After what Shane Ryan calls “a silly, stupid weekend” in late April, he joined the many other men in San Francisco, California, who line up six mornings each week and wait for the doors to open at Magnet. Located in the city’s Castro district, Magnet provides sexual health services for gay and bisexual men. Last year, the center diagnosed 37% of the new HIV infections in the city. Ryan, like most of the other men in line, came to find out whether his condomless sex had the consequence he feared. “Usually, I’m very safe, always precautious, but I went a little sidetracked that weekend,” Ryan said.
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JULIO MONTANER, CO-CHAIR of the Vancouver meeting and the key architect of 90-90-90, took a gamble when he and his colleagues published an editorial in the 5 August 2006 issue of The Lancet that argued for making ARVs the backbone of prevention efforts. “We were told by UNAIDS that we were medicalizing prevention, and that this was irresponsible,” says Montaner, who is at the BC Centre for Excellence in HIV/AIDS in Vancouver (an offshoot of the University of British Columbia). He acknowledges that he and his colleagues were relying more on mathematical models than hard evidence that treatment as prevention worked. But studies vindicated him. “I’m happy we were right.”
Although BC has not declared an explicit goal for “ending AIDS,” Montaner says it is committed to reaching the 90-90-90 target by 2020. Nearly seven times the size of New York state, the province has only 4.6 million residents, an estimated 12,000 of whom are infected with HIV, giving it a prevalence rate of 0.3%. The epidemic boomed in the early 1990s in men who have sex with men (MSM). When heroin use surged around 1996 in downtown Vancouver, HIV infections did as well, which led authorities to declare a public health emergency the next year. The government expanded a long-running methadone maintenance program, distributed free needles, and in 2003 opened the first supervised injection site in North America. In 2011, the province began offering ARVs to all infected people, whereas most of the world, concerned about cost and side effects, still recommended withholding treatment until a person’s immune system was damaged.