This interview was originally published on PositiveLite.com. January 25, 2012.
In part one of this in-depth interview with PositiveLite.com editor Bob Leahy, Dr. Julio Montaner, director of the B.C. Centre for Excellence in HIV/AIDS, discussed his disappointment with Canada’s uptake of treatment as prevention despite the strategy being lauded elsewhere, including in Time, Science, the USA and China. (Read part one here. In part two, Bob explores some of the objections raised to treatment as prevention as well as the future of PreP and the issues we grapple with in an era where an undetectable viral load is commonplace.
Staring treatment early
In the early part of the interview, Dr. Julio Montaner made an impassioned case for Canada to come on side with the kind of treatment as prevention strategies that have made British Columbia’s success envied world-wide, but not in Canada.
But why are some community members wary? One often-voiced question is that if treatment commences on diagnosis rather than waiting until CD 4 numbers reach a certain level, isn’t exposure to any known and unknown toxicities in those drugs longer too?
Montaner doesn’t pause when I pose this question to him. “Look, it’s very simple,” he says. “There is no doubt that antiretroviral therapies have improved dramatically. They are simpler, safer and better tolerated. No doubt about it. Are they perfect? No they are not. Nobody is perfect and HAART isn’t perfect either.
“However, if we are having a discussion here on whether starting treatment immediately or on a deferred basis, the gap between those two decisions is somewhere in the order of months to a couple of years. It varies from person to person but when we’ve done studies, the rate of CD4 decline in an untreated person is somewhere between 60 and 120 cells per year. If somebody today says ‘no, I’m going to wait,’ what I say is ‘sure, you can defer antiretroviral therapy, no problem, we are not forcing anybody to start treatment.’ What we are saying is let’s have a discussion.
“Having said that, for those that want to delay it, I have to remind them that we are talking about a short term delay, may be for a month or a few years, at the most. However, they need to consider that once you start treatment you are going to be on it for three to five decades. In British Columbia – based on the 2010 International AIDS Society-USA Guidelines – we say that most people who are HIV positive should be offered antiretroviral therapy. The only people who really have a reason not to take treatment are people who have undetectable or really low viral load with a really high-normal CD4 count. But other than that, most people need to at least consider starting HAART.
“The problem today,” he adds, “is that most people that are not on treatment, it’s not because they have made the decision not to be on treatment, it’s because they don’t even know they are HIV-positive.”
“If you are asking me, I’m very comfortable that HAART is at least as protective – or more – than condoms.”
Montaner, like many others in the community, has been criticising the criminalization of HIV lately. Times have changed, Dr Montaner said in a recent canada.com interview. "We can't have a discourse that, on one hand. says things are different now — we can identify HIV, we can treat it, you can have a near normal life — and, on the other hand, says if you do not disclose we’ll put you in jail."
And it’s true. The reality of undetectable viral load and the “almost zero risk” of HIV transmission, albeit with important caveats, are a key argument now in the case against criminalization. But why haven’t we seen any changes in prevention messaging aimed at HIV-positive people? It looks very much like business as usual, in fact. I asked Montaner why this discrepancy?
”Well, I think that the data is very definitive at least in the case of sero-discordant heterosexual couples where we have the best available data, as a result of the randomized controlled trial reported on last year where we know that, after you become (viral-load) suppressed, in the absence of other co-morbidities – STIs and the like – the likelihood of transmission is very, very, very low indeed. Now, the problem here is that people very often want to know is there a risk or isn’t there a risk? And that’s a different discussion. We cannot prove the absence of risk.”
Montaner adds: “So I’m perfectly comfortable to tell people that if you want to go forward and have, for example, unprotected sex while you are being protected by antiretroviral therapy, that is perfectly acceptable. On the other hand, you need to know that in the process of doing that, if there was a breakdown in adherence for example, you put yourself at risk. As long as you are willing and able to live with that kind of small risk, I’m perfectly happy to live with it.”
“Some people, they want to be 100% sure that there is no risk. So they are not very comfortable with this kind of approach. What I usually tell people is look, if you think wearing condoms is the way to go and you are happy to advise and counsel people that condoms are as good as safe sex, I think you should be fully comfortable with advising fully suppressed individuals on HAART that they are as well protected as when using condoms, if not better protected. If they are concerned and want to use HAART and condoms, that would be even more protective. But that’s a judgement that fully informed couples should make.”
“If you are asking me,” Montaner says, “I’m very comfortable that properly used HAART is at least as protective – or more –than condoms.”
Wow. He said it! This is good stuff, I’m thinking. Few HIV educators will even come close to admitting this.
Prep – and return on investment
Moving on, I wanted to talk about pre-exposure prophylaxis, or PreP. It’s been bugging me. I ask Montaner if he thinks we should be embracing PreP and, in effect, addressing the uninfected, or putting our resources in reducing the viral load of those already infected? Here’s what he said.
“In British Columbia we have made a decision at this time in favor of focusing our efforts and resources on treatment as prevention. By finding people who are HIV-infected, and facilitating and supporting their access to treatment we are reducing morbidity, mortality and transmission. Why? Because treatment as prevention has a multiple-level benefit when it comes to the return on investment. Number one – it’s good for the individual. It reduces morbidity and mortality, and it restores quality of life. In addition to that it virtually stops HIV transmission. So the return on investment is dramatically superior to anything else in terms of antiretroviral drug-based preventive interventions.”
“Now, the other aspect of this is that PreP has had mixed results in clinical trials. It may work better in some settings than others. The adherence issue is a concern. Furthermore, what happens when you fail PreP and you become infected? Are you going to be resistant to the drugs to start with?……
“The other thing is that in British Columbia today I have an estimated 12,000 people who are HIV positive. Roughly 6,000 of them are on HAART already, and another 5,000 to 6,000 of them are likely to need HAART in the near future. If we are able to engage most of them on HAART, most of the job is done and we would have successfully addressed most of the HIV and AIDS related morbidity and mortality as well as most of the HIV transmission in the province. Now, if you intend to use PreP, things are a lot more fluid. This is specially the case when it comes to identifying the partners (or the potential partners) of the 12,000 HIV infected people in BC, or perhaps more relevant the partners of the 6,000 HIV infected people in BC who are not yet in treatment. These could be 3,000, 6,000, 12,000 or 100,000 and it may change from one year to the next. So as a public health strategy, based on these considerations, we feel that investing in treatment as prevention has a much greater return on investment, both at the individual and the public health level.
“However, it could well be,” Montaner adds, “that after the data gets a bit more clear you may be able to identify particular individuals who are at very high risk – maybe a partner of an HIV-infected individual who cannot or will not take antiretroviral therapy. In that case, PreP may be the best way to go. But we don’t really have all of the data. We are not ready to take that step. At this time we think that PreP is an interesting proposition but the time for it, at least in BC, has not yet come.”
The final solution
It’s almost time to wind up. Montaner has been generous with his time. It’s late on a Friday afternoon and I don’t want to push him. But one big question on my mind remains: Is treatment as prevention of itself capable of ending the epidemic? And what’s the role of other prevention methods?
Montaner answers: “Look, mathematical modelling suggests that treatment as prevention in utopian and hypothetical scenarios could actually lend itself to stopping the epidemic. From Day One when I presented our model in Toronto in 2006 I said loud and clear that I personally don’t believe this is a realistic proposition. I think treatment as prevention can drive the epidemic from a raging epidemic as we had in British Columbia 20 years ago, to a more controllable endemic situation as we are seeing today. We have gone from approximately 900 new cases per year in the early nineties to the current 301 cases identified in 2010. The trend continues to be downwards so we still have yet to see how far down we can push this situation. And that’s where my work is focussed on.”
“We are going to need everything else if we are to truly eradicate the disease. You know, the reality is that other diseases – whether it’s polio or TB – have shown us that even when you have all the tools it may be a very difficult and long term proposition to truly eradicate a condition. Now, having said that, we need to continue to research for a vaccine, we need to continue to research for a cure. Those are going to be essential parts of the final strategy to eradicate HIV and AIDS. But waiting for this to happen is short-sighted, because no matter where we are at, if and when those two (the cure and the vaccine) become available, if we have deployed treatment as prevention aggressively – aggressively in a fully ethically, morally sanctioned way, don’t get me wrong – but if we do this properly by the time we get there, finishing the job is going to be a lot easier. If we wait, and we are doing nothing until then, we will have to contain an epidemic that will be three, five or 10 times greater. Stopping the epidemic at that time is going to be impossible.”
“One more thing, it is also very clear since a long time ago that HIV is a disease with very strong social-cultural-economic determinants. And at the end of the day if we cannot overcome the stigma and discrimination at a systemic level, at the institutional level, at the political level, we are not going to be able to conquer it. Unfortunately, we have a lot to do in this respect in Canada, particularly at the level of the Federal Government. And this, I think is reprehensible. At the end of the day that’s where my energy comes from.”