News

"'What other country in the world would give a poor Latino guy like me the opportunities I've had? It's unbelievable really. It makes me humble and it makes me proud,' the director of the B.C. Centre for Excellence in HIV-AIDS, said in an interview," writes Andre Picard in Canada's man of action ready for the world stage .

"Now he has a new job: president of the International AIDS Society, one of the most high-profile and politically charged positions in the medical world.

" In a fiery speech at the AIDS conference's closing ceremonies, Dr. Montaner called on the world to work more resolutely to combat the global epidemic of HIV-AIDS. Failure to do so, he said, is tantamount to a crime against humanity."

Dr. Julio Montaner answered your questions - on everything from his new role as president of the International AIDS Society to the latest in AIDS research to Canada's role in the fight against AIDS.

Your questions and his answers appear at the bottom of this page.

Dr. Montaner is president of the International AIDS Society (IAS) and a professor of Medicine at the University of British Columbia (UBC), Vancouver. Originally from Buenos Aires, he received his medical degree from the University of Buenos Aires in 1979. In 1981, Dr. Montaner joined the University of British Columbia at St. Paul's Hospital (SPH) where he completed his training in internal medicine and respiratory medicine. In 1988, he became the Director of the AIDS Research Program and the Immunodeficiency Clinic at SPH/UBC. Since then, he has focused his research in the development of antiretroviral therapies and management strategies.

In the mid 90's, Dr. Montaner played a key role in establishing the efficacy of nonnucleoside reverse transcriptase inhibitor (NNRTI) based highly active antiretroviral therapy (HAART). This was one of the pivotal contributions emerging from the IAS-sponsored Vancouver 1996 International AIDS Conference, of which he was a co-organizer. He has held the endowed chair in AIDS Research at SPH/UBC since 1996. Dr. Montaner is a founding co-director of the Canadian HIV Trials Network and is the director of the BC Centre for Excellence in HIV/AIDS. He has been a member of the Governing Council of the International AIDS Society since 1998. Dr. Montaner has authored over 350 scientific publications on HIV/AIDS. His current research interests include HAART as prevention, optimal use of HAART, salvage therapy, new antiretrovirals as well as hard to reach populations and harm reduction.

Editor's Note: globeandmail.com editors will read and allow or reject each question/comment. Comments/questions may be edited for length or clarity. HTML is not allowed. We will not publish questions/comments that include personal attacks on participants in these discussions, that make false or unsubstantiated allegations, that purport to quote people or reports where the purported quote or fact cannot be easily verified, or questions/comments that include vulgar language or libellous statements. Preference will be given to readers who submit questions/comments using their full name and home town, rather than a pseudonym.

Rasha Mourtada, Globe Life web editor: Dr. Montaner, thank you very much for taking reader questions. What is the reality of HIV-AIDS in Canada? Who is most affected by it and how is it spreading?

Julio Montaner: HIV remains a serious problem in Canada. While entirely preventable, HIV infection continues to spread throughout the country. Men who have sex with men and injection drug users continue to carry a large share of HIV/AIDS cases in Canada. However, the disease is also affecting individuals outside these groups. Of particular concern, HIV is increasingly recognized as a problem among First Nations people, the poor, and the homeless among others. For details regarding the state of the epidemic in Canada please click here .

Richard Marcus from Kingston Canada writes: Do you think its possible that you'll be able to convince people to wake up to the reality that we really need to focus on preventing the spread of AIDS in the high risk groups? Do you have any ideas on how to make handing out condoms, needle exchanges, safe injections facilities, and education programs for those people in the high risk groups a priority when donor nations like the American government are actively working against those very policies?

Julio Montaner: You raise very important issues. However, before we point our finger to the USA, I would rather examine where we are currently at in Canada in this regard.

Today, we have about one third of HIV infected persons in Canada who are unaware of their HIV infection. Unless we tackle this issue aggressively, through a concerted public education and testing campaign, the epidemic will remain out of control. Next, we need to engage individuals who are at risk of spreading and contracting the infection with tailored prevention campaigns. Within the latter, we need to embrace harm reduction strategies, including supervised injection sites (a major sticking point with the current federal government). Then we need to expand antiretroviral therapy coverage to 100 per cent of those in medical need, for their own benefit, and to decrease the likelihood of HIV transmission. Finally, we need a legal framework that protects against overt and also subtle forms of discrimination against those infected and those at risk.

Once we have done all of that, I would like to propose that Canada match (adjusted on a per capita basis) the USA with regard to their global funding against HIV (in excess of 35 billion). While I would like to see changes to the USA contribution to the global fight against HIV/AIDS (specifically regarding "strings attached"), this is a relatively minor issue in comparison to the (lack of) Canadian strategy and contribution.

Angela B from Brampton writes: How important is it to be tested for HIV/AIDS if you engage in casual sex? With or without a condom? Are there signs of infection to look out for?

Julio Montaner: Most often HIV infection is associated with NO symptoms. Further, HIV infected people may be highly contagious and yet show no symptoms for over a decade. Therefore, you must take precautions. Casual sex is a risky proposition. If you engage in casual sex, condoms are mandatory. HIV testing does not prevent HIV infection, however, early diagnosis of HIV infection is essential. This allows the infected individual to seek timely medical advice and to prevent passing the infection to his or her contacts unknowingly.

N A from Montreal Canada writes: My question deals with circumcision and AIDS. I have been reading everywhere that circumcision is being touted as a temporary cure for AIDS and that the World Health Organization has embraced it. I think this is very misleading because the tests that have been done regarding the effectiveness of circumcision on AIDS infection are quite biased and incomplete, even inconclusive. Furthermore, the United States and (Israel to a certain extent), have a very high AIDS infection rate compared to Europe, a continent that does not circumcise but has even more liberal moors. Circumcision does reduces penile sensitivity which sometimes pushes males to engage in more risky activities (such as skipping condom use) in order to reach higher climaxes to compensate the loss of sensation. a study has shown that that circumcised men may be a higher risk for an STD :http://www.cirp.org/library/disease/STD/vanhowe6/. If circumcised males STILL have to use condoms to avoid being infected by AIDS then what is the point of getting circumcised in the first place? why not promote condom use rather than trying invasive methods that have not shown their validity. Furthermore this could put women at risk for their circumcised partner could push for unsafe intercourse.

Julio Montaner: Please click here for a comprehensive summary of our position in this area. Below, I have pasted the summary of this document:

Male circumcision has been associated with a lower risk for HIV infection in international observational studies and in three randomized controlled clinical trials. It is possible, but not yet adequately assessed, that male circumcision could reduce male-to-female transmission of HIV, although probably to a lesser extent than female-to-male transmission. Male circumcision has also been associated with a number of other health benefits. Although there are risks to male circumcision, serious complications are rare. Accordingly, male circumcision, together with other prevention interventions, could play an important role in HIV prevention in settings similar to those of the clinical trials.

Male circumcision may also have a role in the prevention of HIV transmission in the United States. CDC consulted with external experts in April 2007 to receive input on the potential value, risks, and feasibility of circumcision as an HIV prevention intervention in the United States and to discuss considerations for the possible development of guidelines.

As CDC proceeds with the development of public health recommendations for the United States, individual men may wish to consider circumcision as an additional HIV prevention measure, but they must recognize that circumcision 1) does carry risks and costs that must be considered in addition to potential benefits; 2) has only proven effective in reducing the risk of infection through insertive vaginal sex; and 3) confers only partial protection and should be considered only in conjunction with other proven prevention measures (abstinence, mutual monogamy, reduced number of sex partners, and correct and consistent condom use).

Patrick Munroe from Canada writes: How close are we to finding a vaccination or cure for AIDS?

Julio Montaner: We have no way of predicting when (if ever) we will have a cure or an effective vaccine. These are areas of active research, however, results to date remain disappointing. Despite this, the research must continue as both a curative treatment and a vaccine would be of great value in the fight against HIV/AIDS, now or in the future. Given the state of the knowledge today, I would venture that neither a cure nor a vaccine will be available within the next decade. Having said that, today we have highly effective prevention strategies and antiretroviral therapy, which if used aggressively and in combination, should make a significant dent on this devastating epidemic.

Adam from Toronto writes:What will be your mandate in your new role as president of the International AIDS Society?

Julio Montaner: For further info please click here .

In brief as the President of the IAS I will work to ensure that we meet our key objectives:

We connect. By convening the world's largest meetings on HIV/AIDS, IAS provides critical platforms for presenting new research, sharing best practice and advancing the fight against HIV/AIDS.

We promote. By promoting dialogue, education and networking, IAS helps close gaps in knowledge and expertise at every level of the response.

We mobilize. By providing support services to our members, we help them do what they do best, advancing the state of the art and expanding access to HIV prevention, treatment and impact mitigation.

J M from Thornhill writes: Some people make the argument that a very small amount of people are infected with AIDS in the grand scheme of things, yet we are pouring disproportionate funds into fighting it, when perhaps these funds should go to fighting cancer or heart disease. I do not agree with this view but have heard it argued. How would you respond to it?

Julio Montaner: This is an issue that comes up regularly. We must avoid falling into the trap of fighting one disease against the other. I rather take a broader view, as we did in a recent paper summarized below:

Exploring disparities between global HIV/AIDS funding and recent tsunami relief efforts: an ethical analysis. Christie T, Asrat GA, Jiwani B, Maddix T, Montaner JS. BC Centre for Excellence in HIV/AIDS, St. Paul's Hospital, Vancouver, BC, Canada. Dev World Bioeth. 2007 Apr;7(1):1-7.

OBJECTIVE: To contrast relief efforts for the 26 December 2004 tsunami with current global HIV/AIDS relief efforts and analyse possible reasons for the disparity. METHODS: Literature review and ethical analysis. RESULTS: Just over 273,000 people died in the tsunami, resulting in relief efforts of more than US$10 bn, which is sufficient to achieve the United Nation's long-term recovery plan for South East Asia. In contrast, 14 times more people died from HIV/AIDS in 2004, with UNAIDS predicting a US$8 bn funding gap for HIV/AIDS in developing nations between now and 2007. This disparity raises two important ethical questions. First, what is it that motivates a more empathic response to the victims of the tsunami than to those affected by HIV/AIDS? Second, is there a morally relevant difference between the two tragedies that justifies the difference in the international response? The principle of justice requires that two cases similarly situated be treated similarly. For the difference in the international response to the tsunami and HIV/AIDS to be justified, the tragedies have to be shown to be dissimilar in some relevant respect. Are the tragedies of the tsunami disaster and the HIV/AIDS pandemic sufficiently different, in relevant respects, to justify the difference in scope of the response by the international community? CONCLUSION: We detected no morally relevant distinction between the tsunami and the HIV/AIDS pandemic that justifies the disparity. Therefore, we must conclude that the international response to HIV/AIDS violates the fundamental principles of justice and fairness.

Jens G from Edmonton Canada writes: Hello Dr. Montaner, Congratulations on your new position, I wish you all the best. I would like to get your feedback in regards to the importance of testing for HIV and whether you believe that it is promoted and funded sufficiently in Third World countries. Also, what is your opinion regarding the new wave of oral fluid rapid HIV testing devices? Thank you, Jens Gerbitz

Julio Montaner: Thank you for your good wishes. With regard to your question, the answer is quite simple: we need to dramatically increase HIV testing efforts if we are serious about controlling the spread of HIV. Please note (as I discussed above) that this is true not also in the developing world, but also in rich countries around the world, including Canada. There is now technology available that allows rapid testing in an office setting using saliva or blood (as rapid as within one minute), which should make it possible to "bring the test to those in need", here and in the developing world. After all, knowing your HIV status is an essential component of a successful HIV control strategy.