Julio Montaner, the Canadian who is president of the International AIDS Society, spoke to André Picard, The Globe and Mail's public-health reporter, about his hopes and expectations going into the 18th International AIDS Conference, which opened Sunday in Vienna.
The HIV-AIDS pandemic started three decades ago and you have been involved since the early days. Do you ever get discouraged?
I remember being asked that question back when we were facing a pandemic of unknown origin, etiology, mechanism of transmission and so forth. But I've always been a cup-half-full type of guy. I was there when we had not discovered HIV, CD4, when we had no treatment and AIDS was a sure death. Through methodic research and with evidence-based decision-making we have transformed a devastating set of circumstances into something we have the tools to control. So how can I be despairing when I've had the privilege of working with patients and health professionals to solve this puzzle? Now, all we need to do is solve the political puzzle - and that's much harder.
There are more than five million people worldwide on antiretrovirals; that was unthinkable a decade ago.
When we began the campaign for universal treatment and prevention we were told this was crazy, inappropriate, impossible. Yet we were able to get the commitment of the G8. This was remarkable, incredible. We didn't reach our initial target - three million on treatment by 2005 - but we did get five million on treatment by 2010. But there is more to do, and our political leadership has somehow gotten distracted, so our task is more difficult.
You have been a strong proponent of treatment as prevention, the notion that if you suppress the virus in a person, they cannot infect others. That philosophy has now been embraced and UNAIDS says that widespread treatment could prevent one million new infections a year.
We now know that the benefits of antiretrovirals extend far beyond the individual, that there are dramatic secondary preventive benefits. Treatment as prevention is a game-changer. With treatment, you make an individual 90-per-cent less likely to transmit HIV, you are dramatically reducing the risk of AIDS in the next generation. By treating more you are actually putting a higher down payment on the AIDS mortgage.
Treatment 2.0, the new initiative by UNAIDS, calls for more than 15 million people worldwide to be treated. It would avert 10 million AIDS deaths by 2025, but at a cost of some $26-billion a year. Can we afford to do this?
The real question we should be asking is: Can we afford to not do it? The answer is simply no. We have a tool that helps individuals and decreases HIV transmission 90 per cent and we need to use it broadly. To treat or not to treat is a false dichotomy. Everyone with HIV-AIDS needs treatment - we can do it today, tomorrow or in three to five years when they are sicker. You don't save money by delaying treatment; later treatment is more expensive and less effective, and that person can also be spreading the virus. You're shooting yourself in the foot by waiting. The case for Treatment 2.0 is extremely compelling economically, morally, ethically, medically. Any way you look at it, investing in antiretroviral therapy, investing in universal access is not only the right thing to do, it's the smart thing to do.
You are arguing that treatment is efficient and one of the buzzwords in the AIDS field these days is efficiency.
There is no question we need to do more with less - in other words, we want less AIDS and still spend the same amount of money, or less. Bill Gates has made "more efficiency" one of his themes and I am 100-per-cent behind that. But the truth is we are a young movement and we're still learning how to roll out programs in the best way, often in very difficult circumstances. Some treatment programs have a cost per person that is dramatically different than others, so we have to adopt those best practices. There is a lot we can do to make our work more efficient and more effective.
The theme of the conference is "Rights Here, Right Now." HIV-AIDS is a health challenge, but is it also a human-rights issue?
Human rights are a major determinant of a person's health. You cannot access appropriate health care if you are stigmatized, discriminated against, persecuted, criminalized, prosecuted, silenced. All of those things apply to the people I work with on a day-to-day basis in Canada and, as you can imagine, they have it much better than many other people with HIV elsewhere in the world. If we address the human-rights challenges that our patients face, we will make treatment much cheaper and more efficient. When you have law enforcement chasing people in one direction - because they use intravenous drugs, because they are men who have sex with men, because they are commercial sex workers, and so on - and public health trying to undo the damage of criminalization, you are wasting a lot of resources. If we discriminate, people won't be tested and they won't be treated. Changing the public-health framework is a very effective way of improving the efficiency of the public-health effort.
There will be more than 20,000 delegates in Vienna. Do giant international AIDS conferences still serve a useful purpose?
This is not a conference in the traditional sense, it's a world public-health summit focusing on HIV-AIDS. It brings together not only physicians and scientists, but the infected-affected communities and the whole movement that's trying to fix this problem. These conferences have been pivotal in changing the face of the AIDS movement and reinvigorating the fight against HIV-AIDS. We hope that Vienna will have, as its crowning moment, the adoption of Treatment 2.0, the recognition that treatment is prevention and the recognition that we need to ameliorate the human-rights deficit to open the door to more efficient treatment. This is an ambitious agenda and we need a very strong presence to move it forward.