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 Winter 2010, Issue 1 Your opinion matters to us! Please take a few minutes to respond to our short survey on Prevention in Focus — even if you read only one article. Views from the front lines
Dr. Julio MontanerDr. Julio Montaner is the Vancouver-based director of the British Columbia Centre for Excellence and president of the International AIDS Society. Dr. Montaner has made bold contributions to the conceptualization of how HIV treatment could be used as prevention. He is one of its most passionate and successful advocates. Dr. Montaner, could you provide some background on the development of your thinking about the role of HIV treatment as prevention?In 2004 and 2005, there was a rapid expansion of people in B.C. on treatment. The availability of a new drug, tenofovir, with fewer side effects, acted as the magnet to draw more people in. Tenofovir is a more costly drug than d4t, and the Ministry of Health was concerned about the increasing costs of the HIV treatment program. In 2005, with mounting pressure from the Ministry of Health to justify the increasing cost of my drug program I argued that in addition to the benefits of treating people with HIV, our program was part of the greater solution because we were contributing to a decrease in HIV transmission. I talked to them about the fact that we had seen a 50 percent decrease in HIV transmission since the introduction of highly active antiretroviral therapy (HAART) despite an increase in syphilis in B.C. This is important because it shows that people still continued to participate in risky sexual behaviours because syphilis continued to be transmitted but HIV transmission went down. They asked that I collect the available evidence on the potential of treatment as prevention. As we gathered the research about this synergistic effect, I started to realize that we were on to something big here. Could you talk about the benefits for marginalized and hard-to-treat communities in Canada?We need more antiretroviral programs in marginalized communities. Instead, we have to contend with the draconian perversions of our health system, which believes that if people don’t come and get health care, then we’re somehow saving money. But the reality is that if people don’t access health care, we’re actually wasting money because we’ll end up spending that money down the road in hospitalizations, emergency care and lost productivity. Expanding antiretroviral (ARV) access is the moral, ethical and intelligent thing to do. It will save lives, decrease hospitalizations and the other associated costs, and reduce the number of new HIV infections. And it will be cost-effective because it will avert costs in the future. Our research has shown that there is currently only selective penetration of ARVs across B.C. HAART has a great effect on age-related mortality rates. Before HAART, people were dying at a significantly younger age compared to after HAART became available. However, current differences in mortality rates have been found between Vancouver’s West End, where many middle-class gay men with HIV live, compared to the Downtown Eastside, where many marginalized First Nations people and injection drug users live. People are dying at younger ages in the Downtown Eastside because of their inability to start treatment. Our research has also shown that in Northern B.C, the mortality rates are much higher and are getting worse. This is mostly in First Nations communities, which have poor access to treatment programs. There have been recent changes in how we view the nature of HIV disease. We have changed from seeing HIV as characterized by a long asymptomatic phase to seeing it as a disease characterized by ongoing inflammatory response. As a result, the IAS-USA has changed its guidelines to encourage initiation of ARV therapy at a CD4+ count of 350 rather than 200, as it was formerly. Plus they have outlined a long list of conditions that qualify you for ARV treatment regardless of your CD4+ count. So the number of people who should be on treatment has grown dramatically with these new guidelines. But the fact remains that many people with HIV in our province are dying without ever having accessed treatment. I like to think that we have one of the best programs in the world here in B.C. and yet over half our patients start treatment late, or never start. What do you see as the challenges to implementing such a program?There are always those people who ask, “How effective is HIV treatment for prevention?” Is it 75 percent effective at reducing transmission? 90 percent? 95 percent? And they think that until we know this percentage exactly, we cannot move ahead. But not knowing exactly doesn’t take away from the fact that we do know that there are benefits of treatment for HIV transmission. Another challenge is to change the delivery of ARVs from a passive “come and get them” program to one of active delivery: what we call “seek and treat.” This is not easily done. It involves supportive, costly programs for people with addictions and people who are isolated or have mental health problems. But my role is not to illuminate the challenges. It is to show all the reasons why we need to increase access to ARVs, and that we need to do this because it is important. Why do you feel so passionate about this issue?It’s important that people understand that HIV is a huge problem here in Canada and elsewhere in the world and that those who are in medical need of treatment are not receiving it. I’m tired of being told to go back to the drawing board to come up with a better road map. I’m tired of people who are always planning to make a plan to plan for the future plan. I like to roll my sleeves up and get my hands dirty. Let’s get on with the job! Suzy CoulterSuzy Coulter is a nurse in Vancouver’s Downtown Eastside where she works in the Downtown Health Centre’s Maximally Assisted Therapy (MAT) program. She and her team do whatever it takes to get daily doses of HIV antiretroviral treatment to street-involved people with HIV. Offering insight into the successes and challenges of working with people deeply entrenched in addictions, Ms. Coulter cautions about the potential abuse of the rights of the vulnerable in any plan to expand treatment access for prevention purposes, if it is not well-planned. Could you describe what is meant by a Maximally Assisted Therapy program?The term Maximally Assisted Therapy (MAT) has become a bit genericized, but to my knowledge we were the first to use this term to describe our antiretroviral (ARV) adherence support program at the Downtown Community Health Centre. The term MAT is meant to capture the comprehensive assistance we offer for medication adherence, a kind of Daily Observed Therapy Plus approach, where we attempt to help minimize the multiple barriers to adherence faced by our clients. The MAT program is an interdisciplinary clinic-based program that provides intensive health support, case management and daily outreach for very marginalized people living with HIV. For 10 years we have been helping people become stabilized and ready to start ARV treatment and then helping them to maintain high levels of adherence. What are your thoughts about the role of HIV treatment in preventing HIV transmission, particularly among the people you work with in the Downtown Eastside?I think there are benefits to providing HIV treatment as prevention. But it is also important to consider the key issues of whether the individual is able to provide informed consent and is in fact ready to go on treatment. A key benefit must be that the person’s own health will improve. And will he or she be able to stay on therapy,and maintain a high enough level of adherence to treatment to prevent development of viral resistance? If people living with HIV are not ready to go on treatment, and not able to maintain a high level of adherence, not only will there be negative consequences for those individuals, but the level of viral resistance in our communities will rise. Having said that, I’ve seen some incredible success stories in our program with people I didn't think could make HIV treatment a priority in their lives—people with mental health and addictions issues, people who have survived multiple traumas who are self-soothing with hard drugs. But they have managed to do it. It’s amazing what being welcoming, giving people a bowl of cereal and laughing with them can accomplish. We have a lot of laughs at our program. And we are committed, seven days a week, to staying connected to them and bringing them their ARVs if they don't make it in, without fail. We are attempting to institute some pretty exciting models in our program including peer-driven initiatives and treatment buddy programs. There’s a lot of intuitive peer support going on among clients. For example, the old-timers help the new clients by talking to them about taking the medications and how they’ll get healthier. Also, people who are getting their medications through this program can become part of the team and help to engage others with their personal testimonials—these are really exciting health models. What do you see are the challenges?There are some people who are so entrenched in their addictions that we’ve been unable to connect with them. They are not ready to go on HIV treatment and unless there is dramatic enhancement of addictions treatment and support services I think they probably never will be. It is hard to visualize them ever being able to initiate and stay on therapy. Similarly, many people living with HIV have significant mental health issues. Many of these people are simply not able to engage in treatment and stay on therapy at present, and they are not receiving or benefiting from optimal mental health care. There will need to be much enhanced support and mental health services put in place before a treatment for prevention approach could be seriously considered. More safe economical housing will also need to be found for many people who are currently either homeless or in unstable housing situations. There is also another challenge—ensuring that people who start treatment are able to stay on therapy—that’s another worry. Starting people on HIV treatment is not always easy, but it’s a lot easier than sustaining them on therapy. The bigger challenge is ensuring that people who start therapy can continue, and not run into viral resistance problems because of lack of adherence. The real worry here is drug resistance. To me this is one of the huge challenges with the concept of treatment for prevention. I have also heard rumours of incentivizing treatment, in other words paying people to go on treatment. This introduces a whole new dynamic around self-care and makes it a commodity—and that concerns me. We have an awesome interdisciplinary team dedicated to helping people in our MAT program—people who are really skilled at gaining trust, engaging people and building rapport. The MAT program sometimes gets criticized for being expensive, but what can I say? This is what such a program costs. In order to do this program properly, there are people you will need to go out and see every day in order to give them their treatment so they can take it. I’m worried that the Downtown Eastside folk who aren’t currently on ARVs are the ones that need one-on-one workers to work with them continuously. How are we going to address this, budget wise? Are we really sure that programs aimed at increasing the number of people on treatment will be able to continue to do this in the long-term? I’m cautious about taking these programs too far in the direction of putting folks on treatment with the main purpose of transmission prevention. For example, I know of a young Aboriginal guy with fetal alcohol spectrum disorder and a crack addiction. He recently seroconverted, had a high CD4+ count and his viral load was just starting to settle. He’s quite a sexually active guy and he was put on treatment to protect others’ health. He’s adhering well through a supportive housing program where his pre-packaged meds are delivered daily to the housing workers by the pharmacy. These housing workers do their best to make sure he takes the meds. But it’s still early days for him. Will he be able to stay on treatment? How long will the support be around for him? Who will support him if he moves? Does he become ghettoized to live only in places with medication adherence programs? There are so many complex issues to think through. Larry BaxterLarry Baxter is the chair of the Nova Scotia Advisory Commission on AIDS, which is currently co-ordinating the implementation of Nova Scotia’s Strategy on HIV/AIDS. He is also a board member of the Canadian Working Group on HIV and Rehabilitation (CWGHR) and is a person living with HIV/AIDS. Mr. Baxter believes that treatment as prevention is an important strategy but must be part of a comprehensive approach that includes enhanced prevention and testing programs. From your perspective, what are the potential advantages of increasing the number of people living with HIV receiving anti-HIV treatment (for those that consent to it and for whom medication is justified)?When I first heard of treatment as prevention, it made sense to me. While treatment has been a lifeline for many, but not the much-desired cure, it has reached the point where most people can receive reasonable benefit and achieve some improved quality of life. With viral loads becoming undetectable, the risk of further transmitting HIV is reduced, although not eliminated. But we have to remember that treatment is primarily a medical intervention for the patient, which may or may not have some intentional spinoff for others in the form of prevention. But to have treatment prevent further HIV infections would be a real bonus. What are the challenges in implementing such a project?I suspect that most people who know they are HIV-positive, who desire to be on treatment and who have the necessary supports are now on treatment. For the others who are not yet on treatment and want to be, treatment may also involve providing adequate housing and/or income, addictions and/or mental health treatment and the basic personal supports that anyone needs when going through this major life event. Treatment is much more than just taking pills. However, the biggest challenge is getting people tested and counselled for prevention before they are even eligible for treatment. Since half of the new HIV infections in Canada are transmitted by individuals who are themselves newly infected and thus untested, we must also find ways of reaching these individuals with both testing and prevention messages, well before the discussion of treatment. Canada’s geography, the access to services and the existing stigma around HIV must be taken into the equation. While there is a major concentration of HIV in Toronto, Montreal and Vancouver, we still have plenty of clients to service outside these metropolitan areas. Moreover, we already have the problem that treatment is seen as a cure. While treatment as prevention may make sense on a population level, with reduced infections, the message may get confused at the individual level with people on treatment thinking they can forget the condoms and the clean needles. Overall, do you think that implementing such a project is a good or bad idea?It probably makes more sense in a country where the HIV epidemic is widespread throughout the general population. In Canada we are faced with not one epidemic but with at least four, if not more, smaller but inter-related epidemics. Treatment as prevention is only one of several important strategies to reduce HIV infection. Canada’s public health approach should include early and honest sexual health education for youth; annual sexual health checkups with counselling options; varied and accessible testing options that do not further stigmatize the person or the issue; targeted and graphic prevention messaging as well as HIV-positive prevention initiatives for PHAs. Summing up, I would endorse treatment as prevention if it were part of a comprehensive approach that included enhanced prevention and testing. |
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Decisions about particular medical treatments should always be made in consultation with a qualified medical practitioner who is knowledgeable about HIV-related illness and the treatments in question. MORE |
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We spoke to three knowledgeable and candid HIV community members, Dr. Julio Montaner, Suzy Coulter and Larry Baxter, to get a better sense of what’s at stake in the debate on the preventative role of HIV treatment.