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As Prevention


Frank talk from Julio Montaner

Wednesday, 22 July 2015 Written by // Bob Leahy - Editor Categories // As Prevention , Features and Interviews, Health, International , Treatment, Opinion Pieces, Bob Leahy

From IAS 2015 Bob Leahy speaks (again) with BC’s Dr. Julio Montaner, the world’s leading treatment as prevention advocate, about 90-90-90, his frustrations with uptake in Canada – and meeting the Pope.

Frank talk from Julio Montaner

He’s co-chair of IAS 2015, a conference of its time notable not so much for its presentation of the latest science but for what seems like a collective determination to stop talking, move forward and IMPLEMENT what we’ve been debating for years. Which suits Julio Montaner, head of the B.C. Centre for Excellence, just fine.

“There is no discussion anymore” he says, “the science is in. IAS 2015 will finally compile a body of irrefutable evidence to make treatment as prevention the global standard of care." He issues a bold challenge. "Political leaders of the world, you are with us or against us”.

That kind of talk is one of the things that sets this man apart. For Montaner, besides being remarkably outspoken, operates not just on the provincial stage but on the world one. He rubs shoulders with UNAIDS and WHO top brass, knows countless diplomats by name, banters with the worlds AIDS czars. If he is a maverick he is a successful one, whose policies, once considered controversial and still often outwardly rejected in Canada outside his home province, have been adopted throughout the world.

He’s one of the architects of 90-90-90 too. It’s a UNAIDS target that has gained traction in many countries but has yet to be embraced in Canada, either federally or provincially, except by B.C. But now it looks a lot like his detractors are out of step with the global response. Thus Canada as a whole performs in a lacklustre fashion, occupying middle ground in the new world order, lagging behind resource-poor countries by almost any HIV measure of performance you can think of. In fact in efforts to reduce population viral load countries like Botswana, Rwanda and Malawi are doing better than Canada in providing better treatment cascade measurements.

Acknowledged over and over this week at IAS 2015 in Vancouver by presenters from around the world though is that BC leads the way. Free HIV meds back up offers of treatment immediately on diagnosis. Innovative harm reduction strategies seen nowhere else in North America. More universal HIV testing than anywhere else. Target driven strategies. Advocacy on both the local and global stages. Much of all this is unmistakably Montaner-driven.

Even if it were just that, Montaner would be a good interview. But spike the policy talk with passion-a-plenty, forthrightness (this man NEVER minces his words) and - yes - bags of South American charm (he’s originally from Argentina) and you have an interviewer’s dream. Which is why this week at IAS 2015 in Vancouver, I met with Montaner, the fourth time we have done so over the years, to share his views with readers.


Bob Leahy: Well, here we are again in Vancouver. It’s great to be here. I’m interested particularly today Julio in your thoughts as to what are the big themes that are coming out of this conference.

Julio Montaner: You know me, there is only one theme (laughs). You know, when I started the process of bidding for the conference to come to Vancouver, plan A was to use the conference as a platform to ensure we were on track as we arrived at the deadline for 15 by 15 (15 million people on treatment by 2015, a target recently met ahead of schedule). I was optimistic that we could use this opportunity to build a coalition for a new target but Plan B was, if that was not to happen, we would use the opportunity to castigate those who were not delivering on 15 by 15. As you know well, I’ve been working on treatment as prevention for the longest time, so two years ago we started the process with (UNAIDS Executive Director) Michel Sidibe who deserves a lot of credit for having the courage, the boldness, the vision to embrace treatment as prevention when many others were very critical of it.  So we started the process to create a post-15 by 15 target that would encompass and synthesize everything we have learned about treatment as prevention

And that’s 90-90-90.

That’s 90-90-90. We had to recognize that to aspire to 100% in each case is very nice but if we get at least 90% in each column that will mean 73% viral suppression overall and by 2030 that is going to reduce the burden of the epidemic by 90%

So in terms of the enthusiasm for and uptake of 90-90-90 targets, how happy are you - first of all globally, because there seems good uptake there and then let’s talk about Canadian uptake?

Well let me step back for a second. I think the ongoing controversy in the scientific and wider HIV community about whether treatment as prevention and therefore 90-90-90 – all of that conversation has allowed political leadership in many places to say “we’re not going to move on this because you guys have to sort out your issues”, whether it was the right thing for public health, the human rights perspective, side effects, everything else, the definitive evidence. So what Vancouver has done. . everything has come together and there is no more controversy. There are no more questions that need to be asked. So the fundamental message that needs to come out of Vancouver is that there is no more controversy. Immediate initiation of antiviral therapy, regardless of CD4 count is the way to go. Expansion of HIV testing to more locales, including self-testing, is the way to go.

We can honestly say that we are coming out of Vancouver with a mandate that yes, treatment as prevention is it, and 90-90-90 is the target. We can say that we are going to make the 90-90-90 the flag for the global movement. So going to your question about uptake, we had on-side first John Kerry (USA). Switzerland, Malawi, Mali, Sierra Leone, Panama, Argentina, Queensland Australia, Spain, France and more recently all the way to the Pope in Vatican City, all basically endorsing the path on which we are on.

Now we have the momentum, the science and we are turning to political leaders and saying ’you have nowhere to hide. Stop asking questions and pretending we don’t have the answers. We have the road map. You are either with us or against is. And if you are against us, you are for HIV and AIDS. You are an enabler of HIV/AIDS and history will judge you for that."

That’s pretty strong language. How will that go down say with the feds?

I think the government here, much that they call me an enabler of conduct that promotes HIV and AIDS, the evidence has shown, and the results are in, that I am succeeding in my fight against HIV and AIDS and that they are actually enabling the continuing spread of HIV and AIDS in this country because of their neglect of the populations that are most affected, particularly First Nations communities.

Have you seen any movement, any budging towards your views yet here in Canada? Because there seems to be movement towards adopting treatment as prevention strategies in various forms without actually labelling them as such.  Some avoid the term “treatment as prevention” like the plague.

My sense is that there is a growing sense of embarrassment in Ottawa that treatment and prevention is being implemented around the world, that Dr. Montaner and BC is leading the charge – and you have heard it hear from everybody, it’s not me saying it –

So at what point does that embarrassment have to translate to action?

I think what they are now doing is saying ”oh well, we are for optimization of the cascade of care”. But we should resent that. We should say ”we want you to stand up, be counted and again, you are either with us or against us, because everything else you are doing is just pretending." If they were honestly trying to pursue a better outcome they would be talking to us here, right here. (Canadian prime minister) Stephen Harper was invited to come and he didn’t come. Why? Because he doesn’t have the courage to come in front of the AIDS community.

Are you able to have frank conversations like this with the people at PHAC (Public Health Agency of Canada)?

I have had very frank conversations with the people at PHAC. 

Has it gone anywhere?

It hasn’t gone anywhere. PHAC in this country is an agency of the Ministry of Health. It doesn’t operate independently to pursue better health outcomes for this country. They are under the direct oversight of the Minister of Health. If the Minister of Health says “no” to harm reduction, PHAC says “sorry we cannot say harm reduction”.  And if you have a health agency which is told what to say and what not to say for political reasons, that doesn’t bode very well for the health of all.

This excuse that I’ve been hearing again and again from the feds too is that they don’t want to get involved in HIV because health in this country comes under provincial jurisdiction – they did get involved though when Ebola came around, they did get involved with the flu and H1N1, because those things affect their voters. The populations we are serving are not their voters and therefore they don’t care.

Montaner's face, with messaging about 90-90-90 and treartment as prevention, looms over  the sidewalk on Burrard St., in downtown Vancouver

OK. Since we last met, we know much more about the health benefits of starting treatment. When the results of START came out a few months ago, which obviously very much bolstered the case for treatment as prevention too, you must have been overjoyed, no?

I want to be totally candid with you. I didn’t think we needed START, But I recognize the fact that now we have it, it's good evidence, that if you start people on treatment early, you decrease the progression to serious illness and AIDS-related events. This is massive. Because it allows us to say “there is no doubt that starting treatment early is the right thing to do.”

I sense though that people are stopping arguing that there is insufficient evidence, it’s too dangerous or it raises human rights issues that can’t be addressed.

I agree. I think people have surrendered to the evidence. You will remember that people were in the camp “oh no, we need more evidence.” Nobody is asking for it anymore. was convinced some time ago   - pre-START - that early treatment was the way to go.

I know you were.

OK a couple more questions. The first is about PrEP. Now the last two conferences at which I’ve heard you speak you have said each time “PrEP is a distraction.” Now since then, the evidence has firmed up, you have got a whole bunch of people backing PrEP as a worthwhile prevention strategy. Do you still think it’s a distraction? You must have shifted a bit, or not?

Well let me put it this way. I don’t want to be characterized as a denialist when it comes to PrEP. I’m not a denialist. What I’m saying is that when you have 22 million people who need antiretroviral therapy today we need to set priorities. And the cost-effectiveness of treatment as prevention is greater than PrEP. And so when PrEP comes under the umbrella and says “we want to be equal partners” I say ‘no you’re not.” PrEP is a luxury, Treatment as prevention is a necessity. Can PrEP contribute to that? Of course it can. But for me to go to the Prime Mister of South Africa who is struggling to put x million people on treatment and say “oh by the way you also need to suck up the PrEP bill”, it IS a distraction.

One more question and it’s about your encounter with the Pope earlier this year. That was pretty intriguing. How did it go down?

I actually brought the science with me. I showed him the details. He understood. They took photos. They were so enthusiastic that I said that I would like to make a statement at the International AIDS Conference regarding their support and the warm reception that we had at the Vatican. And so the answer came back, “feel free to show the photos and tell the story”. And so I wrote back and said “no that is not good enough. I really want something in writing from the Pope because people are not going to believe me. I want the real thing”. And lo and behold, I got the letter and the words were so supportive

That must have been a nice conversation.

It was a beautiful conversation. Some criticized me for doing this. But the reason we wanted the Roman Catholic Church to have a position on this is first – I honestly believe that the Pope is a very progressive man. Secondly I think he is embracing the issue and the populations most at risk in a way that has never happened before.

Ok good note to end on. Julio. You have been very generous with your time. Thanks again so much for taking to 

photos by Bob Leahy

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