“We have an obligation to decide whether the evidence is enough. We’ve waited too long to do what we know is right. Enough is enough. We need to move to implement.”
Acknowledging that “we have a consensus in this room but not outside this room” BCCFE’s Dr. Julio Montaner, looking dapper in a dark suit and bright red tie, opened the third annual International Treatment as Prevention Workshop in Vancouver last week.
Fitting that we should be there in his home town. Vancouver was the site of the 1996 International AIDS Conference where the advent of protease inhibitors caused such excitement, leading some to rush to predict the end of the epidemic was nigh. It wasn’t of course, but the power of those antiretrovirals launched in 1996 to not only restore health but virtually eliminate infectivity in some circumstances has led us all to the place we are at today. That place is a room of three hundred experts from all corners of the globe. There are almost 40 countries represented here, including many high ranking diplomats, scientists and health officials, not to mention people living with HIV from around the globe. We even have a Prime Minister in our midst.
It’s challenging to cover all that transpired in the following four days, so you’ll find only the highlights here. Those with a deeper interest in this hottest of hot topics are advised to go the conference website here for more coverage of the many excellent presentations that will be posted there later this week.
But it would be remiss not to include some highlights here – the stirring opening remarks of Canada’s Stephen Lewis and UNAIDS head Michel Sidibe, for instance, the exciting debate on whether treatment as prevention (TasP) works for gay men, the voice of a remarkable community activist Paul Kawata from The National Aids Minority Council – and the place of PrEP in all this talk about test and treat.
First a few recurring themes which resonated with me . .
The way forward. TasP is clearly seen as the way to end the epidemic, without of course abandoning other strategies like condoms, circumcision and behavioral interventions.
Is it working? Most of the world is adopting TasP strategies in some shape or form, some quite aggressively. (Canada, now seemingly famous for its hesitancy, only has the example of B.C. ) Many jurisdictions are boasting reductions in new infections – New York, San Francisco, Washington D.C. and of course British Columbia are the most quoted North American examples.
When to start treatment. Offering treatment early is now a given to a) produce better clinical outcomes and b) reduce infectivity. Most treatment guidelines around the world either reflect that or are swiftly moving in that direction, with strong support in the room for offering treatment on diagnosis. Having said that, the new WHO guidelines previewed at the conference are still taking a more conservative approach with a recommended CD4 threshold of 500 for treatment initiation in asymptomatic patients.
The human rights angle. In Canada some worry that expanded testing and early treatment to improve health outcomes and help reduce transmission represent the potential for human rights abuses. Globally, TasP presents human rights issues too, but which are almost the exact reverse of our domestic ones – namely the right of patients everywhere to have proper access to testing and to receive early treatment in the face of economic and social challenges.
Expanded testing models. In progressive jurisdictions, HIV testing seems to be gradually moving from an opt-in to an opt-out model. The cost effectiveness of this approach seems to be justified by the unearthing of sufficient numbers of new infections in people who were not previously considered, or did not consider themselves at risk.
The HIV treatment cascade. It’s known by different names but is quickly become the de facto means of visualizing and monitoring the continuum of engagement from testing to viral suppression, so TasP advocates are using the concept to the hilt. It’s also become clear that Canada, and many of its provinces, are not currently well placed to do this kind of monitoring. How many of us are on treatment? How many of us are undetectable? We just don’t know. Other countries do.
Emerging issues. To name but a few . . drug resistance, low rates of retention in care, access to testing, need for more community involvement.
Now on to some personal highlights . .
What Stephen Lewis said
Stephen Lewis, for those who don’t know him, is a former leader of Canada’s NDP party and former United Nations' special envoy for HIV/AIDS in Africa. He is also an incredibly eloquent and passionate speaker. Lewis said this . .
“There seems to be a consensus in the room – almost full-throated in its fervor – of moving from what was a contentious theory to what Michel Sidebé called “a human right”. I think we should all take this moment as a cause célèbre and move the mountains that are necessary and see this as a clarion call meeting for treatment as prevention.
"And I would say to some of my colleagues and friends that we have to stop the groveling and the begging and scraping before the political potentates. Just because Barack Obama and Hillary Clinton have used the phrase “AIDS-free Generation” doesn’t mean that we should wear our knees threadbare in their presence and applaud with unseemly adoration because the phrase is offered. The 1.65 billion dollars that is in the budget for next year for the Global Fund is frankly, compared to the possibilities of the United States, pretty paltry. There is a tremendous fight still to wage! And there is a good feeling in this room that we have the vehicle called ‘Treatment as Prevention’ in order to do it. So along with gender equality, and the rights of key populations, there is another moral imperative in this world, and it’s called ‘Treatment as Prevention’, and it deals with HIV and AIDS.”
What Michel Sidibe said
Michel Sidibe heads UNAIDS. He is also an effective and commanding speaker. Sidibe said . .
“Treatment as prevention should not be seen any more as putting people on treatment but as a human rights issue, one of access to best possible care. It should not be available just for rich people but for people in every country of the world. It is an issue of science, economics, and morality,” he said. “And if you don’t pay now, you will pay later.”
“If we have the evidence that antiretroviral therapy can help someone living with HIV to stay alive and protect their sexual partners from infection by up to 96%, then we have a moral obligation to make it available,” said Mr Sidibé. “Providing HIV treatment as soon as possible is ethically and morally correct, economically and programmatically feasible and consistent with what we have learnt about clinical best practice over the last decade.”
Treatment as Prevention in MSM. Does it work?
One of the most eagerly anticipated highlights of the conference was a lively debate between David Evans of San Francisco’s Project Inform, who argued it does and Myron Cohen, lead investigator for HPTN 052, who argued the reverse. Although in truth the two were not too far apart.
Evans argued that while we need to fully respect the rights of individuals to refuse treatment, there are strong arguments for HIV-positive MSM to use treatment to reduce risk. He cited in particular the biological data that proves ART reduces transmission, and convincingly, that we have a chance here to alter the trajectory of the epidemic. “It's a social and individual imperative” he said. Saying that while there are gaps in the science, we need to use "best guess estimates" on the impact of ART in MSM. “It’s not right or moral to wait for the data to catch up. . . We have come to the limit of efficacy of existing strategies.” Evans highlighted the need to implement TasP in combination with other interventions to remove the stigma and fear associated with HIV and pointed to successes in San Francisco, where a significant reduction in HIV transmissions has been observed despite an increase in STIs.
The affable Myron Cohen then took the stand and immediately framed the argument in terms of receptive anal intercourse (UAI), not MSM sex, which he described as a very efficient means of transmission. He said that there are no direct measurements of the efficacy of ART in MSM, only epi. data which shows mixed results. Out, of course, came the old argument that ART does not eliminate virus from the semen, even though, significantly, he described the concentrations as typically “trivial”. He said STIs are a huge problem in amplifying risk in UAI. He said that modest increases in UAI have countered the preventive benefit of ART in MSM, although in the absence of ART we would probably be seeing many more new infections. His main point though was that implementing treatment as prevention in MSM, which he actually seemed to support, is about managing expectations and how you communicate these risks.
In the questions that followed, Julio Montaner countered that the question is not whether TasP works in MSM but how much it works.
Is PrEP an essential component of treatment as prevention?
A second lively debate, arguing for were San Francisco’s Robert Grant and against, South Africa’s Brian Williams.
Grant described PrEP as a game-changer because of its potential to decrease the burden on treatment programs, motivate HIV testing, and provide more timely identification of acute infections. Most importantly, Dr. Grant argued, PrEP may destigmatize HIV drugs and the people who use them. “You don’t have to be perfectly adherent to show substantial benefits” he said. Williams was far less enthusiastic, countering that PrEP was useful in limited cases but not essential. “The only way to stop the epidemic: he said “is universal and early access to ART. TasP could eliminate HIV, PrEP won’t. Therefore TasP is the more effective strategy."
Again Montaner was active in follow up, suggesting that PrEP is a distraction from the primary need, asking can we afford to focus on it? The consensus seemed to be, though, that it is not appropriate to make a comparison between PrEP and TasP as both have their uses.
Words of a community activist
Paul Kawata of the National AIDS Minority Council scored major points in the closing hours of the conference with a beautifully delivered speech from the viewpoint of a person living with HIV supporting moving forward on TasP. But “when will people with the virus be part of this discussion?” he asked. And “how do you end the epidemic when the communities we need to target don’t care anymore?” He made a powerful argument for preventative strategies rather than tackling social determinants of health. Giving stigma as an example, Kanata argued “we are not going to solve social determinants of health. We can’t let them be an excuse.”
By any standards this was a highly important gathering – a show of global solidarity for a cause whose time has surely come. It was notable for both who was in the room – a stellar collection of impassioned and knowledgeable scientists and advocates – and who wasn’t. Where were representatives, policy makers in particular, of the Canadian provinces, for instance, whose less than stellar performance in containing the epidemic points more than ever to the need for a search for new directions, new strategies?
On a personal level, I enjoyed the conference as much as any I've ever attended. Stimulating beyond words, it left me – and I suspect most attending – with more optimism that we now are poised with tools in hand to end the epidemic than I have felt in a very long time.
During the conference, I took time out to interview Julio Montaner (left). Forthright as ever, he was proud of the progress TasP initiatives have made to date, but profoundly disappointed ("my heart is broken" he said) at the lack of uptake in his own country outside his native province. You can read that interview here.
For those still not convinced, by the way, that treatment as prevention is the way to go, I recommend the excellent interview with Stephen Lewis below, talking with passion on why he feels there really are no alternatives that make sense any more.