Cover Story: Disease Elimination

Promise Magazine: Spring/Summer 2015

Building on 30 years of innovation in HIV/AIDS, the BC-CfE at St. Paul’s sets a new course to eliminate hepatitis C and eventually other communicable diseases

It’s a typical rainy February day in Vancouver, BC, and Dr. Julio Montaner, director of the British Columbia Centre for Excellence in HIV/AIDS (BC-CfE) at St. Paul’s, is on the phone with the United Nations AIDS program office. He’s discussing a topic that’s anything but typical – the proposed UNAIDS global targets to eliminate the HIV pandemic by 2030.

Montaner is the architect of the made-in-BC Treatment as Prevention (TasP) strategy and continues to work relentlessly to build global support for evidence-based strategies to fight HIV and AIDS. This July, he is scheduled to serve as the local co-chair of the 2015 International AIDS Society (IAS) Conference on HIV Pathogenesis, Treatment and Prevention coming to Vancouver.

“With the world coming to us this summer, it’s a unique opportunity to show stakeholders the real possibility of an AIDS-free generation in the very near future,” says Montaner.

Montaner’s assertion represents a monumental advance in medical science, especially when you consider that AIDS was a veritable death sentence 30 years ago, when there seemed to be no foreseeable end to the then-expanding epidemic. That was certainly the case when the IAS Conference was last held in Vancouver in 1996.

Milestones in the global fight against HIV/AIDS

It was at IAS 1996 that Montaner announced his pioneering multi-drug treatment for HIV/ AIDS called HAART – highly active antiretroviral therapy.

“In the early 1990s, an HIV diagnosis was equivalent to a short-term death sentence,” says Montaner. “Then, [in 1996] we came up with new drug cocktails and lab strategies that could extend lives.”

Using data collected from patients on HIV treatment, the BC-CfE continued to refine HAART, which is the international gold standard in HIV therapy. The treatment is now simpler and safer. The life expectancy of a 20-year-old person diagnosed with HIV has improved from 10 years, prior to the development of HAART, to more than 50 years today.

In 2006, Montaner took HAART to yet a higher level, when he unveiled at the Toronto International AIDS Conference his TasP (Treatment as Prevention) strategy, another major game-changer that was eventually adopted by countries around the world. The strategy, pioneered by the BC-CfE, is based on evidence that expanding access to HAART prevents disease progression to AIDS and premature death, and secondarily prevents HIV transmission.

TasP calls for widespread outreach and HIV testing, particularly among hard-to-reach populations, such as intravenous drug users and sex workers, and the immediate offer of treatment and support for those who test positive for HIV. Already, many jurisdictions around the world have adopted TasP to address the spread of HIV, including China, France, Panama, Brazil, Spain, Sierra Leone, Argentina, parts of the United States and Queensland, Australia.

In British Columbia, the development of HAART and the provincial government’s investment in implementing TasP have dramatically changed the outlook for HIV-positive individuals throughout BC. Recent statistics show that AIDS-related deaths in the province have decreased by more than 80 per cent from 1994 to 2013.

Montaner’s success with TasP is at the heart of the recently proposed UNAIDS global strategy, known as the 90-90-90 target, which sets out to eliminate AIDS globally by 2030 by achieving the following targets by 2020: 90 per cent of all people living with HIV know their HIV status; 90 per cent of those diagnosed with HIV receive sustained antiretroviral therapy; and 90 per cent of people receiving antiretroviral therapy experience full viral suppression.

“In 1996, we came up with a strategy to stop AIDS. In 2006, we shifted our attention towards a strategy that could change the course of the global pandemic,” says Montaner. “In 2015, we know we have a strategy that can eliminate the HIV/AIDS pandemic. Indeed, if we meet the UN 90-90-90 target by 2020, we can expect that by 2030 HIV/AIDS will become a sporadic endemic condition.”

Using TasP to stem the spread of Hepatitis C and other communicable diseases

The success of the BC-CfE’s HIV/AIDS research has created opportunities to apply that knowledge and experience to targeting the elimination of other communicable diseases.

“Our work with HIV/AIDS has shown us that the TasP strategy works and we feel we can export it to other areas of medicine,” says Montaner. “As long as we can screen and manage a contagious disease to reduce mor- bidity, mortality and transmission – the strat- egy can apply.”

BC has achieved unprecedented success with the implementation of the TasP strategy; indeed, it is the only province in Canada dem- onstrating a consistent decline in new cases of HIV. While there remains work to be done, Montaner and his team are now focused on applying TasP to address the much larger epi- demic of hepatitis C, a serious liver disease.

Symptoms of hepatitis C often don’t show up for years, and the disease can be transmitted much more readily than HIV. Over time, hepa- titis C can lead to serious and even fatal damage to the liver. Some 80,000 British Columbians are carrying the virus (in contrast to 12,000 liv- ing with HIV), Montaner says, and as many as half of them are unaware they’re carriers.

“To help stop hepatitis C we need to seek out at-risk populations, just like we are doing with HIV/AIDS, and ensure they have prompt access to care to facilitated treatment and transmission-reduction strategies to prevent further infection,” says Montaner.

While the stakes are high, Montaner and the BC-CfE are confident that, in time, with sufficient resources and backed by the know- ledge gained from 30 years of world-leading HIV/AIDS research, care, knowledge trans- lation and advocacy, they will be well pre- pared to stem the hepatitis C crisis as well as other communicable diseases.

Tiko Kerr: One Patient’s Story

When VancouVer arTIsT Tiko Kerr tested positive for HIV in Sydney, Australia, back in 1985, the outlook was grim. A little understood disease with no known treatments at the time, Kerr’s doctors told him to, “Return to Canada and get your affairs in order.”

Within weeks, the then-30-year-old Kerr was in Vancouver and preparing to die: “There was so much fear at that time and so little hope.”

But Kerr was one of the lucky ones. He managed to hang on long enough to benefit from HAART, the groundbreaking drug therapy pioneered by Dr. Julio Montaner at the BC Centre for Excellence in HIV/AIDS (BC-CfE) at St. Paul’s.

Those, like Kerr, who survived the wait, went from 80 pills a day and many side-effects, to 10 pills a day, a negligible viral load and a comparable life expectancy to non-infected individuals.

Today, the 61-year-old Kerr continues to be a prominent artist in the Vancouver community who rows, goes to the gym and is feeling healthy. He is also “a bit of a poster boy for HIV/AIDS and the BC-CfE,” he says.

“It’s the least I can do. What Dr. Montaner and the BC-CfE have done for me is nothing less than miraculous.”