Q&A with Dr. Julio Montaner, M.D

published on February 10, 2015 in National Institute on Drug Abuse

Your Avant-Garde award—awarded in 2008—was given for the project entitled “Seek and Treat for Optimal Outcomes and Prevention in HIV & AIDS in IDUs.” What was your vision for this concept?

The idea of Treatment as Prevention (TasP) originated from our work in the early 1990s when we came upon the HIV drug cocktail that we now know as highly active antiretroviral therapy (HAART). With the effects of the treatment in reducing patients’ viral loads to undetectable levels, the potential for prevention of disease progression to AIDS and death, and secondarily HIV transmission rapidly became apparent.

The main vision for “Seek and Treat for Optimal Outcomes and Prevention in HIV & AIDS in IDUs” project was to address disease progression to AIDS and death, and secondarily HIV transmission among injection drug users (IDUs) through the most cost-effective and evidence-based means.

Once a person is diagnosed with HIV, it is important they receive treatment as soon as possible in order to reduce the amount of virus in their blood and sexual fluids. Once the virus is at undetectable levels, the disease is virtually in remission (that is to say that the chances of progression to AIDS and death are virtually eliminated), and additionally, the chances of transmitting HIV are dramatically reduced.

As a result, it is imperative to create access paths to treatment, as it is a life-saving strategy that also prevents transmission and is highly cost effective and indeed cost saving in some settings. It is important to note that, in this context, IDUs have ease of access to resources and support to obtain, maintain and sustain HIV treatment.

How has the award helped you advance this area of science?

This award has helped us to generate the evidence base that supports the effectiveness of TasP among IDUs as a means to decrease the overall burden of HIV and AIDS in our society. Indeed, our TasP strategy has led to a greater than 90% decrease in HIV/AIDS morbidity, a greater than 95% decrease in HIV/AIDS mortality and the virtual elimination of vertical transmission of HIV. Furthermore, we have documented a greater than 95% decrease in HIV new infections in IDUs, and an overall 66% decrease in HIV infections in the province.

Our work has provided the basis for the 90-90-90 target, which has been formally endorsed by United Nations Secretary-General Ban Ki Moon at the UN General Assembly Special Session on Drugs on Sept 25, 2014. The 90-90-90 target proposes that by 2020 we should get 90% of HIV infected people diagnosed globally, and 90% of them on HAART and 90% of them virologically suppressed. In doing so, we anticipate that by 2030 we will decrease the burden of HIV/AIDS by 90% (compared to 2010 levels).

Have there been any surprises or unusual challenges along the way?

It took some time to get scientific consensus on the role of TasP as a tool to control HIV/AIDS globally. However, we are delighted to see how rapidly we were able to gain UN endorsement for TasP and the 90-90-90 target, once the scientific community reached consensus. The concerted knowledge translation effort associated with our research effort was a key contributor to the effective translation of the science into policy in this regard.

What advice would you give to others seeking similar awards for bold and innovative science?

Trust your instincts. If you think something can be fixed, focus your research energies on your vision for a solution. It is important to stand by your research and its potential for creating change. Especially when science can come under attack from political or social forces, it is essential to be even more than resolute. Be audacious.

Where will your vision of HIV/AIDS research take you next?

My research will continue to focus on expanding TasP to reach as many HIV-positive people as possible. To achieve this means continuing to understand the underlying causes of lack of access to testing, services and treatment, and delays and interruptions in treatment. Given what we have learned from TasP, my vision is to apply its principles to other communicable diseases, such viral hepatitis (Hep C and B) other STIs and tuberculosis. The same principles could also apply to socially communicable diseases such as addiction, obesity and smoking-related illnesses. In essence, this would mean creating a broadly applicable disease elimination strategy that could greatly contribute to the sustainability of our health care system.

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Julio Montaner

BC Centre for Excellence in HIV/AIDS

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Q&A with Dr. Julio Montaner, M.D

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