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Aug27

Canada, the rudderless ship

Thursday, 27 August 2015 Written by // Bob Leahy - Editor Categories // As Prevention , Activism, Current Affairs, Health, International , Treatment, Opinion Pieces, Bob Leahy

Despite sea changes in treatment and prevention opportunities, Canada’s response to HIV is mired in the status quo, says Bob Leahy. And with no National AIDS Strategy, Canada is falling behind other poorer nations climbing their way out of the epidemic

Canada, the rudderless ship

What the numbers tell us

Think that Canada is a world leader in its response to HIV?  Think again. 

It may come as a shock to many that Canada is doing poorer than many lesser developed countries. Typically thought of as the epi-centre of the epidemic, Africa has in fact made huge strides in getting people living with HIV on treatment and achieving viral load suppression. Who ever thought, for instance, that Rwanda would be doing better than we are?  Our most prosperous provinces are now in fact performing at only a slightly better level than sub-Saharan Africa, as this table below, which shows estimates, illustrates. 

The numbers above reflect varied progress in achieving 90-90-90. Not sure what that means?

Many countries, but not Canada, are adopting UNAIDS 90-90-90 targets  to reach by 2020 t. CATIE explains. . . 

In a strategic discussion paper launched at the 2014 World AIDS Conference, UNAIDS proposed that by 2020:

  • 90% of all people living with HIV will know their status;
  • 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy (ART);
  • 90% of all people receiving ART will have viral suppression (undetectable viral load). 

If these targets are achieved, 81% of all people living with HIV will be on treatment and 73% will have an undetectable viral load – the key indicator of ongoing successful treatment – and, therefore, be significantly less likely to transmit the virus to others. Modelling studies show that achieving these targets would result in the end of the epidemic spread of HIV by 2030. 

Most agree that buying into targets requires, first and foremost, the political will. But in Canada, obtaining consensus is a little more complicated by the split jurisdiction for health. Simplified, and in the context of HIV, provinces are responsible for the health care component - treatment, care and support, etc. – while the federal government’s mandate relates to prevention as well as drug approvals etc. But here is where it gets messy. Those silos are (or should be) breaking down as the once separate worlds of treatment and prevention integrate. In the meantime we are left with a jurisdictional divide that is an awkward fit with how we look at HIV today, in terms of a continuum of care from testing right through to attaining undetectable viral load. That fact inevitably hinders a coordinated national response, 

So provinces forge ahead with their own strategies, largely free of national guidance or coordination, yet alone targets. We are a country remarkably free of national guidelines, for instance.

In this fractured environment, national HIV statistics around which global 90-90-90 monitoring will need to revolve are another casualty. For example only BC and Ontario numbers are available - you will see them in the table above - and estimates at that. 

Canada needs a National AIDS Strategy 

Nationally we are currently without a game plan. Laure Edmiston, CATIE’s energetic Executive Director, said in a recent article titled “What Canada can learn from Australia’s HIV response”:

 “Australia’s early response was much swifter and more practical than Canada’s. Their first National Health Strategy on AIDS was released in 1985. Canada’s was in 1998 – 13 years later.  Their recently-released Seventh National HIV Strategy contains targets working “toward the virtual elimination of HIV by 2020”!  Canada’s second strategy, the Federal Initiative to Address HIV/AIDS in Canada, was released over 10 years ago by the previous government, and its vague, motherhood areas of action refer to activities to be introduced between 2004-2005 and 2008-2009. No targets. No efforts underway to update it. Pretty mushy accountability.’ 

In pre-election Canada, the timing may not be the best but community advocates are starting to press for a Canadian HIV strategy. Meanwhile the arm of the federal government responsible for community based  HIV program funding Public Health Agency of Canada (PHAC) engages in an excercise to restructure and redistribute $28 million in funding to service providers and national partners, without the benefit of a master plan. This despite the fact that the entire prevention landscape has changed underneath them since national strategies were last looked at. 

Perhaps the loudest voice demanding a federal AIDS strategy is a controversial one. Julio Montaner of the BC Centre for Excellence, who has been a frequent interview subject of PositiveLite.com, effectively leads the HIV response in his home province. One of the world’s leading advocates for treatment as prevention (TasP), this may in fact be his undoing in gaining support from the provinces because treatment as prevention has been resisted tooth and nail in many quarters. Some have said TasP doesn't work, others that TasP doesn't work for gay men, Only lately have other provinces been  buying in to the fact  that TaSP works, albeit with challenges in the gay community, but animosity remains. Montaner thus struggles to gain Canada-wide support, even in situations like the lack of a federal AIDS strategy, where the need is clear. 

Montaner is known for not mincing his words. In demanding a national AIDS strategy for Canada he calls the federal government’s counter argument that healthcare is a provincial matter “BS.” The Times Colonist reported this exchange in July 2015. 

“(Montaner) said that Ottawa has allowed the standard of care for testing and treatment to vary widely across the country. “Furthermore, they have allowed some provinces to charge HIV-infected patients for co-payments to access therapy, which is a proven barrier to treatment.” 

“In the event of a major catastrophe that affects the whole country, you expect the feds to take a leadership position,” Montaner said. “In HIV/AIDS, they have been missing in action. 

Eric Morrisette of Health Canada said that decisions on HIV/AIDS strategy are “most appropriately based” on each province or territory’s unique pattern of disease, but that Ottawa will continue to examine and share emerging evidence on promising interventions. 

Montaner calls on Ottawa to enact a national policy, which in turn would set the standards of care. 

“If this was anything but HIV and AIDS, they would be all over this strategy,” he said, calling the fallback on health as a provincial jurisdiction “BS.” 

“When SARS came out, the PM was all over the place,” he said. “There were no cases of Ebola, but Ottawa had a national strategy.” 

Still leading together? 

Canada has not had a national AIDS strategy that include targets since the 2005 document “Leading Together”. (Targets were dropped in the revised “Leading Together:” which reflects work undetaken in 2010.

I asked CATIE’s Laurie Edmiston why inclusion of targets in a national AIDS  stgartegy is so critical “Targets help focus jurisdictional and other stakeholders’ efforts on objective,  measureable goals" she said.  “Why would we not engage in a process that spells out exactly what we are collectively trying to achieve to drive down the HIV epidemic?”

"Exciting new scientific developments regarding HIV treatment and prevention point the way toward our achieving significant reductions in HIV transmission. This is the perfect time to develop a national strategy," said Edmiston. "National leadership would help galvanize actions across the entire country."

Times have, of course changed since Canada last had a national AIDS strategy. New approaches now line up to be included. That’s because we know more about risk of transmission, we know the power of antiretrovirals to limit new infections and we have a much larger arsenal of ways to offer to both positive and negative individuals to reduce or even eliminate risk. Think Pre-exposure prophylaxis (PrEP), for example. Think treatment as prevention. Think what we have learned about what kind of messaging is most effective

Other countries understand. The United States for instance has just launched its 90-90-90 flavoured national strategy  for 2015-2020. It’s full of very specific targets, including at the macro level (80% of people with HIV to have an undetectable viral load) right down to the micro level (reduce the percentage of persons in HIV medical care who are homeless to no more than 5%). 

Without a strategy, without targets, without measurement tools and with minimal accountability, it seems foolhardy for PHAC to be engaged at this very moment in funding discussions with potential recipients. Business-wise it makes no sense. 

The government feels otherwise and presses on like a rudderless ship. Rumour has it that some have been warned that upsetting the apple cart is not in the community interest. Putting the spotlight on HIV and HIV funding, it’s suggested, could actually spark a review leading to funding cuts. 

I don’t buy that. In fact I bristle at the suggestion we should keep quiet when the need for a made-in-Canada national AIDS strategy is so glaring. In fact securing a strategy from which our entire response should flow, one that reflects the realities of HIV in 2015 and beyond, should arguably be our number one priority. Let’s put it on our collective radars right now.

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