Julio Montaner: HIV ‘Treatment as Prevention’ Agenda Can’t Effectively Move Forward Without a Major Focus on Human Rights
23 July 2012
Over the next week, world leaders, delegates and community advocates from around the world will meet in Washington D.C. for the XIX International AIDS Conference. There, they’ll define and create a roadmap that will determine the direction of the global AIDS response over the next two years. We know that the strategy of Treatment as Prevention (TasP) will play a key role in conference discussions — with over 8 million people around the world now accessing HIV treatment, there’s no question that the rapid expansion of treatment coverage can play a critical role in further decreasing morbidity and mortality, as well as in markedly curbing the spread of HIV.
How? Well, while a vaccine and a cure remain elusive, HIV treatment plays an essential role in reducing AIDS incidence and HIV and AIDS related deaths. Given that treatment markedly decreases HIV presence in biological fluids, it also lowers the likelihood of HIV transmission. This means that for people living with HIV, HIV treatments stop the virus from eroding their immune system and stop disease progression to AIDS, therefore extending their life expectancy, and decreasing the likelihood of HIV transmission.
Since 1996 in British Columbia, we have been able to carefully document the impact of progressive expansions of HIV treatment coverage. Our experience serves as a witness of the power of TasP in preventing morbidity, mortality and transmission. In brief, we have found that by expanding access to HIV testing and treatment we have driven new AIDS diagnoses to a record low, currently over 85% lower than in 1996. Similarly, all cause mortality among people living with HIV has decreased by over 90% over the same period. And, new HIV diagnoses have also gone down by over 60%. In the early 90’s we used to have about 900 new HIV cases diagnosed every year. Since then the numbers have decreased steadily until in 2011, when we documented less than 300 new HIV cases diagnosed, despite expanded HIV testing efforts and increasing rates of other STIs.
Despite these promising outcomes, it’s imperative to recognize that we can’t expect to effectively move the TasP agenda forward without strong protection against HIV-related criminalization, stigma and discrimination, and human rights protections for people living with HIV and the key populations most affected by it.
One of the reasons why TasP has been so successful in British Columbia is because it’s part of a larger provincial strategy based on a wealth of peer-reviewed research, that has also included the expansion of services for hard-to-reach populations, including opioid substitution therapy, needle exchange, supervised injection sites, and tolerant policies towards sex workers. These initiatives play a critical role in facilitating access to health services by the most vulnerable. As a result, we have shown a marked decrease in HIV and AIDS related morbidity and mortality, as well as HIV transmission, also within people who inject drugs in B.C.
Similar gains are starting to accrue in other jurisdictions that have also embraced TasP as part of the standard of care. Most notably in San Francisco, expanded testing — followed by the immediate offer of HIV treatment — has been associated with noteworthy decreases in community viral load, and declining number of new HIV diagnoses. Other jurisdictions in North America have taken steps in this direction, including initiatives in The Bronx, New York, in Washington, D.C., and more recently in the State of Georgia.
However, we are failing to fully realize the promise of an AIDS-free generation that TasP has to offer because we continue to embrace — even in my own country, Canada, — failing policies, and laws based on ideology, not evidence — a fatal mistake.
We continue to see the criminalization of high-risk populations, including people who use drugs and sex workers. We are seeing an increase in barriers to implementing life-saving harm reduction strategies, like needle exchange and opiate substitution therapies. And we are still seeing firm opposition to an end to the “war on drugs,” despite scientific evidence that it has failed on every level. Without addressing these human rights issues, we are hindering our own progress, and worsening the harm done to populations who need our help the most.
I firmly believe that governments around the world can deliver on an AIDS-free generation. However, in order to do so we need to stop the hypocrisy: world leaders continually promising universal access to HIV treatment, care and prevention, but refuse to fund the very agencies that are responsible for delivering on their promise. Furthermore, we should all recognize that our investment will be fruitless if we fail to support strong human rights protections for people living with HIV and marginalized populations, to ensure that stigma, discrimination and criminalization don’t preclude those with the greatest need from accessing our services, for their individual benefit and for the collective benefit of our societies.
The global AIDS response is at a tipping point. We know what needs to be done, and The Washington D.C. Declaration provides the road map. I urge world leaders, the scientific community, those living with HIV, and the society at large, to sign on to this important document. If we implement The Washington D.C. Declaration, this could be the beginning of the end of HIV. Failing to do so would be unforgivable.
As thousands gather in Washington, the question will be heard again and again: What needs to be done to move the TasP agenda forward and curb the HIV pandemic? The answer is simple: We need to support the implementation of evidence-based health policy and effectively address the needs of communities infected and affected by HIV. We need to fully embrace the Washington DC declaration. Only then can we truly turn the tide together.
Dr. Julio Montaner is the Director of the British Columbia Centre for Excellence in HIV/AIDS, the Chair in AIDS Research and Head of Division of AIDS in the Faculty of Medicine at UBC, and the Past-President of the International AIDS Society (IAS).