Ottawa shunning B.C. lead on AIDS

Katherine Dedyna,  Times Colonist

B.C.’s successful policies for fighting HIV/AIDs are increasingly being adopted by other countries, but not by the Canadian government, says the director for the B.C. Centre for Excellence in HIV/AIDS.

Dr. Julio Montaner credits “unwavering support” by the B.C. Ministry of Health in seeing the provincial infection rate drop far below the national average. But he said that even as a special AIDS adviser to the United Nations, he can’t get Ottawa to adopt the strategies that made it happen.

A federal spokesman responded that the government supports the principles of B.C.’s plan, but that health care is primarily a provincial responsibility.

The UNAIDS 90-90-90 treatment targets — referring to the percentage of HIV cases diagnosed, treated and achieving no virus in the bloodstream — are aimed at rendering HIV/AIDS “a sporadic disease by 2030,” according to the centre.

They are based on B.C.’s Treatment as Prevention policy, which seeks to ensure 90 per cent of HIV cases are diagnosed by 2020; 90 per cent of patients have access to free, high-quality treatment; and at least 90 per cent of patients are virally suppressed by 2020.

Panama adopted 90-90-90 on June 29. China, France, Brazil, Spain, Argentina, Swaziland and U.S. have already adopted Treatment as Prevention, the centre notes, and San Francisco, New York City and Washington, D.C., have also signed on.

Montaner, a professor of medicine, helped pioneered HAART — Highly Active Antiretroviral Therapy — which costs $15,000 per patient annually but is provided free of charge to B.C. patients at a cost of $100 million per year.

He said that Ottawa has allowed the standard of care for testing and treatment to vary widely across the country. “Furthermore, they have allowed some provinces to charge HIV-infected patients for co-payments to access therapy, which is a proven barrier to treatment.” B.C.’s policy is to diagnose and treat HIV without charge to stop transmission.

“In the event of a major catastrophe that affects the whole country, you expect the feds to take a leadership position,” Montaner said. “In HIV/AIDS, they have been missing in action. This is despite the fact that the epidemic is disproportionately affecting First Nations in Canada, an area of their direct responsibility.”

Eric Morrisette of Health Canada said that decisions on HIV/AIDS strategy are “most appropriately based” on each province or territory’s unique pattern of disease, but that Ottawa will continue to examine and share emerging evidence on promising interventions.

In Saskatchewan, Ottawa provided technical support to help investigate the way HIV/AIDS is spreading, Morrisette said.

Montaner calls on Ottawa to enact a national policy, which in turn would set the standards of care.

“If this was anything but HIV and AIDS, they would be all over this strategy,” he said, calling the fallback on health as a provincial jurisdiction “BS.”

“When SARS came out, the PM was all over the place,” he said. “There were no cases of Ebola, but Ottawa had a national strategy.

“So I want to ask Mr. Harper, why doesn’t he go on prime-time television and take the test for HIV to show the public that we should all be tested for HIV?”

Instead, the federal government views injection-drug users and sex workers as enablers of the epidemic instead of people caught in an urgent public health issue across Canada, he said. Ottawa is “interfering with our ability to engage the most vulnerable people because they are so focused on their pursuit of their law and order agenda,” he said.

“I want a standard of care to be set,” he said.

B.C.’s work has shown that more money invested up front saves money in a reasonable amount of time, Montaner said.

A person whose HIV becomes full-blown AIDS can incur up to $750,000 in care costs over a lifetime, but early treatment, at $15,000 a year, can grant that person a productive lifetime and prevent transmission. “And when you eliminate new infections, the return on investment grows exponentially.”

He can’t tell Ottawa what to do with its money, but he asks why there are national strategies for flu and SARS and not for HIV.

“Why are they picking and choosing their winners?”


If Ottawa officially supported 90-90-90, would it mean automatic enforcement by all provinces.

“We will cross that bridge when we have to,” Montaner said. “But the fact that there is no federal leadership makes it even more difficult to have the conversation across the land.”

He said he has met with two provincial ministers of health other than B.C.’s Terry Lake, but it’s a national epidemic that requires national leadership, he said.

“Imagine tomorrow we have Ebola outbreaks in seven cities across Canada,” Montaner said. “Would the feds say it is provincial responsibility? Even if they were not to pay for it, they would set the standard by which everyone would be expected to control the outbreak.”

Morrisette said that Health Canada has been “working very closely” with Saskatchewan, where the majority of new cases are among aboriginal people.

Montaner cited several ways that he said illustrate that Ottawa is interfering with public health efforts.

“They are using procedural steps to stop supervised injecting facilities from opening and discouraging harm-reduction initiatives across the country. They are going out of their way to criminalize commercial sex workers or their patrons, and in doing so making it harder for us to bring services to these communities.

“They have failed to pass legislation to protect against stigma and discrimination of key affected populations and those infected with HIV. They withdraw services from immigrants which are disproportionately at risk or affected. They have failed to pass legislation to ensure that trivial [non-infectious] exposure to HIV is not criminalized.”

“At the international level, they have failed to embrace the made-in-B.C. Treatment as Prevention strategy that has now become the standard of care around the world.”

Following the Panama sign-on, Montaner said he has yet to make contact with federal Health Minister Rona Ambrose or her representatives regarding the strategy.

Montaner said he believes that Conservative politicians are sacrificing public health to social prejudices.

“They view the work that we do as facilitating or promoting conduct that they feel are responsible for the epidemic,” he said.

Prevention strategies for men having sex with men, commercial sex workers and injection-drug users — such as Vancouver’s Insite that battles strong Conservative opposition — are necessary to reduce the risks of transmission, he said. But all adults need to be tested for HIV because up to 20 per cent of people do not know they have it and can transmit it, he said.

“B.C. had the worst epidemic in the country in the 1980s and ’90s and since then, today we are happy to report that we are way below the average,” Montaner said.

“I have literally written a letter since 2006 to the [federal] minister of health once a year where I outline the progress that we have made (in B.C.) and requesting a conversation with them regarding these issues,” Montaner said. “And to be honest with you, this has not happened.”

Morrisette responded that Canada’s chief public health officer has met with Montaner and his team several times and facilitated presentations to the Council of Chief Medical Officers of Health.

Victoria MLA Murray Rankin, NDP Opposition health critic, called on Ottawa to go further.

“I would urge the federal government to adopt this ambitious strategy and work with the provinces to do all we can to prevent and treat HIV/AIDS,” Rankin said in a statement.

Morrisette said that the Canadian government supports the principles of the Treatment as Prevention approach, which include improved access to testing, treatment and support, as well as continuity of care.

“We are following with interest the implementation of the Treatment as Prevention approach in British Columbia.” Montaner disagreed.

Ottawa is not on side in principle, despite official statements to that effect, he said.

“Ottawa sits on the side. They don’t make any commitment and they are not accountable.”

Ottawa told him it would not send a representative to the formal endorsement of 90-90-90 by the UN secretary general last Sept. 25, but noted it would not object.

“[U.S. Secretary of State] John Kerry himself stood up to formally endorse the proposal on behalf of the United States, and it was endorsed immediately after by President [Jacob] Zuma of South Africa,” Montaner said.

In December 2014, Morrisette said, a representative of Foreign Affairs, Trade and Development Canada attended the UNAIDS Program Co-ordinating Board meeting and endorsed the principles behind the 90-90-90 global treatment targets.

Ottawa’s public health agency is exploring “the potential work to develop national indicators and methods,” he said.

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