It’s been ten days now, enough time perhaps to process two solidly packed and incredibly busy days in Toronto at the Ontario HIV Treatment Network (OHTN) Research Conference. But perhaps not enough time. I’m still thinking through some of what I heard, still weighing competing voices, still distilling in my head what I heard. All of which suggests, I think, the real value and – yes – real life impact of events such as this.
True, the level of our engagement was particularly high this year, attending as we do with our PositiveLite.com hats firmly on our heads. It was, in fact, a bit of a whirlwind. We filmed three interviews (more on that later), moderated a challenge panel on smoking cessation, manned the PositiveLite.com booth (a first for us) in our spare time and networked madly. And of course we introduced The Smoking Project to the world, with a series of posters (below right) designed by poz graphic artist Raymond Helkio our opening salvo. Add in all the usual sessions and it was – well – a tiring two days.
But by any measure it was a success. From the conference website: “Over 625 people registered to attend RC 2012 - Research with Real-Life Impact - and the event was a resounding success. We heard from some of the most distinguished researchers in the field from across Canada, the United States, Britain, New Zealand and Australia. We were also privileged to have people living with HIV - leaders in our work - moderating many of our sessions.”
It's hard to single out or even synthesize what went down at the conference in total, so I’m going to zero in instead on the plenary session that made the most significant and lasting impact to this particpant. It happened, in fact, to kick off Day Two and it was entitled “Is Treatment Enough Prevention?” That question, of course, represents the crux of a debate, arguably overdue at least in Ontario, crucial to the success of how we fight the epidemic here.
There is a lot of back story to this session that those familiar with the treatment as prevention story will know. But if not, you really need to be aware of just three ongoing storylines. First, the success of HPTN 052, secondly the enthusiastic adoption of treatment as prevention strategies by early adopters such as B.C.'s Dr Julio Montaner with widely reported favourable results and thirdly the explosion of “Getting to Zero” sentiments exemplified by Hilary Clinton’s address at this summer’s International AIDS Conference in Washington and gatherings that followed. In short, many have been hailing treatment as prevention as the holy grail, THE way to end the epidemic. But is it that simple? The title to this panel discussion suggested not.
Certainly Canadian researcher Dr Barry Adam was quick to suggest that the tone of the debate had perhaps changed since Washington, particularly in light of hard facts that suggest, even in BC where new infections are down overall (and he suggested reasons for that unrelated to treatment as prevention, such as Insite) the gay men’s epidemic seems to be impervious. Further he sounded the alarm that “risk compensation”, the changes that have been seen to occur in risk behaviour as a result of treatment optimism, represents the unwanted fallout of the discourse on treatment as prevention. He cited data, for instance, that suggested that unprotected anal intercourse (UAI) is higher in individuals that have heard of the Swiss Statement. And he suggested that treatment as prevention by itself won’t cut it. “Biomedical solutions are not enough” he said.
That theme “treatment is not enough prevention” was echoed by Atlanta epidemiologist Patrick Sullivan. Talking about the continuing high rates of new infections in gay/bi men, Patrick pointed out that this population was underserviced and under-researched, but he was able to suggest additional reasons why the gay/bi men’s epidemic rages on. Rejecting simple behavioural causes, he suggested we need to look at factors unique to gay/bi men – the biological factors surrounding anal sex, sex role versatility, multiple variants of the HIV strain in the gay/bi population and high numbers of casual sex partners. He said the problem can be cracked with existing technologies, but only in combination - treatment as prevention, PrEP and condom promotion in particular.
Susan Klippax from Australia also echoed the "treatment as prevention is not enough theme", also pointing to reasons why it is not working in gay/bi men in her country, and also fingering perceptions surrounding the efficacy of treatment as a major factor in the rising incidence of HIV infections in gay/bi men in Australia.
Canadian clinican/researcher Rupert Kaul added to the debate by providing the kind of reasoned technical expertise on HIV transmission that we explored with him in his interview with PositiveLite.com here. And Tony Hughes from New Zealand rounded out the debate with solutions similar to what we had already heard – actively promoting condom use and regular testing, facilitating early treatment and implementing vaccination programs for STI’s.
Given the international nature of this panel, it would be hard to argue that these arguments represented a purely Ontario response to the tide of optimism emanating from, say, B.C. and Washington. It does certainly seem that there is sober second thought going on. An alternate view is that opponents (or at least doubters) of treatment as prevention, and they are legion, have been girding up for battle. Certainly, the science, and the epidemiology in particular, is developing, so I think a balanced perspective may simply be that the verdict is still out.
One can’t help but applaud, though, the critical eye we are seeing applied to treatment as prevention though sessions like this. I certainly liked that every speaker identified treatment as prevention as ONE of the techniques we can use to stem the epidemic, right up there with condom use et al. That’s good. Let’s hope that the current uncertainties don’t delay implementation of this critical strategy unduly, when it is clearly urgently needed – to be used in combination with other strategies, of course.
I’d go further and suggest we need to hold our community accountable for how readily they seize this new tool, warts and all, because clearly it has promise, all panelists agreed, although none thought of treatment as prevention a slam dunk. And particularly not a slam dunk when gay/bi men are concerned. All in all, it was a superbly challenging (in the best way) discussion which will surely have lasting impact on the thoughts and actions of all those present.
Incidentally, you can view this session online here.
I wanted to wrap up with two thoughts. First our coverage of the conference is not over. I mentioned earlier that we filmed three video interviews. (Thanks, videographer Guy McLoughlin, for your help with these.) I talked with Patrick Sullivan about the challenges of HIV prevention in gay/bi men. My colleague John McCullagh interviewed Lisa Power about Aging with HIV and will later be interviewing Sean Rourke about brain health. Look for those interviews over the coming weeks.
Secondly there are some acknowledgements I need to make. I hate singling out anybody, because the entire OHTN team is a pleasure to work with. But I’ll name three. Sean Rourke of course, for his leadership, vision and support. Jason Helbig who is our main PositiveLite.com/OHTN liaison and helps us in ways too numerous to mention. And Jean Bacon who organized the conference program so expertly, including amazing work on the panel I moderated for the Smoking Project. Thank you to all!