The End Of AIDS?
What the hell is HAART, you ask?
Well, in B.C. it’s been a game-changer in the fight against HIV/AIDS in the Downtown Eastside of Vancouver, and Prince George as well. It’s stemming complications and death in patients with HIV/AIDS, preventing the number of new infections and offering a long, normal life for many patients diagnosed with HIV/AIDS.
It’s Highly Active Antiretroviral Therapy (HAART) — and as treatment and prevention, it might be the closest thing we have to a cure for AIDS. Typically, it involves a “cocktail” of three to four different kinds of drugs that reduce the reproduction of HIV and bolster the immune system.
Clinicians have been offering it for more than a decade in Saskatchewan, but our province still has the highest rate of new diagnoses in Canada. When Saskatchewan Health released its HIV Strategy 2010-2014, it was “estimated there [were] over 1,400 people living with HIV in Saskatchewan.” Statistics suggest that new diagnoses of HIV are rising fastest in Saskatchewan.
When we’re closer than we have ever been to imagining an AIDS-free generation, why do we seem to be regressing on such a massive scale here at home?
On Nov. 30th, the government of British Columbia announced that their Seek and Treat for Optimal Protection (STOP HIV/AIDS) pilot program would be expanded and adopted province-wide, beginning in April 2013, with a $19-million commitment on top of the initial project’s $48-million cost. In addition to the standard prevention programs, such as encouraging condom use and behavioural changes, the program aggressively promotes testing for HIV.
The STOP strategy adopted in BC also promotes expanded access to HAART. That’s because, according to Julio Montaner and his team of researchers at the British Columbia Centre for Excellence in HIV/AIDS (BC-CfE), getting people diagnosed early and on HAART reduces the amount of detectable HIV in blood and bodily fluid, and therefore “markedly reduces the likelihood of transmission.”
Ultimately, testing, diagnosing and getting HAART to those who need it — for free — would be a cost-averting win-win, since it would “virtually eliminate HIV transmission by all routes,” says the BC-CfE. HIV/AIDS-related morbidity and mortality have decreased by over 90 per cent since 1996, as a result of the use of HAART, the BC-CfE reports. Over the same period, new HIV infections per year in British Columbia decreased by two-thirds, from 900 in the mid-1990s to 289 in 2011.
So, in the midst of these landmark victories, what makes Saskatchewan such a statistical anomaly? As of 2008, this province has a rate of 19 new infections per 100,000 people — the highest in the country.
Saskatchewan Health acknowledges that “surveillance and research,” including increased access to testing, are essential to the provincial HIV Strategy 2010-2014. According to the Strategy, “a person who has HIV and who is treated consistently with HAART and who establishes other health and social stability can live a normal life with negligible risk of transmission. As a result, the cost to the individual, to society and to the health care system is minimized.”
However, Kurt Williams, who specializes in infectious diseases such as HIV, and treats patients at the Saskatoon Health Region’s LiveWell Positive Living Program, says also that “We haven’t articulated the seek and treat strategy. We are advisors to the government, so I think we have to talk to government before we do that.”
Secondly, we need to put Saskatchewan demographics into context, he says.
“We have different populations, so the problems we face are different than the ones they face in B.C.,” explains Williams. “We’ve always had different epidemiology than B.C. Saskatchewan has always had a slight overrepresentation of aboriginal folks, First Nations people, and Métis — 70 to 80 per cent of new cases — whereas BC is a predominantly white demographic,” he says. One might characterize numbers like “70 to 80 per cent of new cases” as a tad more than a “slight overrepresentation,” but still.
As well, a huge number of patients dealing with HIV infection in Saskatchewan are “spread all over the map,” he says. “It’s a big problem in isolated places, and a big problem up north. In comparison, most of the Seek and Treat [in B.C.] has been done in specific, dense urban populations.”
All of this means that in some cases, we need to take a totally different approach to care and treatment than clinicians in B.C.
“If you’re looking at the provincial adoption of such a [Seek and Treat] plan, there can be mistrust of medical professionals. It’s going to be important to introduce this in a way that doesn’t offend people or stigmatize a particular group. We need appropriate consultation prior to implementing that as well,” says Williams.
Strong, local leaders working as advocates for good treatment are absolutely essential, too. “Sometimes we are asked by northern communities to come in and ‘seek and treat.’ If the desire comes from the community, it can work,” he says.
When it comes to HIV, numbers can also be misleading. Considering the high number of cases that remain undiagnosed (and therefore become the greatest public health risk), and given the number of positive initiatives that Saskatchewan Health and the Saskatoon Health Region (as well as AIDS Saskatoon’s Outreach Centre) have been implementing, it could be that the rising rate of new diagnoses indicates that we’re doing a better job of seeking out those who are affected, rather than simply letting things get out of control.
“I think it’s a little bit of both. Certainly there’s been a well-articulated and deliberate attempt to test more people, particularly in identified risk groups. But we’re also seeing a real increase in the number of infections. When we test and find a positive, we rarely know whether this is a new positive, or this is someone who got the disease ten years ago,” says Williams. (The only case in which health care workers can be reasonably sure they are diagnosing a new infection is when they are looking at prison data, since inmates get tested when they enter a facility.)
We can certainly be optimistic when we consider all of the advances in treatment available to those with HIV/AIDS. But how much further do we need to go to end the AIDS epidemic in our lifetime? Williams says he’s watched the medical profession’s approach to HIV change dramatically since he came to Saskatchewan in 1989.
“There’s no doubt that we’re better equipped to handle AIDS than we were in the ‘80s,” he says. At first, the relatively unknown AIDS virus was untreatable. Now, not only are we able to treat HIV/AIDS, effectively prolonging people’s lives by decades, but we can treat people so that they can live relatively normal lives.
“There’s a huge difference between being able to comfort people and being able to add decades to their lives. But, from a physician’s point of view, it’s become a different frustration. Before, we had nothing to offer, but now, we have so much to offer that it’s frustrating to see people not take you up on that. That’s the other complexity to programs that seek and treat — you can’t treat people successfully unless they buy into it.”
Also, HAART can be one of dozens of treatments, so “it’s a matter of finding something that works for the patient,” says Williams.
The more clinicians learn about the effects of treatment, the more it becomes clear that access to treatment is integral.
“Now, we’re offering and pushing treatment for as many people as we can, whether they’re in that critical [stage] or not, because all of those folks, if they’re not being treated, are capable of transmitting HIV. If you let the immune system be suboptimal, in the long term it may lead to more cancer. So what we’re finding now is that even if people are restored to a relatively normal immune system through HAART, their incidence and severity of ‘normal’ cancers like lung cancer and colon cancer are increasing.”
Some have estimated that HAART treatment in Canada costs between $10,000 and $15,000 per year per patient. But many conservative and outdated reports estimate that the cost of treating complications related to untreated HIV/AIDS, and the cost of more infections, is well into $4 billion per year.
“I’m happy to see the sorts of attitudes that are coming out of B.C. To look at this as a public health measure, it’s also important to keep the individual in mind when we’re looking at this as a public health measure. We’re treating people for their benefit, not just the side benefit [of prevention]. Some people are so afraid of spreading it that they cut themselves off from society and ‘hermit’ themselves — but they need to know that in many cases they can live a normal life,” says Williams.
Importantly, the Government of Saskatchewan funds HAART for some of our most vulnerable populations and for people who are on social assistance, “but often it’s the working poor that end up being shafted,” says Williams. Again, as with most public health issues, we end up in a discussion about the social determinants of health, such as homelessness and poverty.
“Here we are, recommending that people take medication for somebody else’s benefit, but [if they] pay up to [their] deductable, then the province pays a portion up to a certain maximum according to their salary — and sometimes, people need to make other choices with how they’re going to spend their money,” including on housing and other essentials, says Williams. “So it’s easy to for us to justify them taking the medications, [but] they often have to make decisions.”
“Before people can concentrate on their health, they need to deal with more pressing issues, which in some cases might be serious addictions. The HIV rate in Saskatchewan is the canary in the coal mine,” he says.