The mandate of the Canadian Institutes of Health Research (CIHR) is to excel, according to internationally accepted standards of scientific excellence, in the creation of new knowledge and its translation into improved health for Canadians, more effective health services and products and a strengthened Canadian health care system. With support from the Federal Initiative to Address HIV/AIDS in Canada, the Institute of Infection and Immunity leads CIHR in addressing this broad mandate in the area of HIV/AIDS. The Institute, with the guidance of the CIHR HIV/AIDS Research Advisory Committee (CHARAC) and through consultation with a wide range of stakeholders, has established six priorities for the CIHR HIV/AIDS Research Initiative.

With the creation of the Federal Initiative to Address HIV/AIDS in Canada, the Government of Canada made a commitment to develop population-specific responses to the HIV/AIDS epidemic. Population-specific research is relevant within the majority of the priority areas described below and is highly encouraged where appropriate. The Federal Initiative has identified eight target populations which include: people living with HIV/AIDS, men who have sex with men, injection drug users, Aboriginal Peoples, prison inmates, youth at risk, women at risk and people from countries where HIV is endemic.

In recognition of the large burden of HIV and AIDS in low- and middle-income countries, the HIV/AIDS Research Initiative will also support HIV/AIDS research in line with the CIHR policies for global health research.

The priorities reflect areas which will be addressed through strategic initiatives such as targeted requests for applications. The priorities are not intended to lessen the importance of other areas of HIV/AIDS research, which will remain eligible for funding through regular CIHR open competitions. The CIHR HIV/AIDS Research Initiative is made up of four different funding streams: Biomedical/Clinical, Health Services/Population Health, Community-Based Research and Canadian HIV Trials Network. The priorities for the initiative do not impact funding allocations to the various streams.

Priorities for CIHR HIV/AIDS Research Initiative

Health systems, services and policy

Increasing access to and uptake of testing, care, treatment and prevention services are fundamental to our ability to get ahead of the disease. Understanding the barriers to accessing services as well as the factors that promote access is important to ensuring sound decision making and policy direction in the health care setting. Ensuring a strong and vibrant community of health-related human resources must also be considered.

With increased access to care and services comes an associated increase in the economic draw on the health care budget. As prevention and treatment research progresses and new strategies and technologies are proven effective, types and standards of care change. The impact of greater access to current services and availability of new services and products must be understood to better anticipate and predict shifts in trends to redirect related policy.

Key areas research

• Access to, uptake, quality and effectiveness of testing, prevention, care and treatment services
• Understanding barriers and facilitators to access, particularly for vulnerable populations
• Sustainability of improved access to services including economic impacts and balancing cost-effectiveness of services with access for populations that are hard to reach, incarcerated or in transition to communities
• Strategies/interventions to increase quality and uptake of and adherence to prevention, care and treatment programs
• The impact of accessing treatment and care on the individual, family and community
• Regulatory issues such as accelerated approval and post-approval surveillance of prevention and treatment products

Resilience, Vulnerability and Determinants of Health

Rates of HIV infection vary greatly in different populations in Canada and around the world. Critical to effectively addressing the epidemic is a better understanding of what makes some populations particularly vulnerable to HIV and other infectious diseases while other populations experiencing similar conditions seem to be more resilient. Determinants of health (e.g., employment, housing, social inclusion/exclusion) can have a major impact on the health and well-being of individuals and communities, including their vulnerability to HIV. Stigma and discrimination towards people living with HIV as well as vulnerable populations also drive the epidemic and research could create a better understanding of these issues and effective mechanisms of reducing these negative conditions.

Key areas of research

• Impact of structural, social, cultural and individual determinants of health on transmission and acquisition of HIV and common co-infections, and on quality of life for those infected
• Effective strategies to decrease vulnerabilities and increase resilience in specific populations
• How different individuals and communities are affected by and deal with HIV/AIDS
• Other factors (e.g., psychological) that result in increased susceptibility to HIV infection in specific populations

Prevention technologies and interventions

Improved prevention strategies are required to reverse increasing infection rates that are occurring in some populations and reduce the spread of HIV. Behavioral, social and medical interventions are all important aspects of a comprehensive approach to the prevention of HIV. Biomedical research in prevention technologies such as vaccines and microbicides, as well as culturally sensitive behavioural and social intervention studies and analyses of legal and policy issues are required.

Key areas of research

• Development of therapeutic and preventative vaccines
• Investigations which lead to the discovery of new strategies such as microbicides or pre- and post-exposure prophylaxis
• Research on behavioral and social interventions specifically for vulnerable populations
• Effects of legal and policy frameworks which have implications for prevention such as harm reduction strategies for injection drug users and expansion of treatment programs to prevent new infections

Drug development, toxicities and resistance

The development of new and more effective drug therapies for combating HIV infection is required. Although current treatments are effective in extending life for those infected with HIV there are serious complications associated with these treatments including drug toxicities and drug resistance. Treatment regimes can also be extremely challenging to adhere to. The identification of new less toxic drugs and simplified treatment schedules continues to be of great importance to those infected by HIV.

Key areas of research

• Identification, development and testing of new drug therapies, including combination and salvage therapies
• Understanding the mechanisms of drug resistance and toxicity
• Role of therapeutic drug monitoring
• Understanding treatment needs and developing therapies appropriate for specific populations

Pathogenesis

Fundamental to our understanding of HIV is an increase in knowledge of the underlying mechanisms of the virus itself and the body's response to it. This research is critical to the future development of new HIV treatment and prevention strategies. All areas of investigation contributing to a more complete understanding of HIV pathogenesis are viewed as important.

Key areas of research

• Host-virus extracellular and intracellular interactions (i.e. restriction factors, cell tropism)
• Virus assembly and release
• Immunology, including cellular, humoral and innate immunity, and correlates of protective immunity
• Molecular and cellular determinants involved in virus transmission and disease progression (including latency and activation)
• Viral-induced end organ injury (e.g., nervous system, renal, skin/fat)
• Experimental human- or animal-based model systems

Issues of co-infection

It is not unusual for individuals who become HIV positive to have, or remain vulnerable to, a host of conditions. This is in part due to the situations responsible for the initial infection such as substance use, mental illness, and homelessness as well as biological factors. The common risk factors for HIV and other infections are addressed in the priority on Resilience, Vulnerability and Determinants of Health. This co-infection priority focuses on the consequences of HIV infection for other conditions, the development of treatments specific to the needs of co-infected individuals and understanding the biological factors that make people infected with HIV vulnerable to other infectious diseases.

Key areas of research

• Biological factors which contribute to the incidence of co-infection of HIV with other sexually transmitted infections (e.g., herpes simplex virus-2) and other infectious diseases
• Impact of co-infections such as HCV, tuberculosis, malaria and other infectious agents on HIV status
• Effective treatments for co-infected individuals and AIDS-related illnesses
• Issues relating to infection with multiple strains of HIV

These six priorities will be used to guide the CIHR strategic investments in HIV/AIDS research and the funding provided by the Federal Initiative to CIHR for extramural research. CHARAC will review funding allocated to the various topics and the need to update the priorities on an annual basis. Further information on the priority setting process can be found in the appendices below.

• Appendix A - Priority Setting Process
• Appendix B - Previously Identified Priorities
• Appendix C - Criteria for identifying and establishing research priorities

APPENDIX A -Priority Setting Process

CHARAC met in October 2005 to undertake the exercise of identifying draft priorities for CIHR-funded HIV/AIDS research to be conducted under the Federal Initiative over the next several years. Prior to the meeting, CHARAC members were provided with a synthesis of priorities offered in previous direction setting meetings, transformative documents and researcher meetings to stimulate thinking of potential discussion points (Appendix B). Sources included the Standing Committee on Health Report on HIV/AIDS, Leading Together and the Federal Initiative to Address HIV/AIDS in Canada. A preliminary report of an environmental scan being undertaken on the state of HIV/AIDS research in Canada was also presented. The discussion and decisions on priorities were guided by previously identified criteria (Appendix C). The result of the October 2005 meeting was a list of seven draft priorities covering a wide range of topics in HIV/AIDS.

HIV/AIDS as a research discipline is very broad; it encompasses all pillars of health research and affects many different populations. It is a discipline which is of interest and concern to many of CIHR's 13 Institutes. To ensure that all CIHR Institutes were informed of the priorities, had the opportunity to provide input, and to explore potential collaborations, the list of priorities identified by CHARAC was presented to the CIHR Research Priorities and Planning Committee (RPPC) in December 2005.

Involvement of stakeholders in decision making is a fundamental principle of the Federal Initiative to Address HIV/AIDS in Canada and CIHR strategic planning. To gain important insight from stakeholders the report on the draft priorities was circulated broadly for feedback. CIHR received 19 responses to the request for feedback from researchers, non-profit and community organizations, professional associations and federal and provincial government departments/agencies.

To refine the priorities and develop strategic research initiatives to address the priorities, the Institute of Infection and Immunity established two working groups which included as members a number of individuals not on CHARAC. These groups have provided an opportunity for involvement of individuals and organizations with expertise in specific areas to make important contributions to the development of HIV/AIDS research priorities and initiatives. The working groups have reported their recommendations to CHARAC.

Feedback from all of these consultation activities has been build into the final list and definition of the six priorities which was approved by CHARAC in November 2006.

APPENDIX B - Previously Identified Priorities

CIHR HIV/AIDS Research Initiative - Previously identified Priorities for HIV/AIDS research

Over the past years, there have been gatherings, formal consultations, strategies and scheduled meetings such as CHARAC meetings where research priority theme areas have been discussed and considered. As expected, common themes emerged from these sources. In an effort to facilitate the CHARAC discussion, the themes were presented to stimulate discussion.

Health of populations and population specific research^1,3

• Includes gender, cultural and population specific and appropriate investigations with a special focus on Aboriginals and women as well as epidemiological, socio-behavioural and community based research.

Prevention technologies and interventions^1,3

• Focuses on prevention technologies and interventions such as vaccines and microbicides and other interventions such as non-pharmaceutical alternatives.

Knowledge Translation¹

• Includes knowledge transfer to inform front line responses and research on analysis of legal, ethical and human rights dimensions

Capacity building¹

• Highlights need for ensuring qualified new scientists in HIV/AIDS research

Biomedical research^1,2

• Biomedical and clinical research including clinical trials and the following specific areas of biomedical research
  1. Virology such as clade identification and monitoring, transmission issues
  2. Immunology including innate immunity and correlates of immunity
  3. Pathogenesis for example mucosal transmission, long term non-progressors and role of T cell-mediated immunity (CD4, CD8s).

Issues of co-infection²

• All aspects of co-infection with all STIs including the epidemiological and socio-behavioural aspects.

Drug toxicities and resistance^1,2

• Focuses on emerging drug resistance, mechanisms, treatment and therapeutic drug monitoring

Health systems, services and policy^1,2

• Includes all research related to access to care and treatment, cost-effectiveness, adherence strategies/interventions and regulatory issues

1. Federal Initiative to Address HIV/AIDS in Canada, January 2005
2. Montreal Researcher Discussion Session, March 2003
3. Standing Committee on Health Report on HIV/AIDS, 2003

APPENDIX C - Criteria for identifying and establishing research priorities

To best define relevant and appropriate HIV/AIDS research priorities, a list of criteria to apply to the priorities was outlined. These criteria were guided by the CIHR principles of multidisciplinary, scientific excellence and need to support research that has the potential for impact in improving the health of Canadians. In addition, the CIHR mandate includes knowledge translation which is accepted as a fundamental portion of all research conducted under the HIV/AIDS Research Initiative.

CIHR Mandate

"To excel, according to internationally accepted standards of scientific excellence, in the creation of new knowledge and its translation into improved health for Canadians, more effective health services and products and a strengthened Canadian health care system."

Criteria for identifying and establishing priority research themes

In addition to the principles defined within the CIHR mandate, research priorities for the HIV/AIDS Research Initiative, a component of the Federal Initiative to Address HIV/AIDS in Canada, will strive to meet the following criteria:

• Inform and address urgent issues among key populations in the Canadian context
• Have the potential to support the international response to the global pandemic
• Build on areas of strength or strengthen emerging capacity where Canada has a competitive advantage
• Be future-oriented and ahead of the epidemic, capitalizing on emerging scientific discoveries or technological advances
• Support coordinated, multidisciplinary efforts
• Build on input from and support community involvement where relevant
• Address gaps, weaknesses and identified areas of need
• Be sensitive to potential for building strong and relevant partnerships