(Reprise) Unacceptable. Reprehensible. Strong words on Canada’s approach to HIV prevention from one of its own.
Bob Leahy with Part One of his exclusive interview with British Columbia’s most famous scientist, Dr Julio Montaner. Treatment as prevention is Montaner’s passion and the world is listening – and acting. But not Canada, he says – and he’s angry!
This interview was originally published on PositiveLite.com January 18, 2012.
Dr Julio Montaner, head of the British Columbia Centre for Excellence in HIV/AIDS is proud of what he and his Province have achieved in reducing HIV transmission rates through treatment as prevention strategies. It’s a trend he doesn’t see elsewhere in Canada, not that he hasn’t tried to make it happen.
“The public needs to get incensed” he said to me last week. “I‘ve been in the White House three times in the last three years. I‘ve seen Obama, I‘ve seen Clinton. On December 1 last year the US said treatment as prevention is the way forward and they are going to be doing it domestically and internationally. And you know, I‘m honoured by it. But I‘m frustrated that my own country keeps on telling me - well, we are not so sure that we agree. Every time that I write to them I get a form letter saying thank you, we acknowledge we have received your correspondence. The Honourable Leona Aglukkaq (Minister of Health) doesn’t have time on her calendar, I wrote to Michaelle Jean, when she was the Governor-General she didn’t answer, I wrote to the Prime Minister – same answer."
A mixture of science and ethics
Listening to Dr. Julio Montaner talk is a revelation. The world-renowned head of the BCCFE speaks with a thick South American accent, a product of his Argentinian upbringing. He talks a lot too – ask him about HIV and he`s off and running, scarcely stopping for breath. He reels out history, facts and figures about a topic about which he clearly feels deeply. But here’s something else - he talks social justice too. In fact his work is rooted in it, he says. Combine the two sides of his passion – the science and the morality of it all - and it`s powerful stuff. He is probably the most driven person I have ever spoken to.
I talked to Dr. Montaner last week in a recorded 40-minute interview, the same week he publically chastised Canada in both the Winnipeg Free Press and the Globe and Mail. In my two-part interview, excerpts of which are featured here, he is even more outspoken, this time naming names and pointing fingers. In fact he is one angry man.
Here’s what he said to me about his crusade to have treatment as prevention adopted Canada-wide. “I have talked to every public health officer for every province in this country in the last couple of years .I have made trips to other jurisdictions including Ontario and talked to the Ministry of Health. I have talked to my colleagues, community and the like. And everybody is always asking me - are you sure? And I say listen to me clearly. What I am saying is that if we make an active effort to bring treatment to the people they do better and public health will do better."
I cannot get five minutes audience with the federal government . .
"I’ve written to Tony Clement when he was the Minister of Health . . . on a yearly basis and the Prime Minister and I’m saying look - Canada has this amazing made-in-Canada strategy that has now been recognized by Science journal as the number one scientific breakthrough for 2011. The New York Times has written about it. You name it. It’s all over the place. And I cannot get five minutes audience with the federal government to say – you know how come it‘s so easy to have a national strategy about childhood obesity, prostate cancer, breast cancer – and AIDS, we have a made-in-Canada strategy that can fix it that cannot be sorted out.”
And the New York Times HAS written about it. So has the Globe and Mail (BC Strategy Hailed Worldwide but not in Canada”). Science magazine named HIV "treatment as prevention" the number one scientific breakthrough of the year. Time magazine included treatment as prevention in its top ten medical breakthroughs of the year.
“Tony Clement had no time for me.”
Montaner has been on the treatment as prevention crusade for a long time, ever since he got wind of the possibilities in 1996 when HAART started to produce good results in clinical trials. “We started to speculate” he said “that HAART had a secondary and unintended benefit of decreasing the number of HIV cases in the province. We couldn’t prove it. But we said wow! Look at what’s happening here! Despite the case that syphilis cases are going up, HIV cases are going down in a way that is proportional to the number of people treated with ART. And the world said - slow down. You haven’t proven anything and we said OK, let me look at it again. And we did studies and epidemiological studies and by 2006, we thought that the data was sufficiently mature to go forward and say - hello, we now have enough data to make a recommendation and we did that in a plenary presentation at the 2006 International Conference in Toronto. I actually brought it to the attention of Tony Clement who was Minister of Heath at the time - who had no time for me.”
Montaner is getting more and more impassioned now as he speaks. “We entered in to a debate with the wider community saying that this is what we need to do. And other constituencies out there, for whatever reason, had difficulty in understanding and they said you haven’t proven that treatment as prevention works. I said - wait a minute, we have enough proof to say that if we treat people who need treatment in a facilitated fashion we decrease morbidity and mortality and transmission.”
“We went further; we did economic analysis, we did everything you want. The province of British Columbia said yes, we are going to support you. A couple of years ago they said - Julio, we are going to give you additional resources to engage hard-to-reach populations who need treatment and in doing so they are going to do better. And we will have less infections.”
Seek and treat
The additional resources resulted in the province undertaking high profile seek and treat testing campaigns, under Montaner’s auspices, which both seek out the most at risk and also normalize HIV testing for all sexually active adults who consent to it, as part of their regular medical check-ups. Combined with offering no-cost treatment immediately on diagnosis, it's a different approach that distinguishes BC from the rest of Canada. PositiveLIte.com reported on B.C's recent testing campaign, “It’s Different Now”, here.
How has the province fared? The British Columbia Centre for Excellence reports that B.C. is the only Canadian province seeing a consistent decline in new cases of HIV. The 2010 published results show a reduction of nearly 65 per cent in new HIV diagnoses in B.C. to 301 cases, down from the 850 cases diagnosed annually prior to 1996. In other Canadian provinces, HIV and AIDS have not declined or have actually increased, in some cases significantly.
I asked Dr Montaner why his provincial counterparts aren’t biting. He speaks angrily. ”In 1996 there was a sense of urgency. Today there is no sense of urgency. The community doesn‘t feel the urgency, politicians don’t feel the urgency – no one is putting pressure on anybody. It‘s like – things are OK If I show you the rates of new infections across the country, you will see that British Columbia has had a roughly 60% decrease in new infections and you will see that Ontario and the rest of the country has shown NO significant decrease over time. And when I show that to my colleagues they say well this is OK, because this is stable. I say, well that‘s unacceptable!”
Montaner minces no words on this topic. “My job as head of the HIV program in my province is to decrease morbidity and mortality and transmission. And if I am not doing that - you know what? They should get rid of me.”
A Draconian perversion
Montaner points to inequalities in access to treatment as something else that riles him. “The medical system in British Columbia has what I call a Draconian Perversion” he says. “It has a little bit of a Machiavellian portion. You have HIV treatment available in British Columbia at no cost, no down payment, nothing – which is different to other jurisdictions across the country. But you have to be able to find your way to me, or any other doctor. And so what happens is that the system is perverse – that's why I called it a Draconian perversion – in the sense that if you don‘t come and get it, we won‘t come and give it to you. …..A person who needs treatment may not access treatment for reasons of mental illness, poverty, social or economic status, education, their addiction or whatever and what happens that persons health suffers and that person, for the time they are untreated, is much more likely to be spreading HIV.”
“And so what I have been able to discuss with my government successfully is that - look - you invest a little bit more and help get access to these people, work with me and help them, if they so wish, to gain access to treatment and by doing so we are doing the right thing, the humane thing, the compassionate thing but at the same time we are investing in health for society."
Across Canada, he sees complacency in the treatment of the marginalized sectors who are hardest hit by the epidemic. “What is happening here is that there is a compartmentalization of the epidemic by which it is us and them, and as soon as it‘s them, we don‘t care. And that‘s unacceptable. This is not the way we operate. The Canada that I know is characterized by the fact that every individual in this society has an equal value and we are eager to protect and help and assist each person if they so wish. The problem is somehow, under this new philosophy, it’s us and them and we are happy with that. And that’s unacceptable."
Don’t call us, we’ll call you.
I pressed him to tell me what he has done to convince his provincial counterparts that treatment as prevention works. “Listen" he says. "The province of British Columbia has been stellar in support of this initiative. The other provinces - all I can do is go, give a talk, show my data and say guys, if you need any help, let me know. So they say “don‘t call us we‘ll call you!“
He’s concerned too about the lack of a Canada-wide testing strategy. “Let‘s have a strategy” he says. "Year after year (it’s reported that) approximately 25% of people in this country infected with HIV are unaware of their infection. Tell me, where is the strategy to increase HIV testing in this country? Except for British Columbia there IS no strategy".
I asked him about Ontario’ testing record and their infection rates. Here’s what he says. “The thing is its “stable”. Like "stable” is good. "Stable" is unacceptable. When I talk to people I get the sense that no, no, no we don’t want to do more testing because it costs more money. And that’s crazy. You know there is no more better investment than doing more testing. It’s peanuts in comparison to the amount of cases saved by identifying those patients and being able to engage them in discussion about the virtues of accessing treatment at an earlier stage,"
"To have the knowledge, much of which has been produced here, to know how to treat, control and stop this epidemic and not implement it because of lack of political will is unacceptable and reprehensible and I’m prepared to do whatever I can to change that. I’m not giving up and I’m convinced that the day will come when we will prevail.”
In Part Two, Bob Leahy talks to Dr. Montaner about the objections raised to treatment as prevention and asks is money spent on PreP well spent, does undetectable viral load mean condom-free sex and can treatment as prevention end the epidemic.
First Photo credit: The Canadian Press/Darryl Dyck