Julio Montaner is executive director and physician-in-chief of the BC Centre for Excellence in HIV/AIDS and past president of the International AIDS Society
On this World AIDS Day, as we reflect on the lasting impact of HIV/AIDS over the past 40 years, we are at a precipice where all the strides made are in jeopardy.
The tide started to turn initially against the HIV/AIDS epidemic in 1996 when we unveiled highly active antiretroviral therapy, or HAART, the first effective means to prevent the progression of HIV infection to AIDS and premature deaths.
In the early 2000s, we recognized that HAART also prevents HIV transmission and we recommended initiating HAART immediately following diagnosis to accelerate overall HIV/AIDS control. The strategy was named “treatment as prevention,” or TasP, since HAART simultaneously stops progression to AIDS, premature deaths and HIV transmission.
With the Joint United Nations Programme on HIV/AIDS, we developed TasP-inspired targets specifically designed to achieve a 90-per-cent decrease in AIDS mortality and a 90-per-cent decrease in new HIV infections by 2030 to meet the goal of “ending HIV/AIDS as a pandemic.”
The UN formally endorsed the 90-90-90 by 2020 target in 2015, and the 95-95-95 by 2025 target in 2021.
Some areas of the world have made great strides toward the UN 90-90-90 target. However, lack of leadership and resources have hampered progress in many regions. More recently, the COVID-19 pandemic and the public-health measures aimed at controlling this new virus compounded these shortcomings, leading to an unintended disruption of medical services including decreased HIV testing, interruptions in the provision of HAART, and funding diversions.
André Picard: A tale of two pandemics: AIDS and COVID-19
This year, the Public Health Agency of Canada released a much-anticipated epidemiological HIV/AIDS update. The results were disappointing, as HIV incident cases in Canada have remained flat since the 1990s. There is a marked contrast between British Columbia and the rest of Canada, in this regard.
HIV incident cases peaked in 1982-84, then behaviour modification led to a substantial reduction in incident cases over the following decade. Subsequently, the trajectory diverged: B.C. had a steady decline in incident cases, but the rest of Canada had no further reduction.
This discrepancy is explained by the success of TasP in B.C. The failure to implement TasP optimally across the country has led to widely different regional HIV incidence rates.
Measured as the number of individuals per 100,000 population, the national HIV incidence rate is 4.8. B.C., which had the highest domestic incidence rate at the peak of the epidemic in the 1980s, is now well below the national average at 2.5, in the low end of the national spectrum, with the territories and Atlantic regions at 2.1 and 2.2, respectively. Alberta and Ontario are just below the national average at 4.2 and 4.1. Contrarily, Saskatchewan, Manitoba and Quebec are above the national average at 23, 7.7 and 5.8, respectively.
Canada knows how to end HIV/AIDS as an epidemic, but is Canada up to the task?
The key requirements are well-established. They include a normalization of HIV testing to ensure everybody knows their HIV status; a decrease in barriers to access health services and support to all affected populations with particular emphasis on harder-to-reach and most-affected populations; and a guarantee of harm reduction services that are widely and freely available.
We must also ensure HAART and pre-exposure prophylaxis, and the related laboratory monitoring, are free to all eligible Canadians. There should also be full transparency and accountability from our health care system, with annual reporting of the progress toward the UN 95-95-95 by 2025 target, HIV incidence, HIV prevalence, and AIDS-related morbidity and mortality by Public Health. And finally, the federal government should sponsor an arm’s-length yearly summit of all relevant stakeholders to promote accountability and transparency, compare regional progress, and share lessons learned in the process.
As a parent of HAART, TasP pioneer and architect of the UN targets, Canada has a global responsibility to support the strategy, and demonstrate that, applied at scale, it will achieve the goal of ending HIV/AIDS as a pandemic.
B.C. served as a testing ground to demonstrate TasP’s effectiveness. It is long overdue for the rest of Canada to optimally implement TasP but this will require a major commitment from the provinces. Canada knows how to end the epidemic domestically; it is high time to get it done.