A dramatic drop in the number of new HIV infections in British Columbia shows that a treatment-as-prevention strategy is making a difference, says a leading AIDS investigator who is frustrated that other parts of the country haven’t embraced the concept to the same extent.
“The truth is that there is no reason why we should be seeing a steady decrease in HIV new cases in British Columbia and we should not expect to see the same thing in the rest of the country,” said Dr. Julio Montaner, director of the British Columbia Centre for Excellence in HIV-AIDS.
Saskatchewan, in particular, has been struggling with an incremental increase in new cases almost every year since 2004.
In British Columbia, the number of deaths from AIDS since 2005 has steadily declined to 55 in 2010, while the number of people receiving HIV antiretroviral treatment has risen.
New HIV diagnoses fell to a low of 301 in 2010 even as testing for the virus increased, said Dr. Montaner as he revealed previously unpublished figures. In 1996, there were more than 700 new diagnoses and throughout the early 2000s, the number of new HIV diagnoses each year was above 400.
Dr. Montaner is a strong proponent of a treatment-as-prevention model that involves seeking out people at risk for HIV infection, treating those who are infected with antiretroviral drugs, keeping them on treatment and supporting them.
Treatment reduces the amount of virus in the bodily fluids of someone with HIV infection. A clinical trial of 1,763 couples in which one partner had a known HIV infection showed that antiretroviral therapy reduced the risk of heterosexual transmission by 96 per cent. The findings of the HPTN 052 trial, led by a North Carolina researcher, were reported in the New England Journal of Medicine in August.
Because of the trial’s profound implications for the future response to the AIDS epidemic, the magazine Science recently named it the breakthrough of the year for 2011.
Dr. Montaner said this made-in-Canada strategy now has been formally adopted by China, which has requested support to implement it, and the United States has said treatment as prevention will become a pillar of its international program.
His New Year’s resolution, he said, is to make it clear to the rest of Canada that “we are missing the boat.”
“Hello, the rest of the world is running behind it. Science magazine is calling it breakthrough of the year. British Columbia has been leading the charge now for what, five years – going onto six – and we in Canada, we’re happy to just walk away and say that nothing happened. This is the biggest disappointment of the last decade,” he said in an interview.
The Public Health Agency of Canada said Tuesday that no one was available for an interview on the subject.
In Saskatchewan, Jim Myres, director of disease prevention at the Population Health Branch, said there is no question that HIV infection has been an issue in his province, but a four-year strategy and “an aggressive campaign” is underway.
“We’re not calling it seek and treat, but essentially that’s what we’re doing. We’re actually going on reserve with an ID [infectious diseases]clinic and trying to get people to do the tests,” he said. “We’re actually seeing a bit of the numbers decline in our big urban centres, and the numbers out in the rural areas increasing as we implement this strategy.”
In 2009, there were 200 new cases of HIV in Saskatchewan and the figure dropped to 2010 to 172, he said. It’s expected to rise for 2011 because of new efforts to go out and find cases.
“We’ve actually had chiefs come to us and say ‘We want you to come on reserve and do an HIV ID clinic.’ I don’t think that’s done anywhere else in Canada.”
The first ID clinic on a reserve was held last summer, Mr. Myres said, and there have been one or two others since. Another ID clinic will be held this month.
Saskatchewan’s situation is a little different than other provinces, he said, noting 70 per cent of new HIV cases are injection drug-use related and a high proportion of them are from the aboriginal population.
“And when we talk about aboriginal populations, there’s a lot of stigma attached to that and therefore they don’t want to come in for treatment, so a lot of education and training is involved.”
Antiretroviral treatment is “absolutely” key to stopping spread of the virus, he agreed.
The province has been working with Health Canada to make the medication easier for First Nations individuals to access.
Pre- and post-test counselling is involved in HIV identification, and medication is prescribed for those identified as HIV positive. In the past, that meant going to a pharmacy and a “long involved process with regards to getting approval for certain HIV medications,” Mr. Myres said.
Less than a month ago, the process was finally streamlined so the antiretroviral therapy could be accessed right away.
“That was not the case with HIV medications for First Nations prior to Dec. 16. There was a long involved process that could take up to a week or 10 days, and this is a population that’s not going to come back. You get them there, you get the prescription, you need to be taking it right away.”
Saskatchewan is also studying practices in other provinces, and exploring whether direct observed therapy makes sense – having a health care provider such as a pharmacist watch as individuals take the medication.
“We haven’t fully gone down that road yet but it’s something we’re looking at. We do it for TB medication for example.”
In British Columbia, the controversial supervised drug injection program Insite, which allows health officials to try to identify infected individuals and facilitate treatment, is just one element of a multi-pronged program.
Dr. Montaner said antiretroviral treatment for HIV needs to be free, with no co-payments or deductibles, because these costs act as a disincentive to keep taking the pills. If a private drug plan gets charged, the information is liable to go back to an employer and could be an element to discourage testing and treatment, he noted.
He also said health-care providers should tell patients to have an HIV test if they’ve been sexually active in the last four to five decades.
“Because the small number of people with HIV that are not aware of their HIV infection are the ones that are most prolific HIV transmitters, because they don’t know,” he said.
“My government bought into it [treatment as prevention]because of the return on investment that all of this represents... if you consider that one infection costs you anywhere between $250,000 and $500,000 over a lifetime – you’re laughing all the way to the bank,” Dr. Montaner said.
Still, Dr. Montaner said Insite has been an important component.
“Only when the province made an effort to facilitate access to treatment to people with otherwise disorganized lifestyles because of drug abuse, etc., we saw a decrease in the new diagnoses among these people in the order of 50 per cent,” explained Dr. Montaner.
“What we learned here was the more you treat, the more you prevent. The faster you roll out the program, the greater the impact.”
Mr. Myres said he doesn’t see an Insite-type program as being on the horizon for Saskatchewan, but “we’re certainly looking at some other things we’ve seen elsewhere that have good value.”
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