Testing, TasP, and PrEP; Canada could become world leader with new HIV strategy

It’s no secret that the last Canadian federal government, Stephen Harper’s Conservative party, did little in the fight again HIV. However, the new Justin Trudeau Liberal government has said they are committed to evidence-based decision making, and Vancouver’s MP, Dr Hedy Fry, is an enthusiastic supporter of Treatment as Prevention (“TasP”), and the wider 90-90-90 Strategy […]

Health Sexual Health Kevin Moroso

This article was published on December 1st, 2015

Dr. Julio MontanerIt’s no secret that the last Canadian federal government, Stephen Harper’s Conservative party, did little in the fight again HIV. However, the new Justin Trudeau Liberal government has said they are committed to evidence-based decision making, and Vancouver’s MP, Dr Hedy Fry, is an enthusiastic supporter of Treatment as Prevention (“TasP”), and the wider 90-90-90 Strategy of testing, treating, and viral suppression.

“I had the opportunity to meet with Justin Trudeau during the campaign,” said Dr. Julio Montaner. “Hedy Fry actually accompanied him to the visit. I was very pleased with everything that transpired as a result of that visit. I had the opportunity to discuss all of our work, not just TasP and the 90-90-90 Strategy but also commercial sex work, legal reform, etc. Certainly TasP and the 90-90-90 Strategy was the focal point of our conversation. He was very supportive. So much so that he actually wrote me a letter dated October 8th.”

In 1987 Dr. Julio Montaner joined the Faculty at St. Paul’s Hospital/University of British Columbia as the Director of the AIDS Research Program and the Infectious Disease Clinic. He is a founding co-Director of the Canadian HIV Trials Network, the Director of the BC Centre for Excellence in HIV/AIDS, and he was the President of the International AIDS Society. Recently, he has been assigned the position of Global Advisor on HIV Therapeutics to the Executive Director of the United Nations AIDS Programme.

Throughout his years, Dr. Montaner has authored over 650 scientific publications on HIV/AIDS, focused on development of antiretroviral therapies and management strategies. He has played a key role in establishing the efficacy of NNRTI based highly active antiretroviral therapy. He then focused his attention to HAART access to hard to reach populations. Since the late 90’s he also pioneered the concept of Treatment as Prevention (TasP). Largely through his efforts, TasP has now been implemented with great success in many places. His work has not gone unnoticed. In fact, Dr. Montaner has received numerous awards and distinctions for his research work.

“In late September we went to the United Nations for the discussion on the Sustainable Development Goals,” said Dr. Montaner. The End of AIDS by 2030 was discussed and of course the road map to the end of the AIDS pandemic. The road map is the 90-90-90 Strategy that we developed; we proposed this and it was adopted by Ban Ki Moon and the United Nations General Assembly. Since then, we have had a lot of support from a number of countries, though not from Canada. I was going back to the United Nations and Canada didn’t want to accompany me. This time I wrote to the heads of all the heads of the political parties and the Chief of the Assembly of First Nations, Perry Bellegarde, who actually came and visited with me and pledged his support for the strategy. I wrote to Stephen Harper, in his role as Prime Minister and candidate, Rona Ambrose (the Minister for Health), my local representatives Hedy Fry and Joyce Murray. The Green Party put out a statement, the NDP put out a statement, Justin Trudeau put out a personal statement, and the Conservations didn’t say anything.”

Health is a provincial jurisdiction, so exactly what and how the federal government would support the 90-90-90 campaign in Canada is a matter of some discussion. For example, it could be argued that there has not been a revision of the National AIDS Strategy since 2006. Dr. Montaner expects the 90-90-90 Strategy would be written into the National AIDS Strategy, amongst other things, and the federal government, as part of the health transfers, would say this is a priority provincially: offering testing, offering free treatment, and other support. Exactly how that would be implemented has yet to be determined, but Dr. Montaner would expect the plan to remain flexible, and the sooner, the better.

“The World Health Organization (WHO) has now formally recommended treatment for everyone infected with HIV regardless of CD4 count so the 90-90-90 is basically part of the WHO recommendations,” Dr. Montaner explained. “What we are saying is we want the governments to implement the WHO recommendations.”

What are the key barriers in Canada to implementing the strategy?

“If we get some sort of commitment to the 90-90-90 Strategy, then we need to get down to the implementation,” said Dr. Montaner. “In my opinion, we need to have widely available testing. For the population at large, we want HIV screening for all adolescents and adults across the country. Of course, people who are at risk should be tested more frequently.”

Dr. Montaner is troubled by the fact that there are places where there are co-payments and deductibles. When people are being asked to engage on treatment, and there are subtle barriers making it complicated. There need to be services that are free and/or subsidized. There are a lot of things in British Columbia that could be emulated. The lack of a national strategy to get to the end of AIDS from a public health perspective is very troublesome.

“The most at risk populations are affected by disproportional stigma, discrimination, persecution, prosecution; for the record, there will be no 90-90-90 Strategy if we don’t address the legal status of sex work, if we don’t address the current status of criminalization of HIV exposure,” explains Dr. Montaner. “Criminalization of exposure is incompatible with the public health goals we are trying to advance. So there are a whole lot of other layers that the federal government needs to address: the issue of illegal substance use and harm reduction. We need to deal with all of that and I think that the federal government really has an opportunity to make a huge contribution without spending a lot of money. These are the structural changes that have to happen. We need federal leadership.”

A survey was carried out in 2012 in Canada on attitudes towards HIV. It found that 29% of Canadians had a medium or high level of stigma towards people living with HIV. This is largely unchanged from 2006. HIV continues to affect the social lives of people living with HIV.

“I think stigma is a function of ignorance first and foremost, including inappropriate fear,” said Dr. Montaner. “The legal framework should be helpful, emphasizing legal protection for people infected with HIV, people at risk, and groups that are most affected.”

In 1996 a Greek activist attended the International AIDS Society Conference in Vancouver where Dr. Montaner was presenting information on triple therapy for the first time. Immediately following the Greek activist started the triple therapy regimen, which he credits for saving his life. Then in 2006, when Dr. Montaner presented a treatment that could stop transmission, he added that it helped to normalize his life. It was at this time that Dr. Montaner was able to put the situation into context. The Greek activist was healthy but was living with the ongoing self-imposed stigma that he was a risk to his partner. But the mere fact that the Greek activist was able to say that he was undetectable for now 10 years made highly unlikely that he would transmit the virus, that lifted a weight that he didn’t realize he had.

“I realized that if we had all of the other pieces I discussed, stopping criminalization, legal reform, and if we were able to tell the public at large that treatment has not only addressed the morbidly and mortality issue but normalized the lives of people affected by HIV, I think that would potentially make a huge contribution to this residual self-stigma and societal stigma,” Dr Montaner commented. “Now whether it would fix it, I don’t know. There are many other emotional layers that go with it but I think it could contribute greatly.”

The number of new HIV diagnoses among MSM increased to 158 cases in 2013 in B.C. from 149 cases in 2012. However, the trend in new HIV diagnoses among men who have sex with men (“MSM”) appears to be declining slightly but not to the same extent as in other exposure categories.

“The first thing is we are seeing slightly more cases because we are testing a lot more; new diagnoses is not the same as new infections,” explained Dr. Montaner. “So we need to be careful about that language. I’m not saying that things are going down by a whole lot and I’m not debating the point, but I wanted to make that technical comment. The second point I want to make is something our epidemiologist and demographer has made a number of times: the number of cases has to be judged using, as a denominator, the number of people in the MSM community. There is every reason to believe the MSM community is also growing. There are fewer people dying from HIV for one thing. So that number, taken by itself, doesn’t tell the whole story.”

It can be debated about how much the HIV infection rate is declining. There is evidence of a dramatic decrease in HIV diagnoses and new infections in injection drug users (“ID users”) but there has not been the same degree of decline in the MSM community. Exploration of the data suggests there is a decline in the MSM community but it’s not comparable to the trend that have been seen in ID users.

“We have data that shows that TasP works,” said Dr. Montaner. “The Partners Study has given us tremendous reassurance that this is the case. So what is the difference? In the ID users community, because we have harm reduction in place, people don’t expose themselves to additional HIV. They are on treatment and they use harm reduction. In the sexual context, it’s much more difficult to get the full effect of TasP because the sexual networks are very active. If I have a person sitting here at the centre of a sexual network, for me to protect this person from HIV, I can treat the official partner in that relationship. It doesn’t matter that we treat the partner if this individual is having additional partners who are infected and these are casual relationships. So what I’m saying is that for me to protect this individual, I can only achieve protection when I deal with the network. If I don’t treat his other partners, I haven’t achieved much.”

This is less of a problem in ID users because the harm reduction strategy is working for everybody. The problem is that condoms are underutilized because people don’t like them. But the truth is patients report they use condoms sometimes, not all of the time. In the future there’s going to be a point, hopefully, with TasP that it will be possible to start shutting down some transmissions in the networks and will see a precipitous decline in these numbers as a result.

San Francisco reported 426 new HIV infections in 2012, when pre-exposure prophylaxis (“PrEP”) use was negligible. New infections fell to 359 in 2013, as PrEP use gradually rose. According to a modeling study, new HIV infections in San Francisco could fall by 70% if about 14,000 city residents used PrEP.

“We know PrEP can be effective,” stated Dr. Montaner. “The WHO has made a formal recommendation to endorse it. We have made that recommendation too; we clinically recommend it but it’s not paid for by the government. We have made a recommendation to the provincial government that they should be looking at this.” The critical issue is to decide the most appropriate people to be offered PrEP. High risk categories can be defined in different ways. For example, if you have one or two uses of post-exposure prophylaxis, you are high risk. Or if you have a partner who is HIV positive who is not on treatment, then you are at high risk. Individuals may be more efficient to offer treatment to a partner that is infected because by treating the person that is infected, two goals are achieved at once and it reduces morbidity and mortality and it reduces transmission as well.

“For us in B.C., the way I would roll it out would be to identify the groups needing PrEP which is something to be negotiated,” said Dr. Montaner, on how he thinks PrEP should be rolled out. “The idea would be to define who are the people that we consider in that risk zone where PrEP would be desirable. We implement that, we monitor it, we evaluate it. We reassure ourselves that it is going well. We then have a conversation on how we expand and modify that risk zone. Basically this is how we’ve been operating all these year – trial and error. I’m less worried about how we define that band of risk; I’m more worried that we need to get started.”

“Now when you are talking about elsewhere, particularly as we move to settings with less resources, the situation becomes more complicated,” explains Dr. Montaner, relating to having PrEP rolled out across Canada. “Then you have the tension that arises between treatment and chemoprophylaxis (PrEP). If you walk into an environment where there are limited resources and the treatment quotas are difficult to meet because resources are limited, then people struggle to figure out what we do first. To be perfectly candid, the efficiency of treatment is many fold greater than chemoprophylaxis for the reasons I’ve alluded to. We know now that, the sooner you start treatment, the better the individual outcome and the sooner you stop transmission. If you’re struggling to meet your treatment quotas, then how could you accommodate the tension with PrEP or even post-exposure prophylaxis, which is something we also recommend?”

In B.C. it is possible to do all of those strategies because the resources are less of a problem. For the administrators and communities in the south of the world, this is a very difficult conversation. They depend on external resources to fund these programs.

“I don’t envy them being in this situation,” said Dr. Montaner. “I think treatment should be the number one priority; that is my personal opinion. There are countries, Brazil for example, though Brazil is not at the bottom end of the socioeconomic ladder, that have said point blank that they are going to be rolling out PrEP. And I think that is great. But they don’t have the same limitations on their ability to roll out treatment. In a context like Uganda, whether you can do that, I don’t know.”

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