World AIDS Day, 2013: What’s the prescription for an ‘AIDS-free’ Canada?
On December 1, World AIDS Day, let’s take a measure of our progress in achieving an ‘AIDS-free’ world.
Globally, there is good news. The World Health Organization (WHO) reports that in 2012, 13 countries, many in the African continent, showed an annual growth in the number of people on anti-retroviral therapy outpacing the number of new HIV infections. This ‘tipping point’ is a welcome development and an important step toward the ultimate goal of ‘getting to zero’: zero new infections, zero AIDS-related deaths and zero discrimination.
In Canada, there is no comparable statistic available. There is, however, substantial cause for optimism. New knowledge, and new tools at our disposal, point the way to our ‘getting to zero.’
Newer medications for people living with HIV are easier to take and have fewer side effects, making HIV treatment more manageable and allowing people to have a near-normal life expectancy. Also, although not yet approved in Canada, medication that an HIV negative person who is at risk of HIV infection from a positive partner can take on a regular basis as a preventative measure (called pre-exposure prophylaxis) holds promise.
We know that diagnosing HIV at an earlier stage has huge potential health outcomes in reducing transmissions. Researchers estimate that the risk of transmitting HIV to another person from one act of unprotected sex is 26 times higher during the first three months after infection than during the months and years that follow. Research also indicates that once diagnosed, the vast majority of individuals take steps to avoid infecting others.
We know there is an indisputable link between treatment and prevention. Staying on anti-HIV drugs so that the viral load (amount of virus in the blood) is fully suppressed greatly lessens the likelihood of HIV being transmitted to a sexual partner or someone who is sharing drug-taking equipment.
Adhering to medications has the potential to bring about very positive results in the overall population. The thinking is that if you increase the number of HIV-positive people on treatment, you lower the total amount of virus circulating in a community and, ultimately, reduce the number of new HIV infections. This concept, known as “treatment as prevention,” has been employed in British Columbia where the province has reported reduced incidence rates in HIV transmission.
The B.C. success story, however, can also be attributed to a significant investment in harm reduction interventions in Vancouver. Fortunately, all provinces have needle syringe exchanges and in at least two (Ontario and Quebec) serious efforts are underway to institute supervised injection sites.
The Vancouver STOP HIV pilot project made a concerted effort to scale up testing opportunities, find people living with HIV who were ‘lost to care’ and link all HIV positive individuals to HIV care and treatment programs, and supporting them to stay in care.
This necessitated a transformation of their healthcare system. We know that service coordination among healthcare and community-based frontline service providers, addressing both medical issues and social determinants of health such as income and housing, is essential for providing the necessary support for sustained, healthful living. Fortunately, there are many examples of coordinated healthcare and community-based services in most provinces.
So where do we go from here? Science has provided us with great insights into the relationship between treatment and prevention, as well as tools we can use to lessen the likelihood of HIV transmission.
We can also be heartened by the professional response to the HIV epidemic in this country. CATIE hosted a national conference in Toronto this past September where upwards of 300 frontline service providers and healthcare professionals considered issues pertaining to the integration of services– a testament to the growing interest in collaborating for an enhanced and more efficient service delivery.
The science and the realities of current on-the-ground service suggest what Canada must do:
- Employ new testing methods in more settings, by diverse care-providers;
- Scale up interventions in communities with particularly high prevalence of HIV infection;
- Provide the supports necessary to help engage individuals in treatment and care and to maximize their well-being;
- Muster resources, creativity and professional acumen to provide more integrated service delivery.
This will go a long way to reaching people, including the estimated 25 per cent of those with HIV in Canada who are undiagnosed, and to achieving that goal of ‘getting to zero.’