Since the last International AIDS Conference in Vienna in 2010, the landscape has changed significantly. Two years ago, for instance, HPTN 052 was not even in our collective vocabulary. Now it’s ubiquitous, and the issues it raised – the promise of a 96% reduction in transmission rates for those on treatment (although it’s not quite that simple) are a principal focus of AIDS 2012, as they should be. But where is Canada on this and other recent advances – and are we slipping from our position as once world leaders in the response to HIV?
I think we are. Not that there isn’t some good news, things we can be proud of - and we’ll get to those in a minute, but in the last year particularly, that has been overshadowed by an overwhelming statis that has set in. So while other countries have recorded remarkable progress in reducing infection rates, for instance, we now flounder, the product of an unsympathetic government and a community that has grown sluggish, uncoordinated and, dare I say, timid.
So where does Canada stand in 2012? Let’s get the bad news out of the way first.
On criminalisation, we do in fact lead other countries – but in the worst possible way. The number of prosecutions for non disclosure here surpasses any other country on a per (HIV+) capita basis. Our response to this, while vigorous, has been ineffective. Praiseworthy efforts by community advocates in Ontario to introduce prosecutorial guidelines to limit the number of prosecutions have instead been met by efforts from the Crown Attorney’s Office to make disclosure laws much, much harsher – with, they suggest, disclosure required for any sexual act regardless of the risk. If successful, this will see prosecutions sky-rocket. It’s a prospect worthy of Iran, and, of course, potentially a major defeat for our community.
Moving to treatment as prevention, ironically a concept fostered in Canada, the world has been taken by its potential as a powerful tool, if not to end the epidemic but perhaps bring it to its knees, along with other prevention technologies. It’s clearly a key focus of IAS 2012, in fact, to see how the world can move towards implementing treatment as prevention, despite huge challenges, not the least of which is a worldwide reduction in the kind of foreign aid needed to make this happen. But where does Canada stand? We are undeniably a divided country, arguing over whether it works or not, and not just in regard to gay/bi men. No one has focussed on those divisions more pointedly than our foremost proponent of treatment as prevention, IAS past-president Dr Julio Montaner of the BC Centre for Excellence in HIV/AIDS. “Unacceptable” and “reprehensible” were the terms he used to describe Canada’s position in an interview with me for PositiveLite.com last year.
Just this week, in a letter to Canada's Minister of Health, Montaner said "You can prevent death, you can prevent morbidity and you can stop transmission. You can deliver on an AIDS-free generation. All you need to do is implement what we already know and we get it done within your political term."
One is not used to thinking of the US as a model, given the huge problems in access to care and treatment that country experiences, but our neighbours to the south have officially embraced treatment as prevention ahead of us. It will be a challenge for them to make it work. But three other recent innovations have left Canada trailing also. Earlier this year, the US was quick off the mark in introducing revised guidelines which recommend, in many situations, that HIV treatment should start immediately on diagnosis. That, oddly, has left scarcely a ripple in Canada. True, Canada has no national guidelines – healthcare is a provincial matter and so there is no real equivalent for the US guidelines – but Canada’s collective silence has nevertheless has been deafening. Given that some of the benefits of starting treatment are better health outcomes, although some would dispute this, I would expect in the interests of newly infected individuals, there would have been a more vigorous debate here.
Are you HIV-negative, sexually active, a frequent tester (we hope so), heard pre-test counselling a thousand times and think access to an at-home oral HIV test would both serve your needs and keep you even safer? OraQuick has been approved in the States to do just that. It’s not available in Canada. OraQuick manufacturers have yet to make application to sell the product in Canada, but the wrangling has already begun, and I’m predicting will sink this product’s chances of increasing our HIV testing platforms here, a necessary step in bringing our new infection rates down. Kudos though to sane voices like that of respected researcher Montreal’s Dr. Mark Weinberg who are stating quite noisily that Health Canada needs to approve the test.
And just this week, the FDA announced approval of Truvada for PrEPin the States, the first officially approved drug for use in HIV prevention, considered by most observers a major breakthrough in the war against HIV. Again, implementation is problematic. But where is Canada?
All this is well and good, you say, but we are winning the war on new infections in Canada, aren’t we? Or at least they are not spiralling out of control? New infection rates are, in fact, stable. But people like Dr Montaner call stable “unacceptable“. "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” he told me.
But are new infection rates in Canada stable? We really don’t know. The most recent Health Canada data on hand in the form of PHAC surveillance reports is from 2009. Now we know that our provincial health structure complicates reporting, but the questions remains: how can we track the effectiveness of this nation’s response to the epidemic on the basis of numbers which reflect the prevention efforts and behavioural trends of half a decade ago? The answer is, of course, you can’t.
Where else are we trailing? Well, it’s hard not to argue that in 2012 our collective commitment to GIPA (Greater Involvement of People Living with HIV/AIDS) seems lukewarm at best. Just look at the number of persons living with HIV being sent to Washington. Time was when provinces like Ontario fielded community members to attend in large numbers, IAS Toronto and Mexico City being prime examples. But these are harder economic times and GIPA is something we do only do if we can afford it. So few will be there.
And, in 2012, we in Canada still don’t have a national organization for people living with HIV, a united voice, like NAPWA in the States, for instance.
Having said all this, not all is doom and gloom. In some of the most important markers of all – PHA longevity for instance - we are doing better all the time. Our drug regimes - and more people have access to them here than in most nations - are simpler, easier to take, and have much improved side effect profiles than even five years ago. Standards of HIV care for many remain very high.
Public attitudes to HIV are improving too. Let’s ignore for the moment that an overwhelming majority of the public supports jailing those who don’t disclose their status, In fact the notion is surprisingly popular even amongst the ranks of people living with HIV. Other attitudinal markers show good progress. For instance, the CANFAR-commissioned report on public attitudes, knowledge and perceptions of HIV in Canada released this year indicates that HIV stigma may be declining, based on a number of measures. For example, the report indicates . . .
- Substantial and increasing majorities of Canadians report that they are comfortable interacting with people living with HIV/AIDS in several situations
- Today, more than three quarters of Canadians would be comfortable working in an office where someone had HIV/AIDS (those who report that they would be “very comfortable” is up 7 points from 42% in 2006 to 49% in 2011) .
- Almost three-quarters (72%) would be comfortable shopping at a small neighbourhood grocery store where the owner had HIV/AIDS (those who would be “very comfortable” is up 4 points since 2006 and up 8 points since 2003).
- Six-in-ten (60%) Canadians would be comfortable if their child was attending a school where one of the students was known to have HIV/AIDS. Those who would be “very comfortable” is up 5 points since 2006.
Lower numbers than we would hope perhaps, but it’s the trend that is important. It’s the result of a lot of work, community education efforts that are paying off.
What else is going well? It’s too early to measure results, but there are exciting things happening on the prevention front as we gain a better understanding of the drivers of behavior, particularly in the gay/bi men’s community, which continues to account for the lion’s share of new infections in Canada. Interventions drawing on gay men’s resilience, for instance, or applying a harm reduction approach to risk behaviour, could produce results that will turn things around.
And while advocacy is a dirty word (funders don’t like) it, activism in Canada is not entirely dead. In fact a revitalized AIDS ACTION NOW! is more active, at least in Toronto, than in a very long time, and doing sterling work to boot.
All in all, it’s a mixed bag – a good news/bad news report card for Canada - but perhaps it’s always been like that. What I think has changed in the context of AIDS 2012 is that Canada went to earlier conferences wearing the cloak of world leaders in all things HIV, our mission to teach. People like our own Stephen Lewis, although representing the UN, were our mouthpiece. World leaders on HIV no longer, we have lots to be proud of, not least in our survival as one of the first nations affected by the epidemic, with thousands still alive and living proud, strong lives. So Canada goes to Washington this time humbled and not to lecture or berate, but to acknowledge that we, as much as any other nation present, have much to learn.