Bob Leahy: Thank you for talking to PositiveLite.com, Julio. The last time we talked was in January 2012 I think. How have things shifted on the treatment as prevention scene in the last fifteen months. Are you starting to feel optimistic in terms of what you’d like to see?
Dr. Montaner: Well as you know I have been feeling quite strongly for quite a number of years now that treatment as prevention truly offers an opportunity to fully realize the potential of antiretroviral therapy, first and foremost at the individual level, secondarily to pay a huge dividend when it comes to preventing HIV, TB and a number of other diseases. For us the challenge was initially to get enough of a data base that the argument could be made compellingly enough so that every level of decision making, from policy makers to community, could rally behind it. In my mind the evidence, particularly when you weigh it against the challenge we are trying to address, was already overwhelming in 2006. Imagine how I feel now!
I think that since HPTN052 came on board that has allowed us to say this is definitive and conclusive evidence, and that we now need to move on to implementation discussions. And in the last eighteen months we have seen a huge political evolution, from Hilary Clinton to President Obama to (UNAIDS) Michel Sidibe progressively increasing the enthusiasm. To me, Michel Sidibe was incredibly valuable in 2010 when he formally endorsed getting to zero through treatment as prevention but I sense that his level of enthusiasm and eagerness today is exponentially greater, which is a great sign.
Bob: But in Canada, how do you feel about this. Have we made progress at all here in the last fifteen months?
You know British Columbia has been unique in the sense that I have been able to galvanize political support based on the evidence exclusively and the return on investment, if you want to put it that way. The Province has been 100% behind us. Unfortunately I have to say that I have been disappointed that the same attitude has not really panned out across the country. There has been a whole lot of intellectual discourse, and it’s incredibly frustrating, you know, when you show data regarding the evolution of the epidemic in British Columbia and you juxtapose that against what is happening in Manitoba and Saskatchewan, for instance, where HIV rates are continuing to rise - and it begs the question what else can I do to make my point?
I point my finger directly at the federal government. I think it is Stephen Harper’s fault and the health ministers’ fault all the way from Tony Clement to Leona Aglukkaq, and PHAC’s fault too because they are unable to release themselves from their political masters to say “we have a crisis, we know how to address it, let’s do it”. In an area where the only answer I get is "this is a matter for provincial jurisdiction" then that allows for all kinds of anarchy to occur and basically we are left without a national HIV strategy.
So how about your provincial partners? Have you been able to make headway with them or are they still looking for more data?
Well that`s the problem. We have had very good conversations with individual leaders all across the country but they have not materialized in to an executive order to move forward and my frustration is that the lack of attention by the federal government to this issue makes it possible for the chaos to continue.
I know CATIE is trying to foster a dialogue by hosting national consultations on this issue and also convening a treatment as prevention-themed conference in September. Do you regard these as positive steps?
In my opinion, anything that will create a forum for this kind of discussion to take place is a very well received opportunity. I am a little bit frustrated about the fact that in the CATIE consultation last year there was lot of discussion but I would have hoped it would be the ideal forum that people would rally around the idea and say we want more, we want better, we want targeted outcomes – and it didn’t happen.
OK. Let me ask you something else. In the room today (at the TasP conference) you could get the impression that Canada, instead of being a leader in treatment as prevention as we once seemed to be, may be falling far behind other nations. How would you characterize our position now in the world?
Well you heard today about the progress we have together made with China. I was instrumental in working with the CDC in China, managing to inform their new policy which came about even before HPTN 052, and we have made phenomenal progress there. I’ve been working with colleagues of mine in Rwanda and their work has been incredible, with plans to expand and with a clear national policy, much like China. It's absolutely brilliant. And then there’s New York City and San Francisco and Washington D.C. The list goes on and on.
So how does that make you feel?
Well I think individually I feel incredibly pleased and gratified I have been able to do this in my province and be able to export that to willing parties around the world. But it breaks my heart that I haven’t been able to do the same thing for the rest of my country.
Well, why haven’t the other provinces taken treatment as prevention up? What’s behind all that?
I can tell you what have been the keys to our success as opposed to why there is as yet no similar success elsewhere in Canada. Firstly, for us it has been important to have a focussed program; at the BCCFE we have one item in front of us and it’s HIV. Secondly, we have a very aggressive data generation mechanism; we monitor everything and based on that data we can go to politicians and say "this is the evidence about what is happening in your own backyard and you need to do something about it". Thirdly we are very strong advocates, we work with community and with partners to create the urgency that is needed for politicians to feel not only is this what should be done but has to be done.
Why is this not happening elsewhere in the country? Well, I think we (nationally) need to get our act together. We need to make this something that the politicians cannot walk away from – and I think the elements . . . when you see the state of the epidemic in the aboriginal community and the MSM community, we need to make this a priority.
OK. Now I have to ask you about the issue of MSM and the fact that your numbers of new infections in B.C. have not declined in that population. Why can’t you get the same results there?
Some have argued that treatment as prevention may not work in MSM. I think that is absolutely wrong. The biology says it does work, it works on the virus no matter where it is. If it works in injection drug users it will work for everyone else.
So here’s the situation. Treatment as prevention works in serodiscordant couples. New infection rates among MSM – older MSM – are coming down. The problem is that the rate in young MSM is going up. Because of stigma and discrimination and all the issues around sexuality they come out poorly equipped to protect themselves. They make choices which put them at risk because the environment is not prepared to welcome them in a supportive manner. So they get infected before we can get to them.
So how do we change that piece?
It’s a very tall order to ask a clinician to change that piece, but I have two answers for you. The first one is that if we offer treatment to everyone we possibly can, we make the world a safer pace for gay youth to come out. Even if nothing else changes, that will help. Of course that’s insufficient. The second one is systemic change where we access youth before youth come out. Now you ask how difficult that is in places like Abbotsford or Hope or even Vancouver where talking about sexuality in schools is problematic. Beyond that talking about homosexuality, in some school districts, is impossible. We need to change that, because if we cannot have those conversations early on and show that we are supportive of gay youth even before they identify themselves then we will always be trying to protect them after they have got infected.
OK. I want to ask about the role of people with HIV in advocating for treatment as prevention. I’ve had a feeling that the community is absent, somewhat, from the discussion and that the discussion when it occurs tends to be driven top down, as opposed to from the bottom-up, and bottom-up is the way direction has come from historically. Do you agree that there is an advocacy gap there and that is something we need to look at?
Look Bob, I’ll be very frank with you. In my early career working with HIV - and I’ve been doing this since the eighties – I was there when the community was against us because they didn’t feel we were doing enough, when we were pushed because we didn’t have the answers, they just weren’t available. I was there when we finally merged and worked together after 1996 to make treatments available faster, to get the regulatory process changed, to get services to the community. But the community has lost its focus. We’ve moved to solve a lot of the problems you have but the sense of urgency to help us solve the next problem is almost no longer there. All the people in the community have different issues. What is missing is that unifying focus that says “Julio, we want you to work with us to end the epidemic.” So I am a lonely ranger here, trying to push for the end of the epidemic.
Well, personally, you know I’ve changed my mind on treatment as prevention. I’m in favour now. And the argument I’ve found most persuasive is that starting treatment early is undeniably good for us.
The reason I started doing this work is not that I had an eureka moment that treatment could prevent transmission. It was not my priority. This was about my patients, my number one motivation.
I don’t think everyone understands that. I think some people feel that people like yourself have a public health agenda first and foremost.
No. And that is the number one problem.
OK. One more question and that is about the expansion of testing towards more universal testing. I know some jurisdictions have an issue with expanding testing to what we’ve regarded as low risk groups and the issue they have is a cost-benefit one – the cost doesn’t justify the small number of new infections you are likely to bring to light. How would you respond to that?
Well I met with the Deputy Minister of Health here and said I wanted to do normalized testing, offering testing for everyone who has ever been sexually active in this province. He said, “Oh no, Julio, here we go again. We cannot afford it”. I said “you cannot not afford it.” He said “people are going to reject it, they are going to refuse.” I said “Let’s pilot it. We’ll offer testing to people at no risk, either self-perceived or perceived by their physician, who don’t have any conditions that make you suspect they could be HIV-infected and so when they come to emergency or admittance at three local hospitals with totally different demographics, we offer them an HIV test." We did 10,000 or so tests and found consistently five per thousand came back with HIV-positive results. My colleagues in Argentina did the same thing in acute care hospitals in Buenos Aires – and five per thousand came back positive. CDC in Atlanta says that if you only get one positive per thousand tests it pays for itself.
So that’s your answer. The return on investment is fabulous because you are doing two things – those people change their behaviours, they recognize that they need care and they render themselves no longer infectious. It’s a no brainer.
Julio, you are very persuasive, I must admit. Thank you so much for talking to us at PositiveLite.com again and thank you too for welcoming us to Vancouver for a great conference.
My pleasure, Bob
Photo by Bob Leahy.
Read my conference report here.