Additional note: TCMP team would like to congratulate Dr. Montaner on being chosen as the 2010 recipient of the “Albert Einstein” World Award of Science.The “Albert Einstein” World Award of Science was created as a means of recognition to those persons who have accomplished scientific and technological achievements which have brought progress to science and benefit to mankind. The 2010 “ALBERT EINSTEIN” World Award of Science will be presented to Dr. Montaner on December 8, 2010 in Mexico.
Dr. Julio Montaner (biography and disclosures)
What care gaps have been noticed?
While an outright cure for HIV/AIDS remains elusive, remarkable advances in HIV treatment have been achieved over the past two decades. Most significant among these advances is the development of highly active antiretroviral therapy (HAART), a combination of antiretroviral drugs that suppress HIV replication.
HAART uptake today remains suboptimal. This is particularly apparent among hard to reach individuals who often have additional challenges related to drug dependency, mental illness, limited education and unstable housing. The BC Centre for Excellence (BC-CfE) has shown that the current approach to HAART, i.e.: passively relying on HIV infected individuals seeking testing and care, needs to be replaced with the active expansion of testing, coupled with novel engagement in care initiatives and supported HAART for all those in medical need. The latter approach would be highly cost effective as a strategy to control HIV/AIDS related morbidity and mortality.
Data that answers these gaps
HAART became the standard of care in developed nations around the world following the International AIDS Conference in Vancouver in 1996. Within months HAART use significantly reduced morbidity and mortality among treated patients, allowing dramatic improvements in the quality and duration of life for HIV-infected individuals. In BC, by 1999, the BC Centre for Excellence (BC-CfE) in HIV/AIDS documented an 85% reduction in HIV/AIDS mortality among patients engaged in treatment.
More recently, we have provided evidence that the viral load suppression achieved by HAART has a substantial impact on the transmission of HIV. Specifically, in August 2006, we outlined the expansion of HAART coverage to all those in medical need as a key strategy to dramatically reduce HIV transmission to those at risk 1. We further proposed that HAART expansion in addition to preventing AIDS morbidity and mortality, would become cost-averting as it would virtually eliminate vertical transmission of HIV, and dramatically reduce HIV transmission by all routes 2.
The powerful and sustained ability of HAART to suppress viral replication is responsible for the decreased risk of HIV transmission among treated HIV positive individuals. Evidence to support this association can be readily found in vertical transmission studies where the use of HAART has led to the near complete prevention of transmission of HIV from the infected mother to the newborn. Further, among sero-discordant couples (one infected and one uninfected partner) transmission is a direct function of the level of viremia in the infected member of the couple, and this is effectively decreased to very low levels (by greater than 90%) with HAART thereby dramatically reducing risk of transmission.
More recently, we published the first study demonstrating the role of HAART in the prevention of transmission in injection drug users in the Downtown Eastside of Vancouver 3. At the population level, the BC-CfE has documented that expanded HAART uptake was associated with approximately a 50% reduction in HIV incidence in BC between 1996 and 1999 when HAART was first introduced, and again by approximately 10% between 2004 and 2009, as a result of a further expansion of HAART coverage. 4
What recommendations are suggested?
The BC-CfE’s proposal of using “Treatment as Prevention” was initially regarded as controversial; however, this notion has gained the support of the international community, including the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS). In January 2009, the WHO AIDS program published a paper which independently validated our proposed approach 5. In February 2009, an international summit in Vancouver co-convened by the International AIDS Society, the World Bank and the Global Fund, with support from the Public Health Agency of Canada and with participation of WHO, UNAIDS, PEPFAR, the Clinton Initiative, Médecins Sans Frontières, the National Institutes of Health, and international research-based pharmaceutical industries, among other key international stakeholders, charted the course for further expansion of HAART in the developing world centered on the proposed “Treatment as Prevention” initiative.
Today, a synergy has emerged between new trends in treatment guidelines6 and the role of HAART in the prevention of HIV transmission. The new guidelines encourage early treatment with HAART even at high CD4 cell counts. This offers a unique opportunity to expand HAART coverage for individual patient benefit with a secondary prevention benefit.7 Therefore, we need to change our practice and actively and persistently seek those infected through liberal testing practices and then offer them treatment with HAART to optimize prevention of HIV/AIDS morbidity and mortality, as well as prevention of HIV transmission.
References: (Note: Article requests might require a login ID with the BC College of Physicians website or UBC)
- Montaner et al, The case for expanding access to highly active antiretroviral therapy to curb the growth of the HIV epidemic. Lancet 2006; 368(9534): 531-536. (View article with CPSBC or UBC)
- Lima et al, Expanded access to highly active antiretroviral therapy: a potentially powerful strategy to curb the growth of the HIV epidemic. Journal of Infectious Diseases. 2008; Vol 198(1): 59-67. (View article with CPSBC or UBC)
- Wood et al, British Medical Journal, 2009. Longitudinal community plasma HIV-1RNA concentrations and incidence of HIV-1 among injecting drug users: prospective cohort study. BMJ 2009; Vol 339 (b1649): doi:10.1136. (View article with CPSBC or UBC)
- Montaner et al, The Lancet, 2010. Association of highly active antiretroviral therapy coverage, population viral load, and yearly new HIV diagnoses in British Columbia, Canada: a population-based study. Lancet 2010; Vol 376(9740): 532-539. (View article with CPSBC or UBC)
- Granich et al, The Lancet, 2009. Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: a mathematical model. Lancet 2009; 373(9657): 48-57. (View article with CPSBC or UBC)
- Thompson et al. JAMA 2010. Antiretroviral treatment of adult HIV infection: 2010 Recommendations of the international AIDS Society USA Panel. JAMA 2010; 304(3): 321-333. (View article with CPSBC or UBC)
- Lima et al. PLoS One 2010. Expanding HAART treatment to all currently eligible individuals under the 2008 IAS-USA guidelines in British Columbia, Canada. PLoS One. June 2010; Vol 5(6): e10991. (View article with CPSBC or UBC)