Canada Urgently Needs an Updated AIDS Strategy

published on January 13, 2015 by Dr. Julio Montaner, in Huffington Post

Being recognized with the Order of Canada represents a great honour that fills me with gratitude and encourages me to continue the work we initiated three decades ago to control and eventually defeat the HIV/AIDS pandemic. This is in large part to fulfill my commitment to the numerous patients, volunteers, colleagues and supporters who selflessly contributed and continue to support our work. All of them were brought together by a single common purpose: to bring an end to the devastation caused by the HIV/AIDS epidemic in BC, Canada, and the world. At this time, I'd like to also express my gratitude to my key mentors, most notably Professors James Hogg, Stephan Grybowski and John Ruedy, whose early influences strongly shaped my clinical and academic career. And above all, the steadfast guidance and inspiration of my late father, Professor Luis Julio González Montaner, a leading academic TB specialist in Buenos Aires, Argentina.

This gratitude comes with the acknowledgment that our work is far from over. We must continue to fight HIV and the persistent stigma attached to the illness. HIV diagnoses are climbing in many Canadian regions and populations - such as Saskatchewan, Manitoba, and even in Ottawa, the nation's capital. The epidemic continues to disproportionately affect men who have sex with men (MSM), persons who use drugs, commercial sex workers, and Aboriginal individuals in this country. Furthermore, access to testing, support, care and life-saving medication is uneven across Canada. Structural and social barriers persist, which perpetuate heterogeneity in access to critical services even within regions. The lack of a comprehensive and up-to-date Canada-wide strategy to control HIV and AIDS remains one of the most regrettable omissions of the last decade.

My own involvement in the fight against HIV & AIDS started quite unexpectedly shortly after I arrived to Canada from Argentina, pursuing a postdoctoral fellowship in Respiratory Medicine at the University of British Columbia in 1981. Shortly thereafter, PCP - a previously unusual pneumonia by a poorly characterized pathogen, pneumocystis carinii - had just emerged as a leading cause of death among young and previously healthy MSM. Over a few years we made remarkable progress, as our team's work led us to develop effective treatment and prevention strategies that effectively conquered PCP. However, it rapidly became clear that there was an underlying viral infection due to a newly discovered retrovirus, HIV, which was responsible for the immune-deficiency that allowed the PCP to develop. Dealing with the pneumonia had little impact on the ultimate fatal course of the disease. It was clear then that we needed to deal with the virus, and thus, we re-profiled our clinical and research activities to the development of effective antiretroviral (ARV) therapy.

The early days of ARV development were full of controversy. However, duplicating the TB model, we enthusiastically embraced the development of combination therapy strategies. In the mid-1990s, I had the privilege of leading a pivotal international clinical trial of a new drug, Nevirapine, within a triple drug combination regimen that for the first time showed that stopping the replication of HIV in vivo was possible. Around the same time, we became aware of similar results derived from a US-based study using a mechanistically different, Indinavir-based, triple drug combination regimen. As such, the triple-drug therapy cocktail, commonly known as highly active antiretroviral therapy (HAART) was born. Within months, AIDS-related deaths were down for the first time since the beginning of the epidemic. Eventually, over the next decade, we were able to refine our ARV regimens so that today we have simpler, better, safer and more effective alternatives, that make life-long therapy a realistic goal. Indeed, with appropriate use of modern HAART HIV-infected individuals today can expect an AIDS-free, near normal longevity, and a near normal quality of life. What was a uniformly short-term life sentence in the 80's and 90's has truly become a chronic manageable condition, and that is not all!

Already in the late 90's, upon rolling out HAART in BC, we noticed that (unexpectedly) new HIV diagnoses were decreasing in the face of steady increases in syphilis rates in BC. This suggested to us that HAART could have a secondary preventive effect on HIV transmission. A decade later, using epidemiological and population-based data we were able to conclude that this was indeed the case, and that the appropriate use of HAART could decrease HIV transmission by at least 90 per cent. We therefore proposed that expanded access to HAART would lead to a dramatic decrease in HIV/AIDS related morbidity and mortality, as well as HIV transmission. The BC government enthusiastically embraced HIV Treatment as Prevention (TasP). As a result, HIV/AIDS-related deaths in the province have decreased by more than 95 per cent since 1996, and we have virtually eliminated vertical (mother to child) transmission of HIV infection. Furthermore, BC is the only jurisdiction in Canada where HIV new infections are falling steadily.

Of note, TasP provides measurable cost-saving benefits. By 2017, the TasP campaign in BC will result in lower annual medical expenditures for treating people with HIV/AIDS, compared with a scenario where access to HAART was restricted. By 2035, the cumulative savings could reach up to $48 million.

In the summer of 2014, UNAIDS released a new ambitious target for ART roll out by 2020, calling for 90 per cent of HIV-infected individuals to be diagnosed worldwide, 90 per cent of them to receive ART, and 90 per cent of them to achieve sustained viral suppression. The "90-90-90 target" would be expected to dramatically alter the course of the HIV/AIDS pandemic, transforming it into a sporadic endemic condition by 2030. The "90-90-90 target" has now been formally adopted by the United Nations (UN) as the candidate post-2015 Millennium Development Goal (MDG) for HIV/AIDS, and is rapidly gaining support from the international community, with formal endorsements from the US, Switzerland, Brazil, South Africa, Argentina, Sierra Leone, and others.

Despite all our progress much remains to be done in Canada. We urgently need an updated national AIDS strategy that encompasses the proposed UN 90-90-90 target. We urgently need to emulate the BC TasP program across Canada by expanding access to HIV testing (including HIV screening), and liberalizing and facilitating free access to HAART, care and support.

We need stronger anti-discrimination legislation that protects those infected and those most at risk for acquisition of HIV infection. We must repel federal law criminalizing HIV exposure and introduce new laws that truly protect the safety of sex workers.

We must promote access to addiction therapy, and as needed, facilitate access to harm reduction (including supervised consumption and medicalized access to heroin). Last and not least, we need to engage with most at-risk populations, including Aboriginal communities (on and off Reserves) to better understand how to culturally adapt access to services.

As I join the ranks of the Order of Canada, my vision is that this incredible milestone will be bested by actually achieving the elimination of HIV in Canada, and in doing so we will provide the road map for HIV/AIDS elimination to the rest of the world. It is my firm conviction that the lessons we have learnt in the fight against HIV and AIDS in BC will be instrumental in helping us to conquer this devastating epidemic -- and this is just the beginning. In due course, these lessons will serve as the inspiration for a novel and costs-saving TasP-based targeted disease elimination strategy, which will markedly contribute to the sustainability of our cherished national health care system.

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Julio Montaner

BC Centre for Excellence in HIV/AIDS

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Canada Urgently Needs an Updated AIDS Strategy

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