging anywhere. When on the streets, I was accepted and validated, and was able to escape from the realities of being transgendered. I did not need to adjust to the real world and the expectations of others. In the straight world we were abandoned, forgotten, and occupied a social status reminiscent of earlier times. In the real world there was no human rights protection, and no dignity for the transgendered.177

Transgendered people - a term that applies to transsexuals, transvestites, drag queens, and cross-dressers178 - are exposed to humiliation, degradation, and discrimination at almost every turn. Many transgendered people are rejected by their families. They are not universally welcome within the gay and lesbian communities. Few workplaces are accepting and accommodating of their identity and dress. Police tend to be polite until they see identification papers, at which point their attitude changes.179 Health care and social service providers may be insensitive, referring, for example, to transgendered people by their sexual identity, not their gender identity. In hospitals and prisons transgendered people are lodged with people of their sex rather than their gender. In prison the risk of violence and coercive sex is high, particularly for those whose sex is male but whose gender is female. In short, transgendered people are rejected, isolated, closeted, and vulnerable within society.

This has numerous consequences in the context of the HIV/AIDS epidemic. Because of their rejection by society, many transgendered people end up on the street as sex workers or injection drug users. On the street, their risk of HIV infection is high. It is estimated that 70 to 80 percent of transgendered people on the streets in Vancouver are HIV-positive.180 Many HIV-positive transgendered people do not attend HIV clinics because their gender is not acknowledged and affirmed.181 Health-care providers may not be sufficiently knowledgeable of and sensitive to the hormonal and psychosocial needs of transgendered people with HIV/AIDS.182 Transsexuals with HIV/AIDS are refused at gender clinics if they disclose that they are HIV-positive. In one case, a physician agreed to perform the surgery requested by a transsexual, but for a surcharge of $5000 over the regular fee. It can be difficult for HIV-positive transgendered people to obtain services they require to maintain their physical appearance, such as electrolysis. Protecting and preserving one's gender in hospitalization and in making funeral arrangements is difficult.183

Recognizing the consequences of isolation and discrimination against transgendered people in the context of HIV/AIDS, health-care providers and community workers have developed peer-driven programs for transgendered street people and clients of HIV clinics. Such programs have provided support to transgendered people who otherwise would not approach more traditional organizations.184 One initiative, a support group for transgendered people with HIV/AIDS at a primary care clinic, reports:

Transsexual patients stated a dramatic increase in trust for their health care providers over the 2 years. The number of clinic appointments missed by all the group decreased from 64% in 1994 to 12% in 1995. The group developed their own community within the clinic, shared HIV and transgender information, provided mutual support, and fought discrimination.185

However, targeted programs and specialist health care must be accompanied by protection from discrimination in law, policy, and practice. Currently, there is no explicit protection for transgendered people in human rights legislation in Canada; transgendered people lodge complaints on related prohibited grounds, such as sex, mental and physical disability, and sexual orientation.186 Only if transgendered people enjoy the same rights, freedoms, and opportunities afforded others in Canada, and are not ostracized by society, will the conditions that place transgendered people at risk of HIV infection be ameliorated.187

Injection Drug Users

I don't like the abuse people take whether it's because they drink rice wine, use drugs or because they are mentally ill. Poor bashing is easy to get away with. The poor don't have the ear of the press.188

Why should people be homeless, sick, beat up, etc. because they use drugs? It's not important if people use or not - they deserve to be treated compassionately. When wealthy people use drugs it is private because they are not homeless shooting up on the streets.

The illegality of the drugs causes damage, not necessarily the drug itself. Did I have to be degraded and criminalized to stop? I think I felt worse about my self and may have used more and longer as a result. People have to see a reason to stop and degradation is not a reason to stop - it's often a reason to use.

A non-judgmental place is the key to a successful place for users. A place where we can help each other. We can say to each other, "It's okay to be who you are and I accept you where you are now whether you are using or not."

When does the addict see anything ever happening? Only when we overdose or get HIV or endocarditis - the rest is a lot of gum flapping.

Addicts are considered the lowest of the low. My name is mud. I used to teach elementary school and was a psychologist assistant. The assumptions made about me because I am identified as a drug addict are that I have no self-esteem, no respect for my body and that I am not capable of anything. No one listens to me - nothing I say is taken seriously. I have a problem. I am an addict. I don't need to be insulted, discredited, humiliated and ignored.

Current Epidemiology

Health Canada reports that "[i]n 1996, approximately half of the estimated 3,000-5,000 HIV infections which occurred in Canada were among injection drug users, illustrating the significance of this group in the current Canadian epidemic":189

• For men, the proportion of AIDS cases attributed to injection drug use has increased from 1.0 percent during the period before 1989, to 2.6 percent during 1989-92, to 5 percent during 1993-96. For women, the proportion of AIDS cases attributed to injection drug use during the same periods has increased even more dramatically, from 6 percent to 15 percent to 25 percent.

• Prevalence of HIV infection among injection drug users in Toronto has increased from 4.5 percent in 1991-92 to 7.6 percent in 1993-1994; in Montréal, from 5 percent prior to 1988 to 19.7 percent in 1996; and in Vancouver, from 4 percent in 1992-93 to 23 percent in 1996-97.

• Estimates of the incidence of HIV infection among injection drug users, as reported in various studies, are as follows: 5-6 new infections per 100 injection drug users per year (100 person-years) in Montréal during the early 1990s; 5 new infections per 100 person-years in Vancouver in 1992-93; 18.6 new infections per 100 person-years in a cohort in Vancouver in 1996-97; and 5.4 new infections per 100 person-years among needle exchange attenders in Ottawa and Québec.

Recent studies indicate that lending and borrowing of needles and other injection equipment is relatively common among injection drug users in Canada:190

• Among 1006 injection drug users enrolled in a study in Vancouver, 40 percent had either borrowed or lent needles, and 11 percent of HIV-positive users and 25 percent of HIV-negative users consistently used bleach.191

• Among 2458 injection drug users recruited at needle exchanges in Ottawa and in the province of Québec, 40 percent had injected with borrowed used needles in the preceding six months.192

Injection drug users also report unprotected sex with regular, casual, and commercial sex partners.193 Among injection drug users recruited at needle exchanges in Ottawa and in the province of Québec:194

• 79.3 percent of women and 73.6 percent of men never or only sometimes used condoms with regular partners. Of the men, 4.4 percent had a regular male partner, and of these 72.5 percent never or only sometimes used condoms.

• 54.9 percent of women and 56.7 percent of men never or only sometimes used condoms with casual partners. Of the men, 6.8 percent had casual male partners, and of these 75 percent never or only sometimes used condoms.

• 40 percent of women and 7.1 percent of men reported having male commercial sex clients, and of these 35.5 percent of women and 63.9 percent of men did not consistently use condoms.

  

Patterns of Stigma and Discrimination

Drug use is a powerful source of stigma, and people who have acquired HIV through injection drug use, like those who have acquired HIV through same-sex activity, live with a double stigma. A study of public attitudes in Australia in 1990 found that drug users who contracted HIV through needle sharing attracted the most blame (92 percent), the least sympathy (18 percent), and the most calls for them to pay for their own treatment (70 percent).195 Similarly, a random-sample survey conducted in the United States in 1990-91 found that 20.5 percent of the respondents thought that "people who got AIDS through sex or drug use have gotten what they deserve."196

The stigma of drug use is reinforced by the illicit status of drug use in law, and by the application of coercive measures, including police surveillance, criminal prosecution, and criminal penalties, against illicit drug users. The legislation is, arguably, itself discriminatory. When one compares illicit drugs with similar licit drugs in terms of their pharmacological action, their psychotropic effects, the damage they may cause to the user's health, their potential for dependency or abuse, and their social consequences, the criminal penalties applied to illicit drug use are not proportional to the harm incurred and do not match comparable penalties to comparable offences.197

In addition, the legislation is discriminatory in its effects. The prohibition of drugs and the application of criminal sanctions, compounded by existing patterns of discrimination based on race and income, has a disproportionate effect on impoverished and minority populations. The greater availability, lower price, and increased use of heroin and cocaine in poor, minority ghettos in the United States, for example, can be traced to the longstanding practice of white middle-class authorities to contain "vice" in its successive forms - prostitution, gambling, alcohol, marijuana, heroin, and cocaine - to minority ghettos.198 Today, although as many whites as blacks use drugs in the United States, blacks are overrepresented among the users that require treatment for drug abuse or drug dependence.199 Blacks and Hispanics are also vastly overrepresented among prisoners convicted of drug felonies in the United States. As a report on drug sentencing in New York State observes:

In New York state, almost 30,000 people a year are indicted for drug felonies, and 10,000 are sent to prison; approximately 90 percent of them are blacks and Hispanics. In New York, as throughout the United States, drug felonies are the single most significant factor underlying the remarkable growth of the prison populations.200

Canada has its own parallels in this regard. Currently Aboriginal peoples are overrepresented among inner-city injection drugs users and among attenders of needle exchange programs.201 Likewise, both Aboriginal peoples and injection drug users are overrepresented in prison populations.202 Many drug users are socially and economically disadvantaged. A study of 582 injection drug users in Toronto found that 12.7 percent had an elementary school education, that 72.2 percent had a high-school education, that only 22.5 percent were permanently employed, and that only 36 percent lived in their own residence, while the rest lived in a shelter (14 percent), a room rented on a daily or weekly basis (16 percent), or had no fixed address (11.5 percent).203 Similarly, among injection drug users enrolled in a recent study in Vancouver, 81 percent had less than a high-school education, 62 percent were living in unstable housing, and 28 percent had a high level of depression.204

The marginalized status of drug users profoundly affects the way they are treated by others. Users attending meetings of the Vancouver Area Network of Drug Users (VANDU) attest to numerous discriminatory and degrading experiences:

My brother and sister couldn't get a hold of me at my hotel. We had a death in the family and when they came to pick me up they wouldn't let them upstairs to get me or go up to tell me they were here to get me. I missed the funeral. It makes me mad. I have no where else to live.

[A certain hospital] is a nightmare! They throw people out. I've really behaved well and I still get thrown out. Every time I go there they treat me like shit. Recently I broke my ankle. I was given crutches and told to leave. The next day they called my mom and asked her to contact me to tell me to come back as my ankle was broken. They wouldn't believe me.

I also need a family physician. They won't take users.

Some police are really dirty. ... I've been beaten up a few times. They sometimes pepper spray you and leave you in the alley.

What about cops helping us with landlords evicting us when we've paid our rent? I've had a very bad experience with this. Police could really be of help to people down here in this way and they aren't.

Does anything ever happen to hotel owners as a result of these violations [room violations, guest fees, illegal evictions]? Where is the City in all this? Where are the by-law enforcement officers?

In other words, drug users find that they are denied the legal protections, health services, and social supports that others enjoy.

Impact of Stigma and Discrimination

Vulnerability to Infection

The high-risk injecting and sexual behaviours among injection drug users are, in part, an effect of the illicit status of drugs and other restrictions on drug users.205 The illicit status of drugs drives up their price, leading users to take the drugs in the most efficient manner possible (injection) rather than by less efficient but safer means (oral consumption). Substitutes that could be taken orally are either prohibited (heroin) or, if they are available, are medically regulated (methadone). As a result of both policies and practices governing the sale of syringes, drug users do not have ready access to syringes in community pharmacies,206 and needle exchanges may impose limitations that do not meet the needs of drug users (such as limits on the number of syringes exchanged at one time).207 To this must be added other features of the illicit drug market, such as having to use drugs of uncertain quality and purity, being vulnerable to coercion or violence, or in some cases resorting to property crime or commercial sex to pay for drugs.

Socioeconomic disadvantages contribute further to the risk of HIV infection among drug users. The Vancouver study, noted above,208 found that HIV-positive injection drug users were disproportionately of Aboriginal origin, and were significantly more likely to have less than a high-school education, to live in unstable housing, and to reside in the poorest postal district in Canada. The sociodemographic characteristics of low education and unstable housing - along with the behavioural characteristics of commercial sex work, borrowing used needles, injecting with others, being an established injection drug user, and attending a needle exchange program more than once per week - independently predicted HIV-positive status among injection drug users.

Programmatic barriers in the form of inadequate or inappropriate services, as well as professional attitudes and practices that are controlling and demeaning, are also factors in the HIV epidemic among drug users. Noting that Vancouver has an HIV incidence of 18.6 percent among injection drug users despite the fact that Vancouver has the largest needle exchange program in North America, the authors of the Vancouver study comment:

In Vancouver, NEP [needle exchange programs] were introduced early, but access to drug and alcohol treatment, methadone maintenance and counselling services remain inadequate. As early as 1990, the lack of appropriate services for addictions treatment in British Columbia, especially for cocaine users, was identified as a major barrier encountered by Vancouver's NEP attenders, among whom there was already a marked demand for HIV-related counselling. This situation continues at present. Our results do not argue against the overall effectiveness of NEP as an HIV intervention, but rather, they lead us to propose that without adequate and appropriate community-wide interventions such as addictions treatment, detoxification and counselling, stand-alone NEP may be insufficient to maintain low HIV prevalence and incidence for an indefinite period.209

The importance of providing a broad range of interventions is reinforced by evidence from Amsterdam, where, as the authors of the Vancouver study note, "a continuum of harm-reduction activities was associated with lower HIV incidence and needle-sharing behaviours, but there was no evidence of a protective effect for single interventions like NEP or methadone maintenance."210 Providing such a range of interventions requires, as the Task Force on HIV, AIDS, and Injection Drug Use recommends, eliminating the barriers that professional and public attitudes, as well as the design and delivery of programs, place in the way of integrated, accessible, suitable, flexible, and respectful services for drug users.211

HIV/AIDS Care, Treatment, and Support

A recent report on the care, treatment and support of drug users with HIV/AIDS describes the difficulties that they often encounter when they seek drug treatment, health care, or social support.212 Service providers may be reluctant to offer service or may do so with an attitude of disrespect because they consider injection drug users to be disruptive or manipulative. Professionals may be unwilling to accept a drug user's choice to continue using drugs or may be reluctant to work with what they consider to be difficult clients. Organizations that are not experienced in working with injection drug users - including established HIV/AIDS organizations - may offer programs that are inappropriate or may be less ready to serve them relative to other populations with which they have more experience or more success. Health and social programs may be designed to address a single problem, rather than the multiple problems that drug users present, and consequently may have neither a sufficient range of services nor a flexible enough set of criteria to be able to serve drug users well.

The clinical care of drug users with HIV/AIDS is complicated by the need to attend to both drug treatment and HIV/AIDS treatment. There are a number of areas where the care that is delivered may be discriminatory. One is the area of pain medication. Drug users frequently report that they are not given adequate pain relief. Pain medication that is offered to other people with HIV/AIDS is not available to them. Another area of concern is antiretroviral therapy. There is considerable fear that drug users will not be offered the current standard of care because it is assumed that they will not be able to maintain the demanding drug regimens. Abstinence as a condition of treatment and care is another area where drug users may experience discrimination. Physicians may be unwilling to provide treatment unless a drug user agrees to discontinue using and enter drug treatment. Similarly, restrictions on drug use in residential facilities may effectively exclude or deter drug users from care.

As the report on the care, treatment and support for injection drug users with HIV/AIDS observes,213 there are numerous legal and ethical issues involved in providing care to injection drug users, in large part owing to the illicit status of the drugs used, concern for professional safety and liability, and prevailing norms and attitudes among health-care providers. For example, health-care providers may perceive an irreconcilable ethical contradiction between preventing illicit drug use and enabling or permitting a drug user to continue to inject. Physicians may be liable to professional discipline or criminal prosecution if they do not follow professional guidelines or government regulations in the prescription of psychoactive drugs. Health-care facilities may face legal problems if they allow illicit drugs on the premises.

While these ethical and legal dilemmas require careful deliberation, it is not acceptable to make decisions without considering the full range of options available (including innovative approaches), obtaining accurate information about the real (rather than stereotypic or imagined) risks to drug users, and, most importantly, recognizing the rights of drug users to health care and treatment. This is especially pertinent in decisions about antiretroviral treatment of HIV in drug users, given the requirements that current drug regimens place on people with HIV - regimens that are demanding by any standard, and not only for drug users. As the Task Force on HIV, AIDS, and Injection Drug Use states:

It must be recognized that injection drug users living with HIV are individuals, suffering in a myriad of ways, and in need of the best possible interventions, tailored to their unique situations. They retain all the rights of every other citizen, and must therefore be given equal access to a continuum of services, as well as the dignity of making their own decisions. If lack of compliance with a drug treatment is feared, then the patient must be supported to ensure adherence to the treatment regime, just as any other individual is, whether diagnosed with diabetes, epilepsy or another condition. Bias against treating [injection drug users] is unjustified and unacceptable.214

Research and Information

The care and treatment of drug users in general, and of drug users with HIV/AIDS in particular, is limited by gaps in research and by difficulty in getting accurate information about illicit drugs. The gaps in research are a result, among other things, of norms and practices that effectively exclude drug users from research, neglect areas of research that are relevant to drug users, or prevent innovative research on drug use. For example, drug users may be excluded arbitrarily as participants in clinical research, without due consideration to the individual characteristics of drug users and potential support for their participation. Research into such questions as the interactions between approved therapies and illicit drugs may be hindered by the stigma associated with drug use, lack of interest in the pharmaceutical industry, and the illicit status of the drugs. Innovative research, such as clinical trials on the prescription of heroin and cocaine, is difficult to initiate, given the prevailing models of drug treatment and public and professional attitudes toward illicit drugs.215

HIV, Drug Use, and Disability

Human rights legislation and human rights commissions in Canada have afforded protection to people who have been or are dependent on alcohol or drugs. The Canadian Human Rights Act recognizes previous or existing dependence on alcohol or a drug as a disability within the meaning of the Act,216 and the Ontario Human Rights Commission, in a complaint against Imperial Oil Limited, determined "that drug abuse and drug dependence both constitute a handicap within the meaning of the [Ontario] Human Rights Code."217

However, in an environment that regards drug use as a choice, a vice, and a crime, considerable education and advocacy will be required to ensure that the rights of drug users are protected and that drug addiction is recognized as a disability. For example, Bill 142 in Ontario, an Act to amend the law related to social assistance, excludes persons whose only substantial restriction in activities of daily living is attributable to the unauthorized use or the cessation of use of alcohol, a drug or some other chemically active substance, from eligibility for income support.218 The first draft of the bill excluded persons whose impairment is the result of unauthorized use of alcohol, drugs or other substances from the definition of disability,219 but this was subsequently amended to exclude such persons only from eligibility.

Bill 142 makes an exception for a person "who, in addition to being dependent on or addicted to alcohol, a drug or some other chemically active substance, has a substantial physical or mental impairment, whether or not that impairment is caused by the use of alcohol, a drug or some other chemically active substance."220 In Vancouver, drug users report that "[s]ome people are getting HIV on purpose to get the increased welfare for the disabled."221 The terms placed on the eligibility for income support in Bill 142 may have the same perverse effect in Ontario.

Participation of Drug Users

One of the guiding principles of the report of the Task Force on HIV, AIDS, and Injection Drug Use is that "[t]hose using the services must be involved in the processes which affect them - the development of policy and programmes."222 This is fundamental to health promotion - "the process of enabling people to increase control over, and to improve, their health"223 - and is reflected again and again in what drug users say:

People are not empowered - they have no control over their lives. Administered welfare treats people like children. It's insulting and disempowering. Too many service agencies take the same approach. There are no services around to really help you get a life. The main way to get empowered is to get decent housing.224

If we're such garbage, why are we still alive? Because we believe we're not garbage. Junkies have strong spirits despite being called everything bad you can think of.225

Well, we know that users aren't going to go away. Nothing to force users to stop using works - not beatings, pepper spraying, arresting - not hate, overdoses, poison in the drugs - nothing stops a person using drugs unless they decide to quit.226

The marginalization of drug users, combined with individual preferences of drug users and the predominantly criminal or medical perspective applied to drug users, creates many barriers to health promotion, to the organization of drug users, and to including drug users in developing policies and programs. Simply disclosing drug use is unsafe. Drug users who are employed risk losing their job and other benefits, such as the opportunity to obtain a mortgage or insurance. Drug users who are unemployed and are dependent on social assistance may lose income support (as, for example, under Bill 142 in Ontario) or may be required to enter into treatment with little or no choice as to the kind of treatment that they believe will be best for them.

Involving drug users is, however, essential if patterns of discrimination, exclusion, and coercion are to be broken. As the Task Force on HIV, AIDS, and Injection Drug Use recommends, drug users must be actively involved in policy development, program planning, implementation, and evaluation. In addition, community-based peer-support and advocacy groups for drug users must be developed. These are first steps, among others, in any strategy to overcome discrimination against drug users among professionals, service providers, and the general public.227

Aboriginal People

I work on the reserve. On the reserve they don't understand at all about HIV. They're afraid of HIV. I'd lose my job and they'd run me right off the reserve. They believe you can catch HIV by kissing. But they believe it will never happen to them. Some friends who know my daughter is on the street but don't know she is HIV-positive say to me they pray she doesn't contract HIV.228

In 1994, I believe it was the Assembly of First Nations and the Royal Commission who did a report on First Nations Suicide Issues. I believe it was called, Bridging the Gap. And in this report, I wanted to find a mention of First Nations homosexuality, of Two-Spiritedness, a mention of it. And unless you knew what you were looking for, unless you could read very small print between the lines, it was mentioned, but not very strongly. And I found an injustice in that. It is unjust that we as First Nations people, have become so suppressed by the Roman Catholic Church, by colonialism and a lot of other things, by the residential schools. So we no longer respect Two-Spirited people for who they are. That we no longer revere them for the spiritual people that they are, that we are, and we always will be, we always have been.229

Many Aboriginal people experience racism in health care and social assistance settings. Some people do not trust Western medicine and practitioners. Some people are not comfortable using mainstream testing facilities. In some cases this reflects cultural difference rather than direct racism.230

One person who works for an AIDS organization related a story about waiting for a doctor for half an hour after the time of her appointment. When asked why she was being passed over in favour of other patients, the receptionist replied, "Oh, I thought you didn't have a job."231

Current Epidemiology

Health Canada reports that, although there are limits to the information available on the HIV epidemic among Aboriginal people, "it is clear that some Aboriginal communities are at increased risk for HIV infection because of their low socioeconomic status, poor health condition, and high rates of sexually transmitted diseases."232

• The proportion of AIDS cases among Aboriginal people, as a percentage of all AIDS cases, has risen steadily over the past decade, from 1.5 percent before 1989 to 3.1 percent during 1989-92 and 5.6 percent during 1993-96.

• Sex with men and injection drug use account for the majority of the 210 Aboriginal male AIDS cases, and injection drug use and heterosexual sex account for the majority of the 39 Aboriginal female AIDS cases.

• Aboriginal AIDS cases are more likely to be younger, to be women, and to be attributed to injection drug use than non-Aboriginal AIDS cases.

• Recent data from British Columbia and Alberta show that Aboriginal people account for 15 to 26 percent of newly diagnosed HIV-positive cases, and that injection drug use and heterosexual activities are the most significant risk factors.

• Aboriginal people are overrepresented in groups at high risk for HIV infection, including injection drug users, clientele using inner-city services, men who have sex with men, and prison inmates.

Patterns of Stigma and Discrimination

Aboriginal people with HIV/AIDS live with many layers of stigma and discrimination. These may include, in addition to being HIV-positive and being an Aboriginal person, being a woman, a two-spirited person, a substance user, a sex worker, or in prison.

Aboriginal Status

As Stefan Matiation observes, what differentiates discrimination against Aboriginal people living with or affected by HIV/AIDS is the history of oppression and social disintegration that has been meted out to First Nations, Métis, and Inuit in Canada.233 This history has resulted in a maze of interconnected spiritual, communal, social, economic and political problems that strain the resources, the will, and the spirit of Aboriginal communities. Therefore, improving the health and well-being of Aboriginal people (including those with HIV/AIDS) means addressing the causes of cultural dislocation, ruptures within families, violence within families, substance use, chronic poverty, unemployment, poor housing and utilities, environmental destruction, lack of information and services, and lack of control over resources and programming.234

Gender Disparity

Women have been doubly disadvantaged as a result of the influence of colonial attitudes and the restrictions of the Indian Act upon Aboriginal society. For much of this century, Aboriginal women were denied a vote in band elections, could not own or inherit property, and lost their Aboriginal status upon marrying a non-Aboriginal man. Aboriginal women have been subject to degrading sexual and racial stereotypes in both non-Aboriginal and Aboriginal communities, and they continue to experience high levels of emotional and physical abuse from Aboriginal men. This violence is itself related to the disastrous consequences of racism and oppression within Aboriginal communities, and in particular among Aboriginal men - high unemployment, poor housing, poor self-esteem, self-hatred, and substance use.235

Two-Spirited People

Sixty percent of known Aboriginal AIDS cases in Canada are among men who have sex with men, and an additional 14 percent are among men who have sex with men and who are injection drug users.236 There is little acceptance of or support for two-spirited people in many Aboriginal communities. Many two-spirited people have lived away from their communities for years and feel rejected because they are two-spirited or because of their HIV status.237 The effects of this are felt by both two-spirited people and heterosexual Aboriginal men. Because many two-spirited people feel unwelcome, they do not care about their own lives and engage in unsafe behaviours. Because many heterosexual Aboriginal men regard HIV/AIDS as a "gay disease," they also do not practise safer sex.238 In addition, homophobia is one of the main barriers to Aboriginal leaders taking action on HIV/AIDS issues.

Substance Use

The rupture of family and community bonds, personal histories of abuse, lack of opportunity and employment, displacement in a non-Aboriginal environment, poverty, and despair have led many Aboriginal people into substance use. Currently in Canada, Aboriginal people are overrepresented among inner-city injection drug users and among clientele using inner-city services.239 This not only contributes to a greater risk of HIV infection; it also introduces a further layer of stigma and discrimination.

Impact of Stigma and Discrimination

Poor Health and Well-Being

The effects of two centuries of racism, oppression, and displacement are evident in the current health status of Aboriginal people. As the Royal Commission on Aboriginal Peoples notes:240

• life expectancy at birth is about seven to eight years less for registered Indians than for Canadians generally;

• the death rate among Aboriginal infants is twice as high as the national average;

• infectious diseases of all kinds are more common among Aboriginal people than others;

• the incidence of life-threatening degenerative conditions (previously uncommon in the Aboriginal population) is rising;

• overall rates of injury, violence, and self-destructive behaviour are disturbingly high; and

• rates of overcrowding, educational failure, unemployment, welfare dependency, conflict with the law and incarceration all point to major imbalances in the social conditions that shape the well-being of Aboriginal people.

Vulnerability to HIV Infection

Many of the factors that contribute to higher risk of HIV infection relate directly or indirectly to the patterns of discrimination noted above. These factors include:241

• high rates of sexually transmitted diseases;242

• high rates of teenage pregnancy, indicating a lack of safe-sex practices and a higher risk to youth;

• low self-esteem, particularly among two-spirited people;

• high rates of sexual and physical violence;

• drug and alcohol abuse;

• lack of access to health information and facilities; and

• poor health in general.

Denial and Avoidance within Aboriginal Communities

Aboriginal leaders have been slow to recognize and respond to the presence of HIV/AIDS among Aboriginal peoples. There have been a number of reasons for this. HIV/AIDS has been seen as "a disease of gay white men in the cities."243 Band councils have many pressing issues to deal with, and few resources with which to do so.244 The majority of Aboriginal people with HIV/AIDS are not living on reserve, and are therefore not within the jurisdiction of First Nations and Inuit leaders. As a result, there is considerable concern at present that, as authority for health services is transferred to First Nations, funding and programs for services for people with HIV/AIDS will be inadequate.245

People within Aboriginal communities have also been reluctant to address HIV/AIDS because of the shame and stigma associated with homosexuality and other sexuality issues. These attitudes themselves compound the problems of trying to reduce the risks of HIV infection among Aboriginal people. As one individual put it:

In our communities, we have been doing workshops on HIV/AIDS and we have tried so many ways: a doctor, an [Aboriginal person with HIV/AIDS] and a two-day workshop with youth, young adults, and elders. The first time the kids were horrible. We are having a hard time, especially with the elders, it is so sad we really don't know what to do. This is a very touchy subject. Risk behaviour is very high around here.246

Moreover, as Matiation reports,

HIV/AIDS workers cannot simply go into communities and talk about HIV/AIDS. All the issues around HIV and public health in Aboriginal communities must be addressed, including the impact of a foreign culture on community practices and traditions, residential schools, assimilationist policies, health problems, sexual and physical abuse, and alcohol. All these topics make it difficult to talk about sexuality issues.247

Disclosure and Rejection within Aboriginal Communities

Because of the shame and stigma associated with HIV/AIDS in Aboriginal communities, confidentiality of HIV status is very important. However, it is often hard to ensure confidentiality in Aboriginal communities, not only because of improper disclosure by health-care providers, but also because of word spread by relatives, friends and acquaintances in small communities.248

The reaction, upon finding out that someone is HIV-positive, has included ostracism, avoidance, and denial of services.249 In the face of these kinds of reactions, one of the three priorities cited most often (after the issues of funding and poverty) in the Aboriginal consultations on Phase III of the National AIDS Strategy was "access to home communities with adequate services, and without fear of discrimination."250

Treatment in Non-Aboriginal Settings

The majority of Aboriginal people with HIV/AIDS live in cities, not in remote communities. Although more services relating to HIV/AIDS or to substance use are available in cities, these may be provided in ways that are discriminatory, particularly to those who are at greater risk of HIV infection, such as drug users or sex workers:

A study in Alberta revealed that Aboriginal people using emergency facilities at a hospital in Edmonton were given sub-standard treatment. Aboriginal people face systemic discrimination in health care. This is particularly acute for inner-city and street-involved people.251

The first step to treating Aboriginal people - including those with HIV/AIDS - with dignity is, clearly, to provide them with services of the same quality as those provided to others. But it also means affirming the insights and practices of Aboriginal cultures (which are diverse) in developing and delivering programs, as well as incorporating traditional healers and healing practices into those programs.252

Jurisdictional Barriers

The Royal Commission on Aboriginal Peoples found that the belief in the interconnectedness of all the elements of life and living is central to Aboriginal perspectives on health and healing:

The idea brought forward perhaps most often was that health and welfare systems should reflect the interconnectedness of body, mind, emotions and spirit - and of person, family, community and all life - which is essential to good health from an Aboriginal point of view.253

However, as many of the presenters to the Commission observed, the separation of resources and programs into isolated streams according to jurisdiction (federal or provincial/territorial, on-reserve or off-reserve, health services or social services, etc), as well as the Western approach of specialization and expertise in health care and social services (each problem with its particular specialist), has presented many barriers to a holistic and interconnected approach to the health and social problems within Aboriginal communities.254

The lack of coordination and collaboration due to jurisdictional divisions has been a major and persistent problem for HIV/AIDS programming in Canada.255 There are a number of initiatives under way that are intended to improve coordination and collaboration in HIV/AIDS programming - multilateral working groups, provincial Aboriginal AIDS strategies, the Canadian Aboriginal AIDS Network.256 To the extent that these initiatives result in HIV/AIDS programs designed by, appropriate to, and controlled by Aboriginal people (recognizing the diversity of First Nations, Inuit and Métis cultures), they move beyond the discrimination (lawful though it may be) inherent in the bureaucratic structures (federal, provincial, and Aboriginal) that are the legacy of the Constitution Act and the Indian Act - structures designed for, rather than by, Aboriginal people.

Sex Workers

Because women involved in street prostitution are stigmatized by society, they cannot count on basic rights such as confidentiality, health care, protection by the police or access to other services.257

In relation to HIV/AIDS, prostitute women are usually viewed as vectors of transmission rather than people in need of treatment/support.258

The well-being of women involved in street prostitution depends as much on access to adequate legal and social counselling and education resources as it does on safety tips and health care.259

Current Epidemiology

There is considerable variation in the practices of sex workers and the conditions affecting their health and safety. Studies of HIV infection among sex workers often draw on samples that are not necessarily representative of all types of sex workers. As a result, it is difficult to generalize about the risks to the health of sex workers, including the risk of HIV infection, from one locale to another. Nevertheless, recent reviews of the literature offer the following observations:260

• In Canada, as in other parts of the developed world, the prevalence of HIV infection among female sex workers who do not use drugs is lower than the prevalence of HIV infection among male sex workers and among sex workers who use drugs.261

• Risks to health and safety, including risk of HIV infection, vary with the type of sex worker: street prostitutes, escorts or prostitutes who work indoors (often in so-called brothels), and women who work in bars or saunas and provide sexual services, usually on a part-time basis. Street prostitutes have tended to be overrepresented in studies of sex workers, so that one must be cautious in generalizing on the basis of such studies about the risks to the health of other types of sex workers.

• There is a high rate of condom use with clients among female sex workers who do not use drugs. This practice, already established before the onset of the HIV epidemic, has contributed to relatively low rates of HIV infection among these sex workers. However, factors such as inexperience on the streets, threats of violence, economic pressure, and drug use can affect sex workers' ability to refuse clients who do not wish to use a condom. In addition, familiarity with regular clients, which can blur the lines between commercial sex and private sex, can lead to inconsistent condom use.262

• There is a much lower rate of condom use with personal partners among female sex workers. There are a number of reasons for this: condoms are associated with "work" and are a barrier to intimacy; condoms represent a breach of trust in the relationship; the woman may be attempting to become pregnant; there may be a threat of violence in the relationship. As a result, sex workers may be more at risk in their private lives than through their work.263

• Poverty, socioeconomic discrimination based on gender and race, a history of sexual abuse, homelessness, lack of education, and drug use are factors in people's decisions to provide sexual services and in people's risk of HIV infection in providing such services. People consulted in the preparation of this Discussion Paper observed, for example, that single mothers tend to work the streets at the end of the month, when their income from social assistance has run out. In Toronto, the disproportionate number of street prostitutes who are black is thought to be an effect of racial discrimination and lack of employment for blacks.264 A study of male sex workers in Vancouver found that, relative to other gay and bisexual men, male sex workers were significantly more likely to be younger, non-white, less educated, live in unstable housing, have a low income, and report non-consensual sex, sex at a younger age, and drug use.265 An investigation into the determinants of trading sex for drugs among 6004 drug users in the United States found that trading sex for drugs was significantly associated (in order of decreasing statistical strength) with being female, homelessness, lack of employment, and crack cocaine use.266

  

Patterns of Stigma and Discrimination

Sex workers live and work in an environment that stigmatizes and marginalizes them in many ways. Personal and public disapproval of sex work is expressed in the attitudes of communities, politicians, and service providers, in local by-laws and police surveillance, and in the criminal status of prostitution. Many sex workers are further marginalized by involvement with the street, poverty, race, alcohol and drug use, and, as with bisexual or transgendered sex workers, sexual identity.

Street prostitutes are often the most marginalized of sex workers. Street prostitution is illegal, whereas escort services are not - a discriminatory feature of the law that has an adverse effect on poorer sex workers. Street prostitutes are more vulnerable to harassment, and are more likely than other types of sex workers to be arrested for soliciting and imprisoned.267

The HIV epidemic has heightened and exposed the vulnerability of sex workers to discriminatory attitudes, attention, and regulation. Sex workers have been characterized as "vectors of transmission," a phrase that ignores the fact that many sex workers use condoms more consistently than other populations, that they frequently exercise more responsibility than their clients, and that they are generally at a higher risk of infection from their clients than vice versa.268 Research on sex workers has focused more on their working lives than their private lives, even though many sex workers may be more at risk in the latter than the former.269 Certain countries, such as the United States, have introduced regulatory regimes comprised of mandatory HIV testing and detention, overemphasizing, disproportionately, the role that sex workers play in HIV transmission.270 Confidentiality of HIV status is often breached, particularly for street prostitutes. Word of HIV status is spread not only by other prostitutes, but also by public officials. In the consultations for this Discussion Paper, an incident was reported, for example, in which police, when detaining an HIV-positive prostitute, loudly announced for all to hear that she was HIV- positive.

The prospect of criminalizing HIV transmission is ominous for sex workers:

[A]s a prostitute, you could be blamed as an easy scapegoat for someone else's unsafe behaviour. You're an easily identifiable target and the potential for this is really high.271

Indeed, in the Thissen case an HIV-positive prostitute was charged with aggravated assault for biting a police officer, although the risk of infection from biting was extremely small.272 As Elliott observes, the charge was a misguided overreaction by police and prosecutors: "while there is no question that biting someone constitutes an assault, the HIV-positive status of the accused does not render a mere bite an 'aggravated' assault."273 Media reports of the case did not question the charge or the sentence; in fact, a Toronto radio host suggested that the accused should have been executed rather than given a sentence of two years in prison.274

Impact of Stigma and Discrimination

Such attitudes, laws, and policies regarding sex work affect the health, well-being and safety of sex workers, particularly street prostitutes, and increase their vulnerability to HIV infection. Sex workers are often disinclined to access health and social services on account of the stigma associated with their occupation.275 By-laws regulating their activity, along with police surveillance, may push them into less safe neighbourhoods, away from drop-in centres, and beyond the range of outreach workers.276 Consequently, as one person in the workshop on discrimination and HIV/AIDS reported, sex workers are driven away from needle exchanges and other services aimed at protecting their health. The illegal status of their activity can prevent sex workers from prosecuting abusive clients and protecting themselves from HIV infection:

The criminalization of sex for money means that hookers who are subject to abuse from their customers are less able to report their abusers. It also makes it difficult for them to insist on condom use with their customers, and thus increases their chances of becoming infected. In conversations I had with a number of women who were raped by their customers, without condoms, they said that because their work is illegal they are not willing to prosecute these men. Instead, they maintain a "bad date" list and disseminate it to other hookers.277

Decriminalization and Protection from Discrimination: Key to Effective HIV Prevention

According to a recent review of international policies and programs, there have been three strategies to control HIV infection among sex workers: regulating sex workers by mandatory HIV testing, treatment, and in some cases detention; providing accessible and appropriate services for sex workers through targeted programs and specialist clinics; and enhancing the ability of sex workers to safeguard their health and improve their position in the industry.278 The review observes that there is no evidence that the first strategy, regulation, has prevented HIV transmission:

Indeed, it has been argued that repression exacerbates the problem since sex workers are further marginalized from health services in the attempt to evade state restrictions on their work.279

Decriminalization and anti-discriminatory measures, on the other hand, have been effective in reducing the risk of sexually transmitted diseases and HIV infection:

[D]ecriminalisation of prostitution and anti-discriminatory measures have been associated with low levels of infection and almost universal condom use. In New South Wales, Australia, and in the Netherlands, legal and social changes appear to have paved the way for more effective health interventions within the sex industry.280

The review concludes that a combination of the second and third strategies is required:

Targeted programmes are important in the short term for those with higher prevalences of infection, including groups of prostitutes. Specialist health care is an important occupational service for sex workers, regardless of the relative prevalence of infection. However, targeted control programmes and specialist health services can only complement, not replace more broadly based interventions to the sex industry as a whole and a general health infrastructure.28

FOOTNOTES

133 C Waldby et al. Epidemiological Knowledge and Discriminatory Practice: AIDS and the Social Relations of Biomedicine. Australian and New Zealand Journal of Sociology 1995; 31(1): 1-14.

134 Mann & Tarantola, supra, note 56 at 431-432; Fisher et al, supra, note 5.

135 Federal Centre for AIDS Working Group on HIV Infection and Mental Health, supra, note 73 at 44. Unless otherwise noted, the stories and reports that follow were provided by individuals interviewed in the preparation of this Discussion Paper or by participants in the 15 January 1998 workshop on discrimination and HIV/AIDS.

136 Canadian AIDS Society. Critical Work: Sustaining Men Who Have Sex With Men Programs in Canada. Ottawa: Canadian AIDS Society, 1997, at 24, 26.

137 Health Canada. HIV/AIDS Epi Update: HIV and AIDS Among Men Who Have Sex with Men. Ottawa, November 1997.

138 P Yan et al. Estimation of the Historical Age-Specific HIV Incidence in Canada. XI International Conference on AIDS, Vancouver, July 1996. Abstract no. Tu.C.573.

139 SA Strathdee et al. HIV Prevalence, Incidence and Risk Behaviours Among a Cohort of Young Gay/Bisexual Men. 6th Annual Canadian Conference on HIV/AIDS Research, May 1997. Canadian Journal of Infectious Diseases 1997; 8(Suppl A): 24A. Abstract no. 204.

140 Fisher et al, supra, note 5.

141 Pryor et al, supra, note 36; Pryor et al, supra, note 37; Fish & Rye, supra, note 35; BA Le Poire. Attraction toward and Nonverbal Stigmatization of Gay Males and Persons with AIDS: Evidence of Symbolic over Instrumental Attitudinal Structures. Human Communication Research 1994; 21(2): 241-279; Peters et al, supra, note 33; Johnson et al, supra, note 33.

142 T O'Hare et al. Fear of AIDS and Homophobia: Implications for Direct Practice and Advocacy. Social Work 1996; 41(1): 51-58. See also Le Poire, supra, note 141.

143 Adam & Sears, supra, note 80 at 67-70; T Myers et al. Variations in Sexual Orientations Among Men Who Have Sex with Men, and Their Current Sexual Practices. Canadian Journal of Public Health 1995; 86(6): 384-388; E Nonn et al. Dimensions identitaires, appartenance à la communauté gaie et prévention contre le virus du sida. 6th Annual Canadian Conference on HIV/AIDS Research, May 1997. Canadian Journal of Infectious Diseases 1997; 8(Suppl A): 9A. Abstract no. 104; E Nonn et al. Construction de l'échantillon à partir d'une population difficile à définir: Diversité versus représentativité. 6th Annual Canadian Conference on HIV/AIDS Research, May 1997. Canadian Journal of Infectious Diseases 1997; 8(Suppl A): 9A. Abstract no. 107.

144 See, eg, JP Stokes et al. Comparing Gay and Bisexual Men on Sexual Behaviours and Attitudes Relevant to HIV/AIDS. XI International Conference on AIDS, Vancouver, July 1996. Abstract no. Tu.C.2404.

145 PGA Cornelisse et al. A Comparison of Risk Factors for HIV Transmission Between Two Cohorts of Gay Men (1982-84 vs. 1995). XI International Conference on AIDS, Vancouver, July 1996. Abstract no. Tu.C.2393.

146 Ibid; Strathdee et al, supra, note 139; A Dufour et al. Risk Behaviour and HIV Incidence among Omega Cohort Participants: Preliminary Data. 6th Annual Canadian Conference on HIV/AIDS Research, May 1997. Canadian Journal of Infectious Diseases 1997; 8(Suppl A): 23A. Abstract no. 201; T Myers et al. Bisexual Men and HIV in Ontario: Sexual Risk Behaviour with Men and with Women. 6th Annual Canadian Conference on HIV/AIDS Research, May 1997. Canadian Journal of Infectious Diseases 1997; 8(Suppl A): 23A. Abstract no. 203. For evidence of continuing high risk behaviour in the United States, see LA Valleroy et al. HIV and Risk Behaviour Prevalence among Young Men Who Have Sex with Men Sampled in Six Urban Counties in the USA. XI International Conference on AIDS, Vancouver, July 1996. Abstract no. Tu.C.2407.

147 SL Martindale et al. Evidence of Psychologic Distress in a Cohort of Young Gay/Bisexual Men. 6th Annual Canadian Conference on HIV/AIDS Research, May 1997. Canadian Journal of Infectious Diseases 1997; 8(Suppl A): 8A. Abstract no. 102. These findings are comparable to those of other studies on the risks faced by gay youth, as reviewed in Health Canada. The Experiences of Young Gay Men in the Age of HIV. Ottawa: Minister of Supply and Services, 1996, at 12-13.

148 Martindale et al, supra, note 147. Similarly, a survey of 1314 bisexual men in Ontario found that 26.4 percent of the men had a history of nonconsensual sex, and that, among those who had had sex with both men and women in the year prior to the survey (1013), men with a history of nonconsensual sex were significantly more likely to report unsafe sex with both male and female partners; see C Strike et al. Nonconsensual Sex and Unsafe Sexual Behaviour: Results from the Bisex Survey. 6th Annual Canadian Conference on HIV/AIDS Research, May 1997. Canadian Journal of Infectious Diseases 1997; 8(Suppl A): 14A. Abstract no. 124.

149 T Myers et al. The Canadian Survey of Gay and Bisexual Men and HIV Infection: Men's Survey. Ottawa: Canadian AIDS Society, 1993, at 57. In a subsequent report of the findings, the researchers report that study participants with a positive attitude toward being tested had a 40-45 times greater odds of intention to be tested compared with those with a negative attitude. Low and high intenders differed on each one of the four items included in the "reasons for not taking the test" scale: "I do not want to know," "I do not want my name on a government list," "It could affect my career or insurance," and "It could affect my relationships." See G Godin et al. Understanding the Intention of Gay and Bisexual Men to Take the HIV Antibody Test. AIDS Care 1997; 9(1): 31-41.

150 Myers et al, supra, note 149 at 71.

151 Jürgens & Palles, supra, note 4 at 60-63, citing extensive literature at nn 164 and 165.

152 I Hertz-Picciotto et al. HIV Test-Seeking Before and After Restriction of Anonymous Testing in North Carolina. American Journal of Public Health 1996; 86(10): 1446-1450.

153 Laryea & Gien, supra, note 81 at 254.

154 RB Hays et al, supra, note 75 at 425.

155 Ibid at 427-428; G Kadushin. Gay Men with AIDS and their Families of Origin: An Analysis of Social Support. Health and Social Work 1996; 21(2): 141-149, at 143, and the literature cited there; JM Simoni et al. Disclosing HIV Status and Sexual Orientation to Employers. AIDS Care 1997; 9(5): 589-599, at 591, and the literature cited there.

156 Hays et al, supra, note 75 at 429-430.

157 Kadushin, supra, note 155 at 143-144, and the literature cited there.

158 Adam & Sears, supra, note 80 at 105.

159 Ibid at 102-106.

160 Ibid at 95.

161 GM Powell-Cope, MA Brown. Going Public as an AIDS Family Caregiver. Social Science and Medicine 1992; 34(5): 571-580 at 575-576.

162 Ibid.

163 Supra, note 155.

164 Pryor et al, supra, note 37.

165 Adam & Sears, supra, note 80 at 125.

166 Ibid.

167 Ibid at 132-133.

168 Jalbert, supra, note 81.

169 Simoni et al, supra, note 155.

170 Fisher et al, supra, note 5.

171 LH Calabrese et al. Physicians' Attitudes, Beliefs, and Practices Regarding AIDS Health Care Promotion. Archives of Internal Medicine 1991; 151(6): 1157-1169.

172 B Tremble et al. Health Care and Social Service Needs of Gays, Lesbians, Bisexual and Transsexual Communities in Ontario. XI International Conference on AIDS, Vancouver, July 1996. Abstract no. Pub.D.1465.

173 Eighty-nine percent of the physicians who responded in the study of Heath et al, supra, note 93, had provided care to gay or bisexual men.

174 Kadushin, supra, note 155 at 144-145.

175 Fisher et al, supra, note 5 at 90.

176 Ibid.

177 D Brady et al. Transgendered People, Discrimination, and HIV/AIDS. Canadian HIV/AIDS Policy & Law Our Sponsors 1996; 2(3): 6-7 at 6.

178 As Brady et al, ibid, explain, transsexuals are people who are born with a core gender identity that is not congruent with their external genitalia. Some transsexual people choose hormone treatment and/or sex-reassignment surgery to bring their genitalia into line with their core gender identity. Cross-dressers are people who dress all the time as members of the opposite gender. Transvestites dress in clothes of the other gender usually in the context of erotic play. Drag queens are often performance artists. Transsexuals, cross-dressers, and transvestites may be gay or straight; drag queens are all gay men. The discussion that follows focuses primarily on transsexuals.

179 Given the process required to change name and gender in official documents, transgendered people often carry identification that does not correspond to their gender identity and their chosen name.

180 Brady et al, supra, note 177 at 7.

181 This was reported in consultations for this Discussion Paper. See also JM Grimaldi, J Jacobs. HIV/AIDS Transgender Support Group: Improving Care Delivery and Creating a Community. XI International Conference on AIDS, Vancouver, July 1996. Abstract no. Tu.D.2953.

182 MJ Bennett et al. An Ethnographic Study of HIV Infected Male-to-Female Transgendered Clients. XI International Conference on AIDS, Vancouver, July 1996. Abstract no. Tu.D.2954.

183 Grimaldi & Jacobs, supra, note 181.

184 Brady et al, supra, note 177.

185 Grimaldi & Jacobs, supra, note 181.

186 Brady et al, supra, note 177.

187 See also the recommendations in Fisher et al, supra, note 5 at 56.

188 This comment and those that follow are from minutes of meetings of drug users in Vancouver.

189 Health Canada. HIV/AIDS Epi Update: HIV/AIDS Among Injection Drug Users in Canada. Ottawa, November 1997.

190 Ibid.

191 SA Strathdee et al. Needle Exchange Is Not Enough: Lessons from the Vancouver Injecting Drug Use Study. AIDS 1997; 11(8): F59-F65, at F61.

192 R Parent et al. HIV Among IDUs: Second Surveillance Year of the Survidu Network. 6th Annual Canadian Conference on HIV/AIDS Research, May 1997. Canadian Journal of Infectious Diseases 1997; 8(Suppl A): 27A. Abstract no. 220.

193 Health Canada. HIV/AIDS Epi Update: Risk Behaviours Among Injection Drug Users in Canada. Ottawa, November 1997.

194 Ibid, with reference to Parent et al, supra, note 192.

195 New South Wales Anti-Discrimination Board, supra, note 22 at 68.

196 GM Herek, JP Capitanio. Public Reactions to AIDS in the United States: A Second Decade of Stigma. American Journal of Public Health 1993; 83(4): 574-577, at 575.

197 Mitchell, supra, note 60 at 221-237.

198 W Kornblum. Drug Legalization and the Minority Poor. In: R Bayer, GM Oppenheimer, eds. Confronting Drug Policy: Illicit Drugs in a Free Society. New York: Cambridge University Press, 1993, at 115-135.

199 DB Kandel. The Social Demography of Drug Use. In: Bayer & Oppenheimer, supra, note 198, 24-79 at 63-67.

200 Cruel and Unusual: Disproportionate Sentences for New York Drug Offenders. Human Rights Watch 1997; 9(2), from a summary posted on the Internet at http://www.hrw.org

201 Health Canada, supra, note 189.

202 Ibid.

203 P Millson et al. Prevalence of Human Immunodeficiency Virus and Associated Risk Behaviour in Injection Drug Users in Toronto. Canadian Journal of Public Health 1995; 86(3): 176-180.

204 Strathdee et al, supra, note 191 at F61-F63.

205 E Oscapella. Criminal Law and Drugs. In: Second National Workshop on HIV, Alcohol, and Other Drug Use Proceedings. Edmonton, Alberta. February 6-9, 1994. Ottawa: Canadian Centre on Substance Abuse, 1994, at 38-40.

206 For variations in provincial policies, professional practices, and professional views concerning dispensing syringes to injection drug users, see T Myers et al. The Role of Policy in Community Pharmacies' Response to Injection Drug Use: Results of a Nationwide Canadian Survey. AIDS & Public Policy Journal 1996; 11(2): 78-88.

207 In Montréal, a policy of one-for-one exchange, intended to encourage multiple visits and binding to a multifaceted prevention program, was abandoned when it was discovered that frequent attenders of needle exchange services had a higher rate of seroconversion than non-attenders. See J Bruneau et al. High Rates of HIV Infection among Injection Drug Users Participating in Needle Exchange Programs in Montreal: Results of a Cohort Study. American Journal of Epidemiology 1997; 146(2): 994-1002 at 1001.

208 Strathdee et al, supra, note 191 at F61-F63.

209 Ibid at F63-64.

210 Ibid at F64, citing EJC van Ameijden et al. Injecting Risk Behaviors among Drug Users in Amsterdam, 1986 to 1992, and Its Relationship to AIDS Prevention Programs. American Journal of Public Health 1994; 84: 275-281. See also Bruneau et al, supra, note 207 at 1001.

211 HIV, AIDS and Injection Drug Use: A National Action Plan. May 1997, at 18-21.

212 D McAmmond. Care, Treatment and Support for Injection Drug Users Living with HIV/AIDS. A Consultation Report. March 1997, at 9-12

213 Ibid at 9-15.

214 Supra, note 211 at 22, noting, in this regard, that "[t]he Portland Hotel in downtown Vancouver is an excellent model of how adherence to drug therapies can be facilitated. 60% of residents are HIV positive. A nurse visits three times a day to ensure proper medication is distributed: needles are available at the front desk."

215 These and other recommendations are included in the report of the Task Force on HIV, AIDS, and Injection Drug Use, supra, note 211 at 23.

216 Section 25.

217 Entrop and Ontario Human Rights Commission v Imperial Oil Limited (1997), Ontario Court of Justice, Court File No 597/96.

218 Bill 142, 28 November 1997, Sched. B, section 5(2).

219 Bill 142, June 12, 1997, Sched. B, section 4(2): "A person is not a person with a disability if the person's impairment is caused by the presence in the person's body of alcohol, a drug, or some other chemically active substance that the person has ingested, unless the alcohol, drug or other substance has been authorized by prescription as provided for in the regulations."

220 Supra, note 218, Sched. B, section 5(3).

221 Comment from minutes of a meeting of drug users in Vancouver.

222 Supra, note 211 at 12.

223 J Epp. Achieving Health for All: A Framework for Health Promotion. Canadian Journal of Public Health 1986; 77(6): 393-424 at 400.

224 Comment from minutes of a meeting of drug users in Vancouver.

225 Ibid.

226 Ibid.

227 Supra, note 211 at 18.

228 Goldie et al, supra, note 65 at 75.

229 Healing Our Nations, supra, note 68 at 68.

230 S Matiation, supra, note 7 at 4.

231 S Matiation, supra, note 6 at 5.

232 Health Canada. HIV/AIDS Epi Update: HIV/AIDS Epidemiology among Aboriginal People in Canada. Ottawa, November 1997.

233 Matiation, supra, note 6 at 3-4.

234 Royal Commission on Aboriginal Peoples. Report of the Royal Commission on Aboriginal Peoples. Vol. 3: Gathering Strength. Ottawa: Minister of Supply and Services, 1996.

235 Ibid at 54-86.

236 Health Canada, supra, note 232.

237 A McLeod. Aboriginal Communities and HIV/AIDS. A Joint Project with the Canadian AIDS Society and the Canadian Aboriginal AIDS Network. Ottawa: Canadian AIDS Society, 1997, at 10.

238 Healing Our Nations, supra, note 68 at 22.

239 Health Canada, supra, note 189.

240 Royal Commission on Aboriginal Peoples, supra, note 234 at 108.

241 Matiation, supra, note 231 at 6-7.

242 Health Canada, supra, note 232.

243 McLeod, supra, note 237 at 12.

244 Matiation, supra, note 6 at 12-13.

245 S Matiation. HIV/AIDS and Aboriginal People: Problems of Jurisdiction and Funding. A Discussion Paper. Montréal: Canadian HIV/AIDS Legal Network, 1998, at 21.

246 Canadian Aboriginal AIDS Network. Report of the Aboriginal Consultation of the National AIDS Strategy Phase I-II. September 22 - October 10, 1997. Ottawa: Canadian Aboriginal AIDS Network, 1997, at 12.

247 Matiation, supra, note 6 at 29.

248 Matiation, supra, note 7 at 23-27.

249 Matiation, supra, note 6 at 5-6.

250 Canadian Aboriginal AIDS Network, supra, note 246 at 21.

251 Matiation, supra, note 6 at 6.

252 Royal Commission on Aboriginal Peoples, supra, note 234 at 209-215.

253 Ibid at 205.

254 Ibid at 207.

255 Matiation, supra, note 245.

256 Ibid at 29-34.

257 K Herland. Mobilisation/Intervention - What Have We Learned? - Commercial Sex Workers. In: C Hankins, L Hum, eds. Women and HIV National Workshop. Montréal, 13-14 March 1995. Montréal: McGill AIDS Centre, 1995, at 24.

258 Ibid.

259 Ibid.

260 LA Jackson, A Highcrest. Female Prostitutes in North America: What Are Their Risks of HIV Infection? In Sherr et al, supra, note 74 at 149-162 (which presents information obtained through extensive discussions with current and former female prostitutes in major cities in Canada); S Day, H Ward. Sex Workers and the Control of Sexually Transmitted Disease. Genitourinary Medicine 1997; 73: 161-168.

261 Jackson & Highcrest, supra, note 260 at 154-155; Day & Ward, supra, note 260 at 163. For a summary of seroprevalence studies among sex workers in Canada, see Division of HIV Epidemiology, Laboratory Centre for Disease Control, Health Canada. Inventory of HIV Incidence and Prevalence Studies in Canada. May 1997, at 31.

262 Jackson & Highcrest, supra, note 260 at 152-154, 155-156; Day & Ward, supra, note 260 at 165.

263 Jackson & Highcrest, supra, note 260 at 156-158.

264 Jackson & Highcrest, supra, note 260 at 153-154.

265 ML Miller et al. Characteristics of Male Sex Trade Workers Enrolled in a Prospective Study of HIV Incidence. 6th Annual Canadian Conference on HIV/AIDS Research, May 1997. Canadian Journal of Infectious Diseases 1997; 8(Suppl A): 8A. Abstract no. 101.

266 WN Elwood et al. Powerlessness and HIV Prevention among People Who Trade Sex for Drugs. AIDS Care 1997; 9(3): 273-282 at 282.

267 Jackson & Highcrest, supra, note 260 at 152.

268 K Bastow. Prostitution and AIDS. Canadian HIV/AIDS Policy & Law Our Sponsors 1996; 2(2): 12-13 at 12.

269 Jackson & Highcrest, supra, note 260 at 149.

270 Day & Ward, supra, note 260 at 163-164; Elliott, supra, note 3 at 19.

271 Elliott, supra, note 3 at 50, citing B Wolgemuth.

272 Elliott, supra, note 3, Appendix B at 13-14. For an up-date, see R Elliott. Justice Delayed and Denied in Biting Case. Canadian HIV/AIDS Policy & Law Our Sponsors 1997/98; 3(4)/4(1): 44.

273 Ibid at 73

274 Ibid at 17.

275 K Herland. Stella: Addressing Sex Workers' Risk for HIV/AIDS in Context. XI International Conference on AIDS, Vancouver, July 1996. Abstract no. Th.C.4640.

276 Bastow, supra, note 268 at 13.

277 Ibid.

278 Day & Ward, supra, note 260 at 163.

279 Ibid at 164.

280 Ibid at 166; see also Bastow, supra, note 268 at 13, n 18.

281 Ibid at 167.