Even at a time of other competing pandemic-status viruses, it is possible for a state or country to move from being an HIV hotspot to achieving the slowest transmission rates. British Columbia (BC), a province in Canada, is one such illustrious example.
Julio Montaner, M.D., former president of the International AIDS Society and head of the BC Center for Excellence in HIV/AIDS (Canada’s largest HIV research, treatment, and education facility), is the physician credited with turning HIV in BC province from a death sentence to a manageable, chronic condition. On Worlds AIDS Day in December, Montaner declared the epidemic of HIV in BC over.
This is astonishing because when COVID-19 appeared, it was feared that HIV testing and medication across BC would suffer. The opposite has occurred. The spread of HIV has declined even further.
“In 2019, we had the record low diagnoses since the peak of the epidemic in the 1990s before treatment became successful. We had a total of 205 cases. We used to diagnose over 1,000 cases per year. This is quite remarkable,” Montaner tells TheBody in a video interview. “AIDS-related mortality has similarly decreased too.”
In the 1980s and 1990s, BC was loosely called, “The AIDS capital of North America,” after two waves of the pandemic took root: First, in the ’80s, when higher incidences among gay and bisexual men caused a rapid increase in infections, and second, in the ’90s, due to the high prevalence among people who inject drugs.
“I was here in the ’90s. When you wanted to get a needle—people who use needles—it was one for one. If you brought nothing, you got none. It was contributing to rates going up,” Hugh Lampkin, a longtime member and activist of the vocal Vancouver Area Network of Drug Users, tells TheBody in a telephone interview.
Unique in All of North America
Montaner and his team did not want to sit back and see if the usually slow government bureaucracy would craft a response that weaves through the injectable drug use community; figuring out where exactly the infection hotspots are located and whether to roll out free ARV therapies. He and his team wanted to be proactive, that is to bring HIV interventions to the impacted communities rather than wait for people to visit the health care system.
Between 1996 and 1999, British Columbia province had a progressive opportunity to roll out triple therapy free of charge to all BC residents who were living with HIV. This was a unique program in all of North America, he says. “In those days, eligibility criteria were quite generous in the sense that there were very limited restrictions on who to treat
By 1999, Montaner, who was responsible for the clinical program in the province, noticed that the number of people dying from HIV had gone down significantly and that the pool of people living with HIV in the BC province had grown. And yet new infections in the province had also gone down.
“So, that at the time was a bit counterintuitive,” he says.
He looked up the syphilis data and noticed infection rates had shot up. He reasoned that HIV treatment was not only suppressing morbidity and mortality, which was the goal in the first place, but additionally, treatment was decreasing transmission of HIV.
By 2008, it was time to make a foray into Downtown Eastside, which is a low-income neighborhood in the city of Vancouver (the biggest city in BC) where the number of people who use drugs is very high.
He needed a way to work effectively with a segment of the population that is impacted most by homelessness and lack of reliable fixed addresses. Montaner reveals a useful approach: “I took a lot of inspiration from my father, who was a TB expert—his therapeutic efforts on TB. There are a lot of parallels between TB and HIV/AIDS. Before HIV came, the TB specialists had the same problem.”
His team embarked on what he calls “minimally, moderate, maximally,” which means recognizing that some people need minimal assistance, others moderate; and others need full assistance to the point of being directly observed, recognizing that people can move back and forth within the spectrum. Medically supervised injection was included.
“We created entry points into the health care continuum for people who otherwise would have no desire to engage with us,” Montaner said.
There in downtown Vancouver, his team did cohort studies, which revealed the concept of community viral load. “We were able to show we were the first to use the term ‘community viral load’ as the average amount of virus circulating in the community.”
What it revealed was that the number of infections tracks very nicely with the community viral load, and this gave a firm indication that treatment was decreasing infection by suppressing viral load in the community, he explains. “In my view, we planted the flag of treatment as prevention. Our efforts to control HIV in the Downtown Eastside have made news all the way to the New York Times.”
Armed With Proof
Thrilled by these findings, it was time to return and convince the government of BC that by expanding treatment, HIV infection, transmission, and morbidity in the population of BC could be reduced. The program ended up being called STOP: Seek and Treat for Optimal Prevention.
What it means is his team were going out in the community, facilitating access to testing, making testing as available everywhere as possible, and then offering follow-up treatment to HIV-positive residents, free of charge—no copayments or deductibles—funded by the BC government.
Profound Impact by 2018
By 2018, it was clear that the efforts of Montaner, activists, and the BC government were having a sterling payoff in driving down the epidemic in the province. But there was an enigma. While they had made great strides, the numbers weren’t budging as much in gay and bisexual men.
“We were doing virus genetic mapping in the community, and we were able to notice smoldering clusters particularly among young MSM [men who have sex with men],” he says. Gears had to be tweaked, again, fast. So they went to the BC government and asked for funds to add free pre-exposure prophylaxis (PrEP) to the provincial government services. And they got it.
After that, HIV infection suppression among the MSM cohort in BC has been pleasing, he says proudly. “I must be clear, our cohort of people living with HIV is aging—they are aging with me,” laughs Montaner.
“We used to be in our 20s and 30s, and so we are now in our 60s and 80s,” he says.
This is a stark achievement compared to other provinces of Canada like Saskatchewan, where activists say the health minister is ignoring warnings of a growing HIV epidemic due to the conservative province’s alleged racist attitudes. There, additionally, frontline workers fear a post-COVID boom in the hepatitis C epidemic, as testing rates are dropping by the thousands in a province with Canada’s highest infection rate. A health spokesperson for Saskatchewan province’s government has not yet responded to TheBody’s request for comment on allegations of health care racism.
The rest of Canada and the world are falling behind, Montaner warned on World AIDS Day 2020. “I don’t tire to emphasize that if we can get rid of racism, we have the chance of an HIV-free generation. If we are not doing it, it’s because we don’t want to,” he tells TheBody.
With its 90% range of control, the jury is still out on whether BC can someday eliminate HIV entirely. “It’s complicated,” Montaner sighs deeply. “To be honest with you, I have been doing this work for four decades, and we have been hoping for a vaccine and a cure or both. I believe that globally we will not be able to finish the job of eliminating HIV until such a time we get a vaccine or a cure or both.”
But as a lesson to other jurisdictions struggling to drive down HIV numbers, the tools we already have of antiretroviral therapy and PrEP are game-changing. “Our experience shows that we have not seen a ceiling of the treatment-based strategy for the control of HIV. Year after year, we have seen that the strategy continues to get better. If you ask me, ‘What is the ceiling for you, Julio, today?’ I would say, ‘I don’t know,’” Montaner says with a laugh of delight.