The doctor who’s been at the forefront of B.C.’s
pioneering, globally imitated battle against HIV and AIDS for the past
three decades is now turning his attention to another looming heath
crisis – an estimated 80,000 people in B.C. infected with hepatitis C.
Vancouver’s
Dr. Julio Montaner was honoured last week, on the eve of Monday’s
International AIDS day, by B.C. Health Minister Terry Lake, who said no
one in Canada has contributed more to HIV/AIDS research and treatment.
The United Nations has also cited Montaner’s work toward achieving “an
AIDS-free generation.”
Meanwhile, at his cluttered office in St.
Paul’s Hospital, the head of B.C.’s Centre for Excellence in HIV/AIDS
has another disease in his sights.
“Hepatitis C is a bigger deal
today,” Montaner said. It is a virus that takes decades after exposure
to manifest symptoms, and the baby-boom generation is a silent carrier
of it.
“We haven’t yet seen the face of it because it takes a long
time to become a real disease. The tsunami is about to start. We still
have a few years to sort out our business, but it’s beginning to happen.
People are starting to show up with failing livers.”
Montaner said his experience in treating and containing the HIV/AIDS epidemic can be brought to bear on the new threat.
“HIV
and AIDS is no longer the big deal that it used to be in this
province,” he said, adding that 20 years ago, for example, a 20-year-old
woman who came to him with HIV faced severe illness followed by death
within 15 years, along with the high risk of passing on the disease to
her child if she got pregnant.
“It was a disaster,” he said.
“Today, I have a 20-year-old woman, just diagnosed (with HIV), and I can
say, ‘Don’t worry … Your longevity will be comparable to your peers.
We will expect that if you engage in treatment effectively you’re
looking to have 55 years of added survival. You are going to be able to
have children, your children are not going to be infected … and the
treatment most of the time is going to be one pill once a day.'”
Montaner’s
method of dealing with the HIV/AIDS crisis was supported by the
development of anti-retroviral drugs, but he also took steps to engage
with Vancouver’s at-risk populations – IV drug users and sex-trade
workers among them – to encourage testing and treatment.
His tactics that have since been endorsed by the UN and adopted around the world.
By
reaching out to at-risk populations, “we are making a smart, targeted
investment on HIV today. Tomorrow, that problem will go away.”
The
tactic has cut B.C.’s annual rate of new HIV infections from about 850
in the mid-1990s to 238 in 2012. HIV/AIDS deaths have dropped by more
than 95 per cent in that time. Earlier this year, St. Paul’s was able to
shut down its AIDS ward.
But Montaner said that many of the
patients now living with HIV are also starting to experience the
symptoms of hepatitis C, notably liver failure.
“Within
my own priorities, AIDS is no longer a first-order killer of my
patients, but hepatitis C is. They are now coming to me and their livers
are starting to give in,” Montaner said.
The difference between
hepatitis C and the early AIDS epidemic is twofold: Unlike AIDS, which
made carriers sick within months, hep C can linger undetected for
decades before beginning to cause liver damage. Also, hep C transmits
more easily than HIV.
“If you walk into the Downtown Eastside
sharing needles, it’ll take you a day to get hepatitis C. It would take
you a few days to a few weeks, depending on how you share, to get HIV,”
Montaner said. “The amount of virus in the blood is huge for hepatitis C
and that’s why it transmits very efficiently.”
The same at-risk
population at the centre of the earlier AIDS epidemic figures
prominently in hep C cases, but as many as 70 per cent of the province’s
estimated 80,000 hep C carriers (by comparison, there are about 12,000
people in B.C. living with HIV) are baby boomers. As many as half of the
carriers are unaware that they have the virus.
“People our age
had an exposure during their youth,” the 58-year-old Montaner said. Some
exposures are due to unprotected sex but many undetected hepatitis C
infections are the result of since-changed medical practices. Disposable
syringes came into wide use after the boomers reached adulthood.
“In
the old days it could well be that because practices in the hospital
were not totally clean, back when we were born, some of us could have
got it in the nursery, or you got it when you went to the doctor and got
an injection, or when you went to the dentist.”
Thousands of those with hep C may not find out they have it until they start showing symptoms.
“Unless
you get a test you won’t be able to tell. but as baby boomers are
getting older, 30, 40, 50 years after (exposure to) hepatitis C, now
your liver is going to start suffering. We’re going to have an epidemic
of people going down with cirrhosis, morbidity and mortality.”
Those
middle-class carriers will end up seeking out doctors and treatment,
but the historically at-risk populations of IV drug users and sex-trade
workers need to be sought out.
“If we’re going to have a smart
investment, we have to have an accommodation for the core transmitters –
injection drug users and the like – because only by addressing their
epidemic are we going to be able to end the epidemic down the road,”
Montaner said.
“If you treat 100 per cent of the baby boomers and
none of the core transmitters, you will have no impact on the number of
new cases generated next year. All of the new transmission depend on the
core transmitters.”
Montaner said he’s encouraged by the
development of several new treatments for hepatitis C, including drugs
in pill form that can cure the disease within three months, with a more
than 90-per-cent success rate and minimal side-effects.
Earlier injectable treatments worked in fewer than 40 per cent of cases and had severe side-effects.
“We
have every expectation based on clinical trials around the world that
they will replace the older treatments,” Montaner said. “Many of them
are being tested here in Vancouver.”
Obstacles include the cost of
the drugs, which are as high as $60,000 per patient. Montaner said drug
companies set those prices on the assumption that few patients will use
the new drugs.
“I’m saying, well, if you thought that you were
going to treat one per cent of people infected with hepatitis C, and I’m
telling you now that we would like to try to treat 90 per cent, we need
to have a different conversation.”
As with the earlier HIV/AIDS
strategy, seeking out patients for treatment rather than waiting for
patients to come to doctors involves a rethinking of the way Canada’s
health-insurance system usually works.
“One of the reasons I
stayed in Canada was that I fell in love with the Canadian medical
system,” said the Argentine-born Montaner, who first came to B.C. in
1981.
“You had to be from somewhere else to appreciate how good it
is. But what happens sometimes is that the services are available, but
… the system is crafted in a way whereby, if you don’t come and get
it, I’m saving money. That’s going to cost more tomorrow – what we
called the AIDS mortgage.”
Glen Schaefer
The Province
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