Wednesday, May 14, 2009
Julio Montaner urges expansion of HIV care to vulnerable communities
Julio Montaner, director of the B.C. Centre for Excellence in HIV/AIDS and president of the International AIDS Society, vividly remembers the moment when a diagnosis of HIV infection ceased to be an automatic death sentence. It was 1995 and he was acting as the lead investigator in an internationally coordinated drug study called the Italy, Netherlands, Canada, and Australia trial.
"A number of us started to feel that we could do better if we were to give these people a larger amount of drugs: more combinations," he recalls during a long and intense conversation in his cramped St. Paul's Hospital office, a room overflowing with papers, journals, textbooks, and portraits of his wife and four children.
"The senior virologist of the study was Dr. Mark Wainberg from the Jewish General Hospital in Montreal," he continues, his Argentine accent (he grew up in Buenos Aires) still strong, lending his speech a clipped, forceful quality. "I met with him in Montreal about a separate issue, and he calls me aside and he says, 'Julio, I think we have a problem. In nearly half of the patients in our trial, I cannot grow the virus. I think you guys are messing up the samples.'"
As it turned out, the samples weren't messed up at all, which Montaner confirmed with a separate testing method. "To our surprise, we couldn't culture it," he says, "but we couldn't measure it, either. And we thought, 'You know what? I think that this is because the treatment is working.'"
In what remains the most important breakthrough in the history of HIV/AIDS treatment, the virus had been suppressed. A few months later, at the 1996 International AIDS Conference held in Vancouver, Montaner's findings were unveiled, along with treatment guidelines, to the global AIDS community. It marked, in short, a revolution.
"We coined the term 'highly active antiretroviral therapy' [HAART] for it," Montaner explains. "And if you look at the statistics after the mid '90s, AIDS deaths in our program, and anywhere in the rest of the world where this treatment was used, dropped by more than 90 percent. So it's fantastic."
In effect, HAART has transformed HIV infection into a chronic and manageable condition for those who undergo treatment. As Montaner points out, although the rate of HIV infection in general has gone down across B.C., there are certain communities in which that rate is actually increasing and where individuals may become infected and even die of AIDS without ever being tested.
For example, in a study entitled Mortality Is Influenced by Locality in a Major HIV/AIDS Epidemic, published last February in the British HIV Association's journal, HIV Medicine, Eric Druyts, epidemiologist with the HIV/AIDS drug-treatment program at the Centre for Excellence, compared rates of HIV survival in the Downtown Eastside and the West End. He found that three times as many people died from AIDS-related causes in the Downtown Eastside between 1997 and 2005 as in the West End. And according to figures from the centre, only 13 to 18 percent of HIV-positive Natives who are eligible for HAART are actually engaged in treatment, and only 40 percent of eligible intravenous-drug users have ever been on HAART.
So as the majority of HIV-positive patients were able to benefit from the breakthroughs of the mid 1990s, observes Montaner, "there was a second epidemic, you know, evolving in front of our eyes. Even with the tremendous success that we have treating people with HIV, there is a gap that we have making that success available to less privileged people, whether they are First Nations or Downtown Eastside dwellers."
And that is where Montaner's most ambitious project comes into play: a research proposal entitled Seek and Treat for Optimal Prevention of HIV/AIDS or, for short, STOP HIV/AIDS. The goal? To drastically increase access to HAART among vulnerable communities in B.C. in particular, injection-drug users, sex-trade workers, incarcerated individuals, First Nations individuals, and those with other underlying conditions such as mental illness. The plan includes, among other measures: providing rapid HIV testing and HAART to residents of the Downtown Eastside; treating known HIV-positive individuals who are aware of their status but are not being cared for; linking patients to existing research cohorts; and engaging in partnerships with groups, including the B.C. Aboriginal AIDS Society, the B.C. Persons With AIDS Society, and the B.C. Positive Women's Network.
Thomas Kerr is one of the principal investigators in the Centre for Excellence's Urban Health Research Initiative, which is conducting four long-term cohort studies that now include 1,700 intravenous-drug users, 25 female sex workers, and 75 street-involved youth.
"Right now, we refer people to a treatment provider when they need HIV treatment," he says in his St. Paul's office. "We would probably build more of the HIV treatment in-house, so people can get it on the spot and see a provider right there and then not have to be referred externally. It's really integrating research and clinical care."
What makes the project so compelling and groundbreaking is not just its lofty goal of achieving better health care for all British Columbians but also its plan to test what has only recently become accepted wisdom in the HIV/AIDS medical community: that HAART can actually diminish the risk of HIV transmission.
For generations of people raised on the mantra that safe sex and clean needles are the only way to protect themselves against HIV infection, the idea that someone being properly treated for the virus is unlikely to infect others sounds almost heretical. But, as Montaner notes, it's been something of an open secret among the medical community for years.
"People don't talk about it, but we all know that when you treat somebody, they become less infectious," he says. "All along, back in the days where we were just starting to understand about AIDS, we used to tell the surgeons, the nurses: 'Don't worry. If you get poked [with a used needle] and the patient['s viral load] is undetectable, you'll be fine.' We always knew treatment played a role in prevention. But we never put the story together."
It wasn't until 2005, Montaner says—when he began feeling pressure from the provincial deputy health minister (Penny Ballem, now Vancouver city manager) to justify the rising drug costs of treatment programs that the Centre for Excellence began gathering evidence to support what health practitioners had been quietly observing for years.
"It was really out of self-preservation, trying to protect our programs, that we decided to formally look at this issue," he admits. And the evidence was there to be found. First, Montaner explains, quickly clicking through one of the numerous PowerPoint presentations on his Mac computer, they looked at mother-to-child transmission.
"What we noticed was that the number of HIV-infected babies in Canada had dropped dramatically after 1996. Quite interesting. And that is despite the fact that there was no decrease in the number of women infected with HIV having babies. In fact, it was steady growth And why was that? Well, because in 1996 we recommended that these women be treated with antiretroviral therapy."
Next, there was evidence from various studies of discordant couples (in which one partner is infected with HIV) that the fewer the copies of the virus in the infected partner's bloodstream, the less likely that person is to transmit the virus. And, finally, there was the coup de grâce: ecological evidence from the centre's own research of a 50-percent decrease in the number of new cases of HIV infection in B.C. from 1996 to 1999 in the face of increased rates of syphilis in the province that saw infection rise from 0.5 to 3.4 per 100,000 during those three years, according to the B.C. Centre for Disease Control. It turns out that people weren't really practising that much safe sex after all. (Nor do they now: syphilis rates in B.C. have continued to increase, up to 6.9 per 100,000 in 2007, the latest year for which figures are available.)
"All along, there has been a concern that if people become confident that treatment is good for them, then they can eventually say, 'Well, if treatment is available and it works, why do I have to wear condoms anyways?' People argued that if there is increased reliance on the treatment to deal with HIV, then the number of infections would go up because increased risky behaviour could drive infections up," Montaner observes.
As part of the STOP HIV/AIDS proposal, which aims to expand HAART from the current 4,000 people accessing treatment to 6,000, the centre plans to measure the number of new HIV infections over three years. The expectation is that with an additional 2,000 HIV-positive individuals on treatment, the infection rate will decline by 10 percent. And that, Montaner says, is the study's biggest selling point when it comes to making a case for funding.
He brings up a mathematical model for the year 2005 that estimates that about 400 new cases of HIV infection were averted because of the number of people accessing HAART and no longer infecting others: "The minimum cost of a lifetime treatment of HIV is $250,000. In that year , we treated nearly 4,000 [individuals in B.C.], and that cost us $50 million," he notes. "So $50 million was used to treat 4,000 people in B.C., which was a cost-effective intervention because it saved their life and kept them healthy. But in addition to being cost-effective, it also had a multiplier effect, because it allowed us to save $100 million on future expenditures of antiretroviral therapy."
At current treatment and adherence rates, the number of new HIV infections is expected to increase from 421 cases per year to 462 cases per year between 2006 and 2030. But should HAART be expanded from the current 50 percent of those in need to 75 percent, the annual number of new infections in B.C. would decrease by 37 percent.
Montaner is coy when asked what sort of financing such an undertaking would require, and he won't give any figures except to insist: "It's peanuts compared to the current expenditures in the Downtown Eastside. The issue is not how much it costs, it's what is the savings that you can generate by having that investment. The way I talk to the government is, 'Look, this is a shovel-ready project. This puts people to work, saves lives, and it makes a very worthwhile investment at a time when the government is looking to reactivate the economy.'"
When reached by phone, provincial health minister George Abbott says he's interested in applying Montaner's ideas to Native communities in northern and central B.C. as well as the Downtown Eastside. "What we've been discussing is the possibility of undertaking a HAART outreach program in one or more of those areas through a pilot project," he says. The cost of such a project would be, he estimates, about $10 million to $15 million per year but without federal involvement, he doesn't see it happening.
"From my perspective, it is absolutely imperative that the federal government be partnered in this," he insists. "Health Canada and FNIHB [the First Nations and Inuit Health Branch of Health Canada] have responsibilities for the delivery of health care on reserves in British Columbia. So it would not make a lot of sense to undertake a pilot project that did not include the active participation of the First Nations and Inuit Health Branch particularly, and, more generally, Health Canada."
On April 23, a campaigning Gordon Campbell opened an international HIV/AIDS conference in Vancouver, promising up to $20 million a year for a pilot program in Prince George and the Downtown Eastside. It now remains to be seen whether the newly elected premier follows through on that pledge.
For its part, the federal Health Ministry remains silent on the matter: a request from the Straight to speak with federal health minister Leona Aglukkaq or a Health Canada official received no response. To be sure, Montaner is not exactly on the feds' most-popular list. He's been one of the Conservatives' most vocal critics, most notably of their disapproving stance on Insite, Vancouver's safe-injection site. Last September, he went so far as to accuse the Harper government of "genocide" in the matter, stating at a news conference: "When you neglect purposely a percentage of the population that can be defined on the basis of a particular characteristic, that's genocide. And I will tell you that is exactly what they are doing. These people, they have no morals and they are after this population because they want them gone."
So far, despite endorsements from UBC president Stephen Toope, the B.C. Persons With AIDS Society, the Canadian HIV Trials Network, and former UN HIV/AIDS envoy Stephen Lewis, among others, the only funding STOP HIV/AIDS has received has come from the U.S. National Institutes of Health. In September, the National Institute on Drug Abuse awarded Montaner its inaugural Avant-Garde Award, worth $500,000 per year for five years.
But Montaner is nothing if not tenacious. The son of one of Argentina's most prominent physicians (pulmonary specialist Luis Julio Gonzalez Montaner, who was once president of the Argentine Medical Association), he has always been an overachiever. Reflecting on his six younger siblings, he muses: "We are three physicians, three architects, and one agriculture engineer. And we are all very competitive. The three eldest, we grew up competing against each other. Still today, we're still insufferable when it comes to it."
Montaner, a father of four adult children, none of whom plans to enter health care, admits that his dedication to medicine borders on an obsession. "My life revolves around my work," he concedes unapologetically, though he confesses that his wife, Dorothy an X-ray technician, has been known to describe holidays with him as "like visiting Julio at the office".
But, he insists, he can't help it. "You know, you can call it an obsession. But at the same time, you know, an obsession that is a passion doesn't hurt so much."
Kerr notes: "Julio is an incredibly passionate individual. I think that on the exterior, people see him as very intense and driven, but working with him on a day-to-day basis, I can also tell you that he's a very kind, caring, and generous individual who, I think, treats his team very, very well. He fights very hard for what he believes in, and I feel sorry for those who want to take him on, because he's determined and he's tough. And he's usually right."
He goes on: "But you know, that's what you need in someone who's leading the International AIDS Society. That's what you need from someone who is responsible for the delivery of HIV treatment in a province where that's not been done that well. I think it's a draining thing to do, to take this fight on and to fight it day to day. But it's the right fight, and so I think that's what keeps us all going. We know that there's no reason why a third of people in British Columbia who die of HIV die without ever accessing treatment. That's insane."
Created: May 28, 2009
Last modified: June 20, 2009
Commercial Sex Information Service
Box 3075, Vancouver, BC V6B 3X6
Tel: +1 (604) 488-0710