Treatment as Prevention©
The made-in-BC Treatment as Prevention® strategy (TasP® ) pioneered by BC-CfE, and supported by UNAIDS since 2011, inspired an ambitious global target for HIV treatment. The UNAIDS 90-90-90 Target to end AIDS as a pandemic by 2030 is a United Nations Sustainable Development Goal. To end AIDS, by 2020, 90% of people of people living with HIV must be diagnosed, 90% of people of those diagnosed must be on treatment and 90% of those on treatment must have an undetectable viral load.
Access to early HIV testing and immediate treatment improves quality of life for people living with HIV and curbs transmission. Pioneered at the BC-CfE by Dr. Julio Montaner, TasP® is a proven effective strategy for controlling the HIV and AIDS epidemic. TasP® is based on the concept that early access to HIV testing and immediate, sustained access to universal HIV treatment improves quality of life and longevity for people living with HIV – while curbing HIV transmission. On consistent and sustained treatment, an individual living with HIV can achieve an undetectable viral load, at which point they cannot transmit the virus.
TasP® saves lives and money, according to research from the BC-CfE. BC is the only Canadian province to implement TasP® and the only one to see a consistent decline in new HIV cases.
A number of jurisdictions worldwide have adopted the made-in-BC TasP® strategy to address their HIV/AIDS epidemics including: France, Spain, Brazil, Panama, China and several cities in the United States (San Francisco and Washington, DC).
To cut new infections in half, we’ll have to heed Julio Montaner’s years of pleas to implement Treatment as Prevention® and implement combination prevention programs. We can save a lot of lives if all this is done.
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TasP® forms the foundation of the Undetectable equals Untransmittable (U=U) movement
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The principles of TasP® can help to curb communicable and socially communicable diseases.
The BC-CfE is applying TasP® to therapeutic areas beyond HIV/AIDS, including viral hepatitis and substance use disorders, to promote Targeted Disease Elimination® as a means to contribute to health care sustainability. The BC-CfE works in close collaboration with key stakeholders, including government, health authorities, health care providers, academics, and the community to decrease the health burden of HIV/AIDS, hepatitis C and substance use disorders across Canada and around the world.
The early science supporting TasP®
The concept that antiretroviral therapy (ART) can impact HIV transmission has been under consideration since ART first emerged in the 80’s. While it has been clear that biologically ART can decrease HIV transmission, there was a longstanding concern this effect could be overwhelmed by increased risk behaviours, commonly referred to as behavioural disinhibition, risk overcompensation or therapeutic optimism.
However, shortly after the roll-out of highly active antiretroviral therapy (HAART) in 1996, ecological data from Taiwan and British Columbia suggested that HIV new diagnoses had decreased in an unexpected fashion. Most intriguingly, in British Columbia, the effect of HAART on HIV new cases was apparent despite a steady rise in syphilis rates. At the same time, it became clear HAART had the potential to eliminate vertical transmission of HIV (from mother to child). Taken together, these data suggested that HAART could be much more effective in reducing HIV transmission at the population level than it had been previously suspected. These observations fueled the interest of the BC-CfE to further explore the potential of HIV Treatment as Prevention®. Using demographic and mathematical models, the pivotal research suggested that maximal coverage with HAART could lead to the near elimination of HIV transmission – effectively stopping the epidemic in its tracks.
In 2006, these milestone scientific results were published in The Lancet in a paper by Dr. Julio Montaner, and presented at the International AIDS Conference in Toronto: “The case for expanding access to highly active antiretroviral therapy to curb the growth of the HIV epidemic”. At first the concept of widespread, immediate access to HIV treatment was met with controversy within the scientific and medical community. Later, in 2014 The Lancet Editor-in-Chief Richard Horton called the paper “truly landmark”.
A 2009 Lancet paper by Dr. Montaner further bolstered the case for TasP® . The study showed use of HAART in BC increased 547 per cent between 1996 and 2009, while the number of new HIV diagnoses fell 52 per cent.
The findings dramatically enhance the return on investment for [antiretroviral] therapy, and bolster the campaign for treating people earlier and more broadly because they will be less likely to infect others, Dr. Montaner said.
In brief, HAART rapidly and effectively decreases HIV levels to undetectable in blood and sexual fluids in the vast majority of treated patients. Among those infected, HAART-induced sustained HIV undetectability allows for immune reconstitution, therefore preventing the emergence of AIDS-related diseases and premature death. At the prevention level, HAART-induced, sustained HIV undetectability eliminates the possibility of HIV transmission. These principles support the Treatment as Prevention® strategy.
The scientific and medical community have coalesced around the idea of TasP® —in particular, expanding access to immediate and sustained HIV treatment. TasP® , pioneered by Dr. Julio Montaner, forms the foundation for the UNAIDS’ 90-90-90 Target to end AIDS by 2030.
Endorsements
- Treatment 2.0
"Evidence shows that successful viral suppression through treatment can substantially reduce the risk of vertical, sexual and blood-borne HIV transmission. […]Effective implementation of antiretroviral therapy will also result in other prevention benefits, including lower rates of tuberculosis, lower incidence of pregnancy-related deaths among women, and fewer cases of malaria.”
- World Health Organization
“ART lowers the concentration of HIV (also known as viral load) in the bloodstream and in genital secretions. Since viral load is the single greatest risk factor for all modes of HIV transmission, ART use decreases the risk that HIV will be transmitted from one person to another. […] WHO has started the process of facilitating a dialogue among key partners to further evaluate the role of ART in HIV prevention or its use for individual and population level benefits and will guide the planning of research and keep partners abreast on its progress.”
- Dr. Anthony Fauci, NIAID Director
"The strategy of providing widespread, voluntary testing for HIV infection, identifying individuals infected with the virus and better linking those patients to antiretroviral treatment and medical care is one that NIH is pursuing in a number of different populations […] It is a potentially viable way to reduce HIV transmission and improve the health of those infected with the virus."
- Dr. Zunyou Wu, Director, Chinese CDC
"We believe that Treatment as Prevention® is the model of care and containment that will best help China meet its goal of bringing HIV and AIDS under control by 2015.”
- Premier Christy Clarke
"It was British Columbia under the leadership of Dr. Julio Montaner and the BC Centre for Excellence in HIV/AIDS that put the pieces of the puzzle together to realize that expanded treatment could prevent the spread of HIV/AIDS […] We are proud to be able to share this effective treatment against the spread of HIV/AIDS with Canada and the world.”
- Hillary Clinton, US Secretary of State
“We now know if you treat a person living with HIV effectively, you reduce the chance of transmission to a partner by 96 percent […] If we take a comprehensive view of our approach to the pandemic, treatment doesn’t take away from prevention. It adds to it.”