The fourth workshop in the current series of free open discussion forums for people living with HIV hosted by the AIDS Committee of Toronto (ACT) will be held on Wednesday, December 5, 2012 at 7:00 pm at the Ramada Plaza Hotel, 300 Jarvis Street in Toronto. 

This month, the forum will provide an overview of both the International AIDS Conference held in Washington in July 2012 and the Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC), held in San Francisco this past September. 

The guest speaker is Dr Sharon Walmsley, professor of medicine at the University of Toronto and assistant director and clinical staff physician, Immunodeficiency and Infectious Diseases, at Toronto’s University Health Network. 

Topics to be discussed at the forum include: 

• Based on presentations at the 2012 International AIDS Conference, what new information is there and what could we expect to hear more about?
• Overview of the San Francisco Interscience Conference on Antimicrobial Agents and Chemotherapy.

The forum will be webcast live so those who cannot attend in person can participate in the event online. The forum and the webcast will begin promptly at 7:00 pm and last two hours. 

To join the live webinar: login at 7:00 pm EDT on December 5 (00:00 UTC, December 6) at www.actoronto.org/forum   

The forum will also be recorded and should be available for viewing on the day following the event at the same website: www.actoronto.org/forum  

This forum and webinar are free and no registration is required. For those attending in person, a light buffet will be available from 6:00 pm. 

For more information, see the flyer below or contact Robin Rhodes at This email address is being protected from spambots. You need JavaScript enabled to view it. or 416 340 8484 ext. 219.

This article by Jake Sobo first appeared in PositiveFrontiers.com   here and is republished with kind permission of the Editor-at-Large. (Thanks Alex).  Readers are encouraged to read the entire My Life on PrEP series on PositiveFrontiers.com. 

A few months before I started taking Truvada for PrEP, I got hit up on Manhunt by a gorgeous HIV-positive guy who wanted to fuck me bare. He was frank about it, telling me that his viral load was undetectable and had been for years and that he wouldn’t cum inside me. In all honesty, I blanched at his frankness.

For years, I had been telling friends (and anyone else who would listen) that choosing to only have sex with guys who think they’re HIV-negative wasn’t really an effective prevention strategy for guys in areas of the country like mine. Where I live, there are plenty of guys who think they’re negative who are actually positive because they haven’t been tested in eons. Transmission is mostly likely going to occur with these guys – not with guys who know they’re HIV-positive.

That may seem confusing at first, but the science behind it is straightforward. When you’re diagnosed as HIV-positive today, most doctors immediately recommend you start taking medication to treat the virus. HIV treatment can fight the virus so effectively that it makes the virus “undetectable” in your system. If the virus is undetectable in your body, it’s virtually impossible for you to transmit the virus. Guys who don’t yet know they’re infected aren’t taking these drugs. Without treatment, there could be tens of thousands or even millions of those tiny little critters in just one milliliter of blood. Having that much virus in your system dramatically increases the odds that the virus will be transmitted during sex.

This isn’t just my “opinion”: a recent study estimated that the majority of new HIV-infections in the US are the result of having sex with someone who didn’t yet know that they were poz. The CDC estimates 20% of HIV-positive people in the US don’t know they’re infected – yet it’s this 20% that researchers estimate account for between 54% and 71% of new infections.

The hard-to-swallow truth is that, for guys with a lot of partners (like me), fucking poz guys with undetectable viral loads is actually safer than fucking raw with guys who think they’re negative.

All right, so I’ve known these numbers for years – and yet I was still having trouble wrapping my head around the idea of condomless sex with an HIV-positive guy. I had been trained my entire life to think of that as anathema, akin to reckless self-endangerment. The kind of thing only a crazy person would do. I knew the science had totally debunked that kind of stigmatizing fear-mongering, and yet here I was, faced with an enticing proposition from an HIV-positive guy and feeling downright anxious. It was then and there I decided that it was time I put my money where my mouth was; it was time for the rubber to hit the road.

Unfortunately, the guy ended up being a creep, so I didn’t get to test my metal. It wasn’t until I started taking PrEP (about two months ago) that I started to seriously think about what it would mean to fuck with poz guys. Because I liked to fuck raw, I had pretty much organized my sex life around the rubric of “serosorting” (or, only fucking other guys with the same HIV-status) – but I knew that this system was flawed and bound to fail. With PrEP at my side, I started to incorporate poz guys into my sexual community. I started messaging them online. I joined BarebackRT, where the bulk of guys are poz. I began to open myself up to the possibility of sex across the sero-divide.

As it turns out, seeking out sex with poz guys raised a new set of issues that I didn’t anticipate. First, just as I had spent years telling myself that I wasn’t supposed to be fucking poz guys, many poz guys are simply not interested or willing to have sex with HIV-negative guys. Why concern themselves with my limits, when they can find sex with poz guys who don’t have to worry about transmission?

But more importantly for me, I had to learn exactly what my limits were. This is more of an ad hoc process than I anticipated. Do I let poz guys cum inside me? And what about poz guys whose viral loads aren’t detectable? I learned my answer to both of these questions recently, but not until my legs were already in the air. Before having sex with the first poz guy I let fuck me raw, I had a lengthy discussion about viral loads and safety. He reassured me that his partner of eight years was negative, and that “I know how to keep my bottoms safe.” It was, in fact, reassuring. As he was about to cum, though, I was faced with a dilemma. I love for guys to cum in my ass, but I could feel the nerves running through me that told me I wasn’t so sure I was up to it. He asked where I wanted him to cum, and I told him to cum on my back. You gotta take your harm reduction where you can find it, I suppose.

More recently, I was having sex with a poz guy and he started rubbing his dick against my hole. It felt fantastic, and I wanted him inside me. But we hadn’t discussed viral load and I knew that he had only been diagnosed two or three months before. I asked him, dick-pressing-against-my-hole, “So what’s your viral load?” He looked conflicted, shyly confessing that he couldn’t remember. I kissed him. “But I guess it was something, then, and not undetectable?” “I guess so,” he replied. I told him I would be down to fuck, but only with condoms.

I couldn’t believe the words were escaping my mouth. Condoms!? I was suggesting condoms? But as I came to realize later that day, our encounter may well have been his first time with a negative guy since he was diagnosed. We were both learning, it turned out.

I’ve heard from guys who’ve emailed me to say that PrEP has helped give them a certain peace of mind, but what has been remarkable is the variety of ways that guys report PrEP pushing their boundaries. Let’s face it: PrEP won’t magically turn a guy who’s deathly afraid of swallowing cum into a barebacking, cumguzzling trick-turner. Wherever your boundaries are now in regards to HIV, PrEP is likely to push at them – but how far, and to what end, is entirely dependent on where you begin your journey.

For me, PrEP allowed me to start incorporating poz guys into my sex life, when they had for so long been absent. I am deeply grateful for that. I have long believed that excluding them was wrong and more likely to be informed by stigma than science, but I didn’t have the guts to change my ways. PrEP changed that.

Of course, some guys out there may think PrEP and undetectable viral loads are redundant – that PrEP is really there to protect you with guys whose viral loads aren’t undetectable. Scientifically, that’s almost certainly a sound statement. But our sex lives aren’t a perfect science. They’re driven by gut, emotion, and pleasure – the kinds of things for which science can’t account.

Learning sex takes practice. There’s no manual. There’s no “right” way. We figure it out as we fuck.

So here’s to practicing! As always, send a note with your thoughts. I’d love to hear from you!  This email address is being protected from spambots. You need JavaScript enabled to view it. .  

Jake Sobo is a pen name used for anonymity. Jake has worked in the world of HIV prevention for nearly a decade, and is eager to share his experiences taking PrEP. Having closely followed the development of PrEP from early trials to FDA approval, he was excited to give it a shot when it was approved for use among MSM for preventing HIV.He has spent the better part of his adult life having as much sex as possible while trying to avoid contracting HIV, and started taking PrEP as a way to help him stay negative. He is well aware that the drug is not 100% effective and that he could test positive; while he hopes that does not happen, he knows that he can rely on his numerous HIV-positive friends to deal with that situation should he seroconvert.

It’s sexy on the surface – and that’s good - but scratch below the skin and you’ll find there’s much that’s new – and controversial -  in an Australian campaign designed to help gay men seriously understand the risks associated with unprotected sex and the strategies they can use to reduce the risk.

That approach isn’t new in itself, but the risk assessments are. They’ll challenge what you thought you knew. Is fucking without a condom ALWAYS high risk, for instance?  Think again.

First the basics. Here’s what ACON, New South Wales’ largest community-based AIDS service organization, said in a press release last week: 

“A new HIV prevention campaign is aiming to increase gay men's knowledge about the degrees of risk involved in not using condoms when they're having sex.

Called Know The Risk, the campaign has been developed by ACON and provides an analysis and evaluation of non-condom based risk reduction strategies which are commonly used by some gay men.

These strategies include: strategic positioning or ensuring the HIV-negative partner is insertive (i.e. the ‘top'); serosorting or seeking partners with the same HIV status (i.e. pos-pos or, under prescriptive circumstances, neg-neg); and incorporating an informed understanding of undetectable viral load into risk reduction practice. All these strategies carry risks that vary according to practice and circumstance."

So let’s be clear, we're dealing with unprotected sex here, aka barebacking. No raised eyebrows, please.  It isn’t new for progressive AIDS Service Organizations to lend a risk reduction hand to guys who fuck without condoms. The AIDS Committee of Toronto has this   on its website, for instance, which is good on tips and tricks but perhaps doesn’t reflect current knowledge (or sometimes best guesses)  in its risk assessment section. Other organizations like HIM out in Vancouver who do admirable work in gay men’s sexual health have also introuduced interactive Risk Calculators, like this one which is also good, but balks at assessing the risk when viral load is undetectable.  The ACON Risk Calculator, on the other hand, goes one step further and includes the ability to factor in an undetectable viral load.  More importantly, it uses the latest science and what we can extrapolate from it.

Play around with their risk calculator and you’ll get some surprises. Say, for instance you're an HIV-negative guy, a top, and you’re fucking someone who is either HIV-positive or whose status is unknown. What’s the risk? A resounding HIGH if you believe traditional markers, including all those used in Canada. But only MEDIUM if you use this calculator.  And lower still if the HIV-positive partner has an undetectable viral load sustained over six months or more. 

The risk calculator showing fucking without a condom when the top is neg and the bottom is poz is medium risk, not high. It also allocates a medium risk rating when the top is poz, fucking without a condom but has had an undetectable viral load for six months, when the bottom is negative.

And you know what? The numbers, like that from blue-ribbon sources like the CDC combined with what we can extrapolate from HPTN 052 suggests ACON's right.

(HPTN 052 was a study that measured the impact of aniretoviral therapy on HETEROSEXUAL couples; a 96% reduction in transmissions occurred in the study group.  While traditionally we've said we don’t know what is the impact of antiretrovirals on gay sex, some are now suggesting that in relation to INSERTIVE sex at least, i.e. fucking, there is likely a similar reduction in risk.)

But let’s be clear. It's very important to recognize that if YOU ARE BEING FUCKED without a condom by an HIV-positive guy whose is NOT undetectable OR one of unknown status and you are negative, the risk remains high. While all risk is subjective (more on that later), I certainly buy that one.

What’s good to hear then, is that the Australian risk calculator recognizes, finally, that we need to look at the risk between insertive and receptive sex – fucking and getting fucked - differently. We have tended to lump them together despite the evidence which demonstrates  the difference in risk, as well as ignoring the evidence which suggests undetectable viral load potentially makes a huge difference.  Thus statements like “sex without a condom is high risk” have become truisms that ignore the exceptions to this rule and are now starting to be challenged.

Of course we are talking about the risk of HIV transmission here.  There is always the danger of contracting STIs through condomless sex.  And there is always the danger of running afoul of the law too.

Complicating all this is the fact, experts agree, that risk is very subjective. It's essentislly true that one man’s high risk is another man’s walk in the park. That’s why some people won’t fly in airplanes while others, like pilots, work in them daily.

In any event, all this talk about condomless sex, which may be unsettling to some, is equal parts evolution and revolution, a sign of advancements in knowledge, such as HPTN 052 which is finally being interpreted in ways (some would say leaps of faith) relevant to gay men, rather than saying “we just don’t know.”

But does this campaign suggest that condoms could be dispensed with? Hardly. In fact the website has lots of cautions, like this:  “Fucking without condoms always involves a degree of risk - greater, lesser, obvious and not so obvious” it says.  “But if you choose to fuck without condoms, you owe it to yourself and the guys you fuck with to know the risk involved – whether you're topping, bottoming, positive, negative or don't know.”  It concludes “Know The Risk isn't a guide to unsafe sex or a recommendation to fuck without a condom.”

So, all in all, I like this campaign a lot.  It’s a major step forward.  But I have three reservations.

The site contains graphic art work

First, I’m an inquisitve person and I need to know how they calculate risk. I applaud how they’ve tried to define it for us in a new way. Example: “high risk is any sexual activity that offers little or no barrier to cum (including pre-cum), arse lining secretions, vaginal fluids or blood passing from an HIV positive person into the bloodstream of a HIV negative person. Unsafe sex presents a high risk of HIV transmission.”  This is a better definition than what we see in our own made-in-Canada risk guidelines, admittedly outdated and needing replacement. BUT (some) people need to know the numbers on which those risk calculations have been made, so that they can judge for themselves, because . .

Secondly, risk is very subjective. Rupert Kaul says of his own practice  “I often see people . . who may have been exposed to HIV in one setting or another – sex, needle stick injury, whatever. We talk about what happened, come up with a “best guess” as to the risk of transmission, and then talk about whether a short course of antiviral medications is indicated to reduce that risk. In one case we arrived at a risk of 1/100 of acquiring HIV, and this person said that this risk was much lower than they had expected, and that they did not think it was significant enough to take antivirals for month. On the other hand, in another case we arrived at a number of 1/1,000,000 (one in a million), and the person was adamant that this was very significant, and that they wanted to take the antivirals even though they were not covered and it would cost them well over $1,000 out of pocket. To my mind, there can be no clearer indication that getting everybody to agree on what constitutes a “significant” risk of HIV transmission is just an impossible job.”

Thirdly, like most other such tools, it doesn't adequately bring home that what is being measured is the risk form a SINGLE act, If you are a sexually active person - we hear some in the gay community are (grin) - you'll need to recognize that what may be medium risk once represents not so medium risk activity when repeated hundreds of times.

But overall ACON has done a great job on their Know The Risk campaign. I think it is also serves as a signal to others to get with the times, to recognize that the science is evolving and so are gay men’s ways of reacting to the epidemic which still rages in our midst.

Here’s how ACON addresses the topic of changing times in their press release.

“Nothing in life - or sex - is without risk, and over the last 30 years, the journey of gay men through an ever-evolving HIV epidemic continues to produce new ways of balancing HIV risk with desire and pleasure. ACON has supported this process by providing factual information aimed at enabling men to make evidence-based decisions - individually and collectively - about minimising risk and maximising pleasure. What we're doing with Know The Risk is responding to the ever evolving reality of how gay men adapt to and deal with HIV as an ongoing feature of gay life."

Well done, ACON. Now let’s see what the rest of the world has to say.

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

This article first appeared on the website of CATIE  here.  

Une version française est disponible ici. 

Recent advancements in our understanding of HIV transmission, treatment, prevention and testing are changing the landscape of our response to HIV and generating a significant amount of optimism. The buzz at the International AIDS Conference this past July in Washington D.C. was that we may now be able to achieve an ‘AIDS-free generation’ where first, no one will be born with the virus; second, that as people age, they will be at a far lower risk of becoming infected than they are today; and third, that if they do acquire HIV, they will get treatment that keeps them healthy and prevents them from transmitting the virus to others.

Similarly, the United Nations AIDS organization has launched a ‘Getting to Zero’ campaign for this World AIDS Day, December 1, signifying the aim of getting to zero new infections, zero AIDS-related deaths, and zero discrimination.  

There are many reasons why we should feel these commendable goals can be achieved. But there are also significant challenges that need to be addressed before we get there.

New understanding about HIV

First, a word about those things that give us confidence.

We now have newer medications for people living with HIV that are easier to take and have fewer side-effects, thereby making HIV treatment more manageable. These medications also allow people living with HIV to have a near-normal life expectancy. We also have a much better understanding of the importance of starting treatment earlier in order to achieve better health outcomes.

Treatment can also help prevent the transmission of HIV. Research shows that people living with the virus who are on successful antiretroviral therapy and have a fully suppressed viral load (undetectable) are less likely to pass HIV onto others.

Due to these advancements in our understanding of the virus, treatment guidelines now recommend that people living with HIV begin antiretroviral therapy as soon as they are ready after diagnosis.

The importance of early detection

To complement the uptake of early treatment, we have also made progress in developing new testing technologies and strategies that allow us to detect HIV earlier and faster than ever before, allowing HIV-positive people to learn about their status much sooner after becoming infected. 

Early diagnosis is crucial to our success in preventing HIV transmission for three major reasons.  First, it may help identify people during the first few months after HIV infection when their viral load and risk of HIV transmission is at an all-time high. Second, it gives newly diagnosed individuals the option to start treatment earlier. And lastly, the majority of people diagnosed with HIV take active measures to reduce their risk of passing HIV on to others.

New prevention approaches

Although condoms and clean needles are the backbone of our prevention efforts, we are learning about additional prevention tools that can also be used. We now know that the same drugs used to treat HIV can be used by HIV-negative people to help reduce their risk of an HIV infection. These preventative approaches are known as post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP). While PEP is the standard of care for occupational exposure to HIV, its availability for non-occupational exposures and its cost vary greatly across Canada. Although PrEP is not currently approved for use by Health Canada, some doctors may already be prescribing it to their patients (known as ‘off-label’ use).These new prevention approaches are promising options for HIV-negative people who are at a high risk of getting HIV.

HIV drugs, in combination with other strategies such as not breastfeeding can also help eliminate the transmission of the virus from an HIV-positive mother to her newborn child.

Challenges we still face

Despite these advancements, translating them into a generation without AIDS or without new HIV infections remains challenging. The hurdles we continue to face include limited financial resources applied to HIV prevention and treatment, and the barriers people living with and at-risk of HIV face when accessing HIV-related services.

Additionally, people living with HIV can be criminally prosecuted for not disclosing their HIV status to their sexual partners, which can discourage them from wanting to know their status, and thereby opting out of getting tested.

Stigma, discrimination, and poverty can make it difficult for marginalized populations to access services, which explains why some populations are more strongly affected by the HIV epidemic. The reality is that a number of Canada’s communities have a high prevalence of HIV. According to the latest estimates (2008) by the Public Health Agency of Canada, gay men and other men who have sex with men represent a majority (51 per cent) of people living with HIV. People who use injection drugs represent 20 per cent, people from regions where HIV is endemic (such as Africa and the Caribbean) represent 14 per cent, and Aboriginal people represent eight per cent of the total HIV epidemic in Canada.  

Where do we go from here?

It’s clearer than ever that HIV prevention, testing, care and support, and treatment are all mutually reinforcing elements of an effective response to realizing an ‘AIDS-free generation.’ At CATIE, we feel these advancements call for an ‘integrated approach’ to HIV treatment and prevention. Such an approach will be discussed, for example, in September, 2013, when CATIE will host a forum that will explore the recent developments in HIV and determine ways to integrate HIV treatment and prevention for us to move forward in an effective way.

While we are still years away from an ‘AIDS free generation,’ we appear to be on the right path. It only takes a look back 30 years ago at the despair we once felt in the face of this unknown disease to see how far we’ve come.