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.
