CATIE throws out the challenge
Hidden away in the pages of the Spring 2015 edition of CATIE’s Prevention in Focus, a series of articles intended to inform the work of service providers, comes a document that is staggeringly important for all to read. "Changing the Narrative: Why HIV prevention work in Canada needs to embrace HIV treatment" is also exactly right for the times. Meticulously researched by CATIE’s Tim Rogers, it not only sets out the case for including treatment as part of the prevention narrative, it excites in that it pushes the argument for early treatment harder than it has ever done before.
It also suggests, as PositiveLite.com has done in the past, that Canada is not doing enough.
Says CATIE “The new UNAIDS strategy emphasizes that the tremendous potential of HIV treatment is not being realized, not even in developed countries like Canada. This must change to bring the HIV epidemic under control.”
CATIE concludes “Around the world, many new campaigns have been launched that seek to engage communities and individuals to think about HIV differently and to start new discussions about prevention and treatment based on the advances we have made in our knowledge of HIV. The time has come for everyone to join in the discussion.”
It’s hard not to argue that Canada needs to get serious about the role treatment can play both in preventing transmission and in improving health outcomes for people living with HIV. Until that happens, I’d argue that people living with HIV are not being as well served as they might.
Why do we need to change?
People newly diagnosed with HIV in particular – I’ve recently seen an instance of this firsthand – walk through a minefield of positive and negative attitudes towards starting treatment. If they are lucky, they tap into informed sources which accurately reflect the latest knowledge - basic but compelling things like improved life expectancy for early starters, for instance. But their ability to transmit the virus to others is equally important to people living with HIV and they need to know, accurately, what science says about that.
Getting that information, not to mention advice and opinions, may not come naturally to someone who is confused, bewildered and doesn’t know what to believe. Chances are they will in fact hear a community discourse on the role of antiretrovirals, whether for use by positive or negative people, that can be confusing at best, and potentially marred by bias and inaccuracies. The Resonance project is illustrating that well.
So yes, knowledge brokers like CATIE have a huge role to play in stating clearly and deliberately what we know, while leaving individual decisions in the hands of people living with HIV, as they always should be. CATIE is also adept at looking at strategies like 90-90-90, which ultimately are about reducing the global epidemic to manageable levels, to illustrate how prevention and treatment approaches need to change not just nationally, but right down the line to the patient level
How do we need to change?
Lately, CATIE seems to have taken on the role of instigators of change, or at least reflectors of what needs to be done in Canada, We have often been short-changed on big-picture strategies from others. Filling that void is highly commendable.
That their latest article is not wrapped up in a “treatment as prevention” banner may confound some who are more familiar with that concept. But in truth politics and personalities have intruded in to the Canadian debate and for reasons too complex – and frankly too nationally embarrassing – to discuss here, many are more comfortable in calling "treatment as prevention" something else. (Personally I have no problem with the term, but if people want to call it “Treatment and Prevention” or "Treatment is Prevention” or even not to refer to it all – I’m still game. The important thing for me is not what name you call it but that you talk about it, period.
I’m also not going to talk here in detail about the case for treatment, both in the context of improved health outcomes and prevention benefits. That’s described ably in the CATIE document. I would say though that the case against early treatment strikes me as less convincing by the minute. That’s not to say we don’t need to hear from those who have doubts. In fact that is, I suspect, the kind of dialogue that CATIE would like to see happen. I certainly would. But it’s hugely important that that debate be science–based, even as it airs our community’s historical concerns from back when treatment was perhaps quite rightly viewed with suspicion.
Nor am I going to expound on the need for safeguards to protect the rights of people living with HIV from being coerced into courses of action they do not want, or are not ready, to take. That, and education of medical professionals, support workers and patients alike, are a given..
What I’m saying is that, simply put, the case for treatment as being good for people living with HIV has been made convincingly from multiple perspectives.. We now need to move on to managing the change that this new reality implies.
How difficult is that task? Hard to say. Certainly the idea of treatment as prevention has had more than its share of opponents in the past. But that was then and this is now. One suspects that the winds of change are blowing through the community, so we are seeing Canadian jurisdictions start to adopt policies which, if not mimicking its every nuance, certainly are influenced by TasP.
The bottom line . .
It’s a bit of a sea change for some, but then CATIE has more than once referred to developments in the science of transmission as ”game-changers.” So let’s change our game. Here is the opportunity to use 90-90-90, or something akin to it, as the basis for a renewal of national and provincial policies that use target-driven strategies both to turn the epidemic around and make a difference to the lives of people living with HIV,
Certainly widespread adoption of the treatment cascade concept is a major step in that direction. True, Canada’s shaky efforts at establishing where we stand in terms of our performance in the cascade is depressing - see the chart in the CATIE article - but that can and will change with improved data collection methods arising from identification of this very problem.
Bottom line here is the need for an end to the pussyfooting. We know we have the tools to put a huge dint in the epidemic, but we need to employ them. We know that early treatment benefits those living with HIV – the science is overwhelming – and we need to make sure that every person living with HIV has the chance to benefit from that knowledge. And we know that treatment has the enviable potential to reduce a positive person’s infectivity to levels virtually consistent with HIV-negative people. We also know – or at least can surmise - that acting on this knowledge can lead to a reduction in stigma that no blogs, no sites like PositiveLite.com, no government funded anti-stigma campaigns can achieve.
Given all this, it’s inconceivable that we as a country and as a community should ignore the challenge thrown out by CATIE. That challenge is not just to have a discussion around how we think about treatment, but to actually change the narrative.
Let's do it.