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A brave new world

Wednesday, 28 October 2015 Written by // Bob Leahy - Editor Categories // International AIDS Conference , As Prevention , Activism, Conferences, Sexual Health, Health, Treatment, Opinion Pieces, Bob Leahy

Changing prevention landscape, changing attitudes. Bob Leahy on how the Canadian HIV community is in a more progressive mood these days than ever before

A brave new world

“...reality, however utopian, is something from which people feel the need of taking pretty frequent holidays....” ― Aldous Huxley, Brave New World 

There is no doubt that here in Canada we are in a state of flux. Call it a fulcrum, a turning point or even teetering on the edge of achieving greatness, but that’s where we are.

We are coming from what seems like a bad place. I don’t think I need to reiterate that Canada is performing poorly on the world stage HIV-wise. CATIE resources have said that. We have said that

Occasionally, you'll see suggestions to the contrary, like this one from the Toronto Star, which reported that Ontario is closing in on 90-90-90 targets.  (The reality is that what is reported here is a subset of Ontarians living with HIV, a clinic-based cohort engaged in particularly comprehensive care. Representative of Ontario as a whole it really isn't. In fact there isn't Ontario-wide data. Our data collection methods are just not up to par  - yet. Ditto many other jurisdictions within Canada.)

Where have we come from?

The good news is that we are not where we were even at the beginning of this year. We are in a better place, the product of a shift in thinking brought on by overwhelming scientific evidence on a variety of fronts

In the past, our national and regional conferences were, with a few exceptions, concerned not with moving ahead but pulling apart the data on which others were already doing so. The movement as a whole was remarkably non-progressive. Treatment as prevention (TasP) was widely distrusted in Canada outside B.C. Assertions that “TasP doesn’t work for gay men” have been rife for years. Condoms were being prominently featured by a leading Canadian AIDS Service Organization as recently as July 2015 as the "best" method of avoiding HIV transmission.

On emerging research, for years we were being warned not to put too much into the (as it happens, highly predictive) results of the Swiss Study (2008), HPTN 052 (2011) and latterly the interim results from PARTNER (2014). Prior to START (2015) it was common to hear community activists railing against the dangers of early treatment, and the ultimate bugaboo, the “medicalization” of HIV.

For an example of where we were, read this: “Swiss guidelines take a troubling turn”, It's uber-cautious. Why some community members, farsighted or not, chose even then to jump to the conclusion that undetectable viral load equates to minimal risk of transmission is too lengthy a topic to dissect fully here. Certainly there were early adopters and late adopters of this premise, depending on our respective comfort with empirical evidence and what thresholds of proof we required. In a nutshell it's about how cautioius  - or not- we are.

Said one recent entry in the CATIE blog from Laurel Challacombe " ...messaging around new prevention options has been cautious. Benefits have been described alongside a litany of factors that could reduce effectiveness in the real world. Effectiveness has been communicated vaguely and sometimes inconsistently, using different numerical and qualitative values."

Indeed, the caveats that have been loaded onto each piece of good news have been enough to sink the Titanic! In any event, cautious or not, for years we concerned ourselves with research but seldom with implementation.

This era was marked by progressive voices  - those pointing to strong but not conclusiive evidence - being outnumbered. But progressives knew who their allies, their like-thinkers were. At times it was very covert.

The present

It’s hard to say exactly when the tide turned, but arguably it was with the IAS 2015 conference in Vancouver this past summer. It was exhiliarating. The feeling that "the evidence is in, now let’s move forward” was palpable. Almost overnight, we become poised to move forward.

Not that IAS 2015 was really the first to make “the evidence is in” call.  B.C., arguably using a lower standard of proof, has being singing that tune for several years now. But inter-provincial politics being what they are, their call has been ignored by many elsewhere until recently. You can only try holding the flood gates of evidence closed for so long, after all. And so it came to pass that positions started to shift, subtly at first but more or less in the same direction.

That shift was particularly brought home at the CATIE Forum in Toronto this past month “Making it Work – from Planning to Practice". The event was notable as much for its excellent content as the feeling that (almost) everyone was (sort of) on the same page in relation to the need to capitalize on recent advances in knowledge as well as new prevention opportunities like PrEP, PEP and TasP. 

One can’t underestimate the role of our national knowledge broker, CATIE, in all this. Even to the casual observer, it’s clear that CATIE has increasingly taken a leading role in the charge towards the future, not just as a resource for information on all things HIV and Hep C, but now as a prime instigator of change. It has become our leading progressive voice through means such as its blog, the nature of its recommendations for community-based organizations and its ability to convene and contribute to the national dialogue.

That having been said, are we in fact all on the same page regarding approaches to testing, prevention and treatment? The answer is “not quite” and that’s not necessarily a bad thing. I’ve often spoken about the dangers of “group think”, which our community has reverted to all too frequently. Two other factors will always inhibit us thinking entirely alike too . . 

  • The lack of pan-Canadian approaches which many, including, argue need to be formulated post-haste by way of a National HIV strategy that recognizes the realities of the current decade
  • The split jurisdiction for health-care between the federal government and the provinces which virtually guarantees provinces will never entirely see eye to eye.

The fact is though that progressives voices now clearly outnumber the rest. That’s been an encouraging trend. But some people take longer to change their minds when it requires a complete reversal of previously held positions, and we can live with that.

The future

The issue becomes, now that most everybody appears poised to move forward, the direction they will take. And how long will it take to get them out of the starting gate and in to the first lap, to experience this brave new world that awaits?

Fortuitously, this opportunity comes at exactly the same time here in Canada as a change in government from Conservative to Liberal, a change from a government seemingly unsympathetic to HIV issues to one that is much more aligned with the values of our community. That could result in a number of potentially positive developments, like . .  . .

  • A much stronger federal  commitment to more supervised injection facilities like Insite, whose existence has been fought tooth and nail by the former Conservative government  for years
  • Realization of the Liberal’s promise to decriminalize marijuana, which in turn would help people living with HIV to better access a substance with proven medical benefit without enduring the bureaucracy of the current system.
  • Consultations leading towards a much needed federal AIDS strategy, including a pan-Canadian commitment to UNAIDS 90-90-90 targets.
  • Reopening of the community-based AIDS movement’s demands for a doubling of federal funding of on the ground HIV work in Canada

So the shift in the political landscape, and with it a youthful new national leader with a convincing majority in the House of Commons, comes at a very good time. There is renewed optimism in the air, a sense that government shares our values, that they are on our side. This in itself will bind us as a community, one expects.

The barriers which confront us are many.  We have been timid in our approaches to testing – how we do it and where we do it – but there is the potential for boldness to pay big dividends. We have been derelict in properly tracking data necessary to monitor our progress on the engagement cascade. But that is being addressed. Access to PrEP is woefully lacking and may be for some time – and that’s a crime when we know it has the power to prevent so many new infections. But community activists have put the ball in motion to have Truvada licenced for a prevention role in our country. Access to HIV medications is surprisingly uneven, but a long talked about National Pharmacare solution looks more promising than under previous governments.

We are of course left with a string of inequities – marginalized populations have tended not to be treated well in the face of an epidemic that hits them hardest. Thus high rates of infection in gay men, in aboriginal people, in transmen and transwomen in particular remain challenges to be met. We must not lose sight of those inequities in moving closer to 90-90-90. In fact they are central to its achievement. And we must always maintain a civil rights focus.

The opportunities pile up. In a presentation I made at a recent well attended Cafe Scientifique in Toronto earlier this month I talked about “moving forward into that brave new world in brave new ways.” I said that we have been slow but there are signs that we are now starting to do just that. It’s true. The mood I sense in the air is a good one.

I sense that people are weary of arguing with each other. I’m not sure if all the hatchets have been buried; past divisions between provinces have been particularly bitter. But the existence of different approaches is sometimes necessary, sometimes a good thing, sometimes. But game plans have more similarities now than differences - and that’s good

There is something of a consensus that the status quo isn’t working and that’s good too.

Too often seeing an end to the epidemic has been missing from our collective strategies. There too I sense we will see more focus on the prize.

So much work to be done, so little time. Are we up to it? I think so.

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