AIDS Treatment as a form of Prevention

A lot of people thought Julio Montaner was a little crazy when he first suggested that the best way to eliminate the AIDS epidemic would be a massive scheme to give AIDS medicine to every infected person.

What about the huge financial cost? What about the moral issues, the human-rights issues, the overwhelming number of tests and drugs that would be required? Wouldn't it undermine years of lecturing on monogamy and abstinence? Wouldn't it promote "condom-free sex," as some critics said?

Faced with a host of objections, the Canadian scientist was a lone voice in the wilderness for the past three years, unable to win support from the global AIDS establishment.

But this year, Dr. Montaner's solitary crusade - the controversial notion of "treatment as prevention" - has suddenly become one of the hottest issues in AIDS science. And yesterday, at the International AIDS Society conference in Cape Town, his once-ridiculed idea was endorsed by experts from around the world.

Among the latest support for his proposal is a model by World Health Organization researchers that predicts a 95-per-cent reduction in new HIV cases within 10 years if his idea is adopted.

The proposed new strategy - universal voluntary testing for HIV, combined with immediate anti-retroviral drug treatment for those who have the virus, even in its earliest stages - could save more than seven million lives by 2050, the model says.

The WHO, which had resisted the treatment-as-prevention concept for years, is now organizing a special conference this November to discuss the "feasibility and acceptability" of the concept.

"Treatment as prevention is the topic of the year," Swiss scientist Bernard Hirschel told the AIDS conference yesterday.

"I think Julio deserves a lot of credit for this. Is treatment going to be the answer? We don't know, but we'd better find out."

Dr. Montaner, president of the International AIDS Society and director of the B.C. Centre for Excellence in HIV/AIDS, has been a prominent scientific researcher on AIDS since 1981, before the virus was even identified. A pioneer in the use of anti-retrovirals and other AIDS drugs, he has been campaigning for the treatment-as-prevention strategy since 2006.

Willy Rozenbaum, one of the early discoverers of the AIDS virus and now the president of France's National AIDS Council, was another scientist who lent his support to Dr. Montaner yesterday. Providing proper treatment to those who have the AIDS virus "sharply reduces the chances that they will transmit the virus," he told the conference.

Dr. Rozenbaum acknowledged that researchers must study whether the use of medical treatment as a prevention strategy would encourage "risky" behaviour by those who think that the AIDS virus has been virtually eliminated from their bodies. But medical treatment and condom use can coexist, he said.

In an interview, Dr. Rozenbaum said the notion of treatment as prevention is being resisted by many governments because they are afraid of the cost and reluctant to admit the failure of the traditional prescription of condoms and monogamy. "They've been promoting condoms as the answer for 20 years," he said.

After initial progress in reducing AIDS in the developed world, the condom strategy has failed to make further progress in recent years, he said. "I'm not happy with a plateau. We can't accept just a stabilization of the problem."

As for the short-term financial cost of a massive expansion in AIDS medicine, it would be outweighed by savings within five or 10 years as the transmission rate is swiftly reduced, he said.

The new WHO model of how this strategy could work, presented at the conference by WHO researcher Reuben Granich, says the treatment strategy would drive up costs at first, but "may provide cost savings" in the long run as it increasingly prevents new HIV cases.

Dr. Montaner conceded that some "recalcitrant" people with the AIDS virus will refuse to be tested or treated. His plan would not force them to be tested, but this would not weaken the strategy, he said.

"A person who is appropriately treated becomes dramatically less likely to transmit," he said. "The more you treat, the more you reduce the cases. ... When we first suggested this in 2006, people thought we were a little loony. But it's now fully accepted. We just need to get started."

The notion of treatment as prevention "creates a powerful new rationale" for the expanded use of anti-retrovirals and other AIDS drugs, he said. "We have transformed treatment from being merely a life-saving tool. Now it means we are protecting society, we are protecting our children."

The Harper government in Ottawa is still resisting the proposed new strategy, even as global experts are accepting it, Dr. Montaner said. When he suggested the strategy in a letter to the federal Health Minister, he received only a form letter in response. "It's been increasingly adopted around the world, but where is Canada on this?"

*****

The global AIDS battle

World health leaders are gathering in South Africa to discuss ways to fight the disease

PEOPLE WITH HIV/AIDS AROUND THE WORLD

PERCENTAGE OF WORLD TOTAL/ 2007

Latin America and the Caribbean/ 5.0%

High-income countries/ 5.4%

Eastern Europe and Central Asia/ 3.9%

Asia/ 21.4%

Africa/ 64.4%

The overwhelming majority of people with HIV/AIDS, 95%, live in the developing world.

MONEY AVAILABLE FOR GLOBAL AIDS FIGHT, IN BILLIONS $ US

'05/ $7.9

'06/ $8.8

'07/ $11.3

"08/ $13.8

THE GLOBE AND MAIL / SOURCE: UNAIDS, AVERT.ORG