“Canada can do more” said Canada’s likeable new Health Minister Jane Philpott in a recent Globe and Mail interview.
She’s right of course. So why aren’t we doing more? Opinions may vary. Certainly after just coming back from from South Africa and hearing how other countries far less wealthy than Canada are beating us in PrEP, treatment coverage, testing options, surveillance (tracking and number crunching) and even on more progressive criminalization approaches, we seem to be mired in a sea of mediocrity.
So yes, Canada can do more. The minister’s increasing Canada’s contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria from $650-million to $785 over three years, a 20-per-cent increase over its previous donation, is really good news. And if you followed bulletins coming out of Durban last week, you know that an overall drop in global funding is causing concern amongst experts, who insist more money, not less, is needed to eliminate AIDS by 2030.
Note that the Global Fund is not all about HIV. About 53 per cent of the Global Fund currently goes to HIV, 30 per cent to malaria and 17 per cent to tuberculosis, even though TB is the biggest killer. And don’t confuse any of this with the $28 million which goes to fund community based programming in Canada. The disposition of that pool of funds is currently up for grabs, in a PHAC call for proposalsl that pool has not been increased for years.
I’d be highly surprised if the domestic funding pool increases any time soon. Our NGO’s have been advocating unsuccessfully for years on this topic, arguably to the detriment of other issues, and in a time of economic austerity at home, it looks like $28 million will have to do. (Of course agencies have other major sources of funding besides the Government of Canada.)
In any event, the Minister’s commitment to increasing Global Fund dollars is welcome. And as I said earlier in the context of meeting her personally in Durban, this Minister is one who listens and gets it when it comes to prioritizing what needs to be done. She’s also a hard worker. At Durban, reports the Toronto Star, she was everywhere. “In five days she delivered eight speeches on topics ranging from mother-to-daughter HIV transmission to the “undeniable and unacceptable gaps” in health outcomes between indigenous and non-indigenous populations in Canada.”
Plus she found time to chat with me! I like her.
In the same Globe and Mail interview, Philpott did something a little odd. The newspaper reported “Dr. Philpott said she would like to see all provinces adopt British Columbia’s treatment-as-prevention strategy and other harm-reduction measures suited to their circumstances.”
Now anyone knowing the history of treatment as prevention (TasP) in Canada will view this statement as somewhat incendiary, one that stirs up old wounds and interprovincial rivalries that are perhaps better not revisited...
Why so? B.C. has of course been a longtime proponent of TasP while other provinces were historically far less enthusiastic. “Don’t listen to BC”, said Ontario voices. "Treatment as prevention doesn’t work". And later, when it clearly did “it doesn’t work in gay men”. So unenthusiastic were those voices that at least three organization I know intentionally removed the phrase “treatment as prevention” from their vocabulary.
Even progressive Canadian voices like CATIE were guarded. Said one 2013 article “The evidence available so far is observational and has its limitations. Even if it is found that the number of HIV diagnoses (or HIV incidence) decreased in a population as more people accessed HIV treatment (a positive finding), it is difficult to know exactly why this happened. For example, a decrease in HIV diagnoses may have been the direct result of increased treatment coverage or it may have been the result of other HIV prevention interventions that were implemented at the same time.”
Negative assessments of TasP, like this 2010 position paper from the Toronto PWA Foundation were the norm in pre-PARTNER Canada. (My own supportive take on TasP included in my 2013 article “Changing my Mind on Treatment as Prevention" won me few friends.)
Why the controversy around the science? In some ways it was personality-driven. TasP’s principle backer, B.C.s Dr Julio Montaner has a forceful, no-nonsense style which irritated some. But Montaner, in fairness, is also a driven, passionate and forward-thinking man. One of the first to see the prevention benefits of ART way back in 1996, he’s one of the minds behind 90-90-90 and has the ear of politicos around the world. Minister Philpott is clearly one of them.
Of course his “test and treat" manta has been adopted in multiple countries - and it seems to be working, in some cases spectacularly. Not that his policies are well received everywhere, even in his own province where gay men are less convinced that they have his attention. Montaner is also no big fan of PrEP, citing it numerous times as “a distraction”. Thus while BC commendably provides for no cost medications to all people living with HIV it has so far drawn the line on funding no cost PrEP.
But if the language of treatment as prevention has not gained traction in other Canadian provinces, its strategies have. Even long term doubter Ontario has a provincial AIDS strategy which, despite its failure to promote no cost ART, some have termed ”treatment as prevention lite.” It’s just not called treatment as prevention.
So back to The Globe and Mail. Minister Philpott’s suggestion that other provinces should follow B.C.’s lead is somewhat redundant now. They mostly already have in some shape or form, without admitting it.
Ultimately though it doesn’t matter. The responsibility for health care delivery is provincial, so Minster Philpott's entreaties to follow BC’s lead may ruffle feathers but will be ignored by those who want to do so. Her words will carry no influence. They are too little and too late. The TasP train has already left the station. And that's good!.