October 13, 2020 – 10am – Dr. Julio Montaner, “Towards the end of HIV/AIDS: Fact or Fiction”- ZOOM

Dr. Julio Montaner, Prof. UBC Director BC Centre for Excellence in HIV/AIDS

Dr. Julio Montaner is a founding Co-Director of the Canadian HIV Trials Network.  He is the Executive Director and Physician-in-Chief of the BC Centre for Excellence in HIV/AIDS, Professor of Medicine and Chair in AIDS Research at UBC, and Past-President of the International AIDS SOCIETY. He was the founding head of the Division of AIDS for a decade in the Department of Medicine at UBC (2007-2017).

Dr. Montaner has authored over 850 scientific publications on HIV/AIDS. In 2010, he was chosen as the winner of the “Albert Einstein” World Award of Science for his relentless advancements in the treatment and prevention of HIV/AIDS since the early 1980’s. Dr. Montaner and his team at UBC, have pioneered the advancement of prevention of this dangerous disease, and saved countless lives worldwide.

In December 2014, Dr. Montaner was appointed to the Order of Canada, in recognition of his contributions to establishing the global standards of care for HIV/AIDS treatment and prevention, and for his leadership in the international HIV/AIDS community.

Summary of Dr. Montaner presentation.

Back in the ’80s, a positive HIV diagnosis was considered a death sentence. It’s thanks to the research and dedication of hard-working people like Dr. Julio Montaner that with treatment, patients can now live long and happy lives with the disease. Furthermore, his strategizing and campaign work has reduced transmission rates globally.

Dr. Montaner’s medical career started in pulmonary medicine. He began working with AIDS patients suffering from Pneumocystis carinii, a type of pneumonia common with the disease. Through adjunctive therapy with corticosteroids, his team was able to transform a rapidly lethal form of pneumonia to something that could be treated. With additional research and new antibiotics, Pneumocystis carinii was effectively prevented and eventually almost eradicated. This treatment has also now been shown to be effective in treating COVID-19 as well.

Unfortunately, treating the pneumonia didn’t change the outcome for people with HIV in a significant manner. The underlying defects persisted and people would often go on to succumb to other complications brought on by the disease. In the mid-’80s, Dr. Montaner shifted his focus onto working to treat the other complications brought on by HIV-AIDS. In 1995, Dr. Montaner combined several drugs that had mixed reports (AZT, ddI, and NVP) to propose a triple-drug combination. Nevirapine was effective in treating HIV initially but lead to rapid drug resistance. Inspired by his dad’s work in anti-TB drugs, Dr. Montaner rationalized combining the three drugs would curtail the issue of drug resistance. This treatment resulted in nearly full-suppression of the disease, leading to almost undetectable levels of the virus, which in turn prevented disease progression and prolonged survival.

The new Highly Active Antiretroviral Therapy (HAART) development was announced to the world at the 1996 Vancouver One World One Hope Conference. By making the treatment available to anyone infected with HIV, the number of deaths from the disease decreased significantly. The BC government was supportive at every step in ensuring that the drug was made available and free of cost to anyone who was HIV positive. This was critical to the treatment’s success.

In their continued efforts to bring treatment to people in need, Dr. Montaner’s team discovered a new and unexpected dimension to the treatment results. Despite the fact that more people were living with HIV, the rate of new infections in the province actually decreased. At the same time, the rates of Syphilis were increasing. The team discovered that HAART was rendering people infected with HIV with an undetectable viral load noninfectious. This was highly controversial at the time. However, Dr. Montaner’s team pushed to use this discovery as a case for expanding the use of the therapy and making the drug available freely to curb the growth of the epidemic internationally. This culminated in the U = U campaign. Undetectable = Untransmittable. Now, every single health agency around the world has endorsed this campaign. With the support of some key advocates, access to treatment rapidly expanded. However, in 2000 anxiety about the potential side effects of the medication including the costs and complexities of life-long treatment was creeping in. This prompted Dr. Montaner’s team to launch a campaign to further expand access to treatment. This campaign applied a lens of Treatment as Prevention and argued that society couldn’t afford to not make access to HAART free. Expanding treatment and support to everyone who needs it, actually saves money, saves lives, and improves public health. For example, by expanding free access to HAART for every person in South Africa that was HIV positive in 2010, 5.5 million lives would be saved and there would be an overall savings of $28.7 billion USD by 2050. The treatment as prevention strategy is now being expanded to many other diseases including Hepatitis C, Type II Diabetes, COPD, and even addiction to substance use in the Downtown Eastside.

In 2010, Dr. Montaner was invited to join efforts with the United Nations AIDS program as a special advisor. He was given the task of developing the new ambitious treatment target for the world with the aim of writing the final chapter of the AIDS epidemic. Along with his team, Dr. Montaner developed the 90-90- 90 model to decrease the overall disease burden by 90% from the global 2010 levels. This model entails that by 2020, 90% of all people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy and, 90% of all people receiving antiretroviral therapy will have viral suppression. This model suggested that achieving these targets by 2020 would enable the world to end the AIDS epidemic by 2030, which in turn will generate profound health and economic benefits. Eventually, the 90-90-90 target was adapted it into the Sustainable Development Goals as a formal target.

In December 2019, Adrian Dix formally announced the end of AIDS as an epidemic in BC. While HIV still exists in the province, there is a limited entry of new cases, and morbidity and mortality caused by the disease can be predominately controlled. However, with the onset of COVID-19, testing levels have decreased significantly. And it is uncertain as to what this reduced amount of testing will have on the results of the campaign. While BC is approaching the 90-90-90 goal, UNAIDS released a report indicating that the global efforts are off-target. At the end of the day, healthcare sustainability is a major concern for Canadians across the country. More needs to be done to ensure that the sustainability of our healthcare is optimized. Treatment as presentation and targeted disease elimination for diseases, infectious or not in nature, play a key role in ensuring the long term success of our country both on a public health and economic level.

Dr. Robert Baird thanked Dr. Montaner for his excellent and informative presentation.

Q & A session

Question: How can your strategies be applied to the COVID-19 pandemic?

Answer: Well actually it is totally doable. The essence of our strategy is to seek, test, treat, and retain. STTR. And what that means is that we need to go there and first and foremost identify people who are at risk for the condition, so that we can offer widespread testing so we can identify the individuals that are infected, and then optimize their management with whatever tool we have available. In doing so, we decrease the likelihood of them progressing to disease, premature death, and transmission.

So what I would say for COVID-19, is that all of the elements are there. We know that there are populations that are more susceptible for socio-demographic reasons, etc.

So the immediate priority should be to deploy aggressive and frequent testing to those populations, so that the positive can be managed optimally. Meaning, either isolate if they’re asymptomatic or treating them with the appropriate therapies that we now have available. Remdesivir, Corticosteroids, and others that may come down the road. In doing so, an infected individual who is unaware of his or her infection is more likely to expose others because they simply won’t know. For as long as asymptomatic individuals are not aware of the infection then we have a problem. I would tend to like a more aggressive approach with regard to testing. I think that we are not really deploying testing to the extent that it should be encourage and unfortunately, this is a movie that I’ve seen before. When we started our efforts for treatment through prevention, partners across the spectrum from the ministry to other agencies would tell me that expanding testing was not affordable. I think I’ve shown you now that the data suggests that not expanding testing is something that we cannot afford because that’s the driver of transmission.

The same thing applies to COVID-19 so I am, like many other of my colleagues, extremely disappointed. How come six months into this pandemic, we are still uncertain as to what our testing strategy should be and rather than liberalizing testing, we seem to be constraining testing? Now, you see these messages going one way and the other way from one day to the next, that’s something that I find very problematic.

The other thing that we have learned from HIV treatment prevention campaigns is that there are tools that we can use to be more specific as to how we deploy our resources. I did not address that in the presentation today, but I’ll point to it very briefly. HIV is a virus. As part of our effort to diagnose the virus, we can quantify the virus and optimize the treatment that we offer people with HIV. We do genetic fingerprinting of the virus because that’s going to determine what treatments are more appropriate for that individual. We’re not quite there for COVID-19, but what we do know is that that fingerprinting can be done for COVID-19, and in fact, we do it frequently as part of our diagnostic testing in British Columbia in any case. Using that fingerprinting you can actually map the virus from various people in your community and identify where those viruses may be linked genetically to a cluster. You may notice that there has been some back and forth regarding contact tracing and for example, Ontario recently admitted that they had to abandon contact tracing because they have no capacity to accommodate it. Well, we have actually offered the province of Ontario to do genetic fingerprinting for the virus so that they could optimize the contact tracing resources. In other words, doing contact tracing on individuals that have isolated viruses will have a very low yield because there is no evidence of cluster development around those individuals, but if you find 3-5 more individuals that are related to a cluster, you know you had to do contact tracing in that setting, even if it was not readily apparent when you looked at the social demographic for that group. We are at the cusp of implementing such contact tracing in the province of British Columbia and again, this is part of the stuff that we have learned from our HIV work.

 

Question: Creating a vaccine for HIV has been difficult. Is it going to be difficult to create a vaccine for HIV or COVID-19?

Answer: For HIV the answer is yes, I hope so, but not yet.  And as you have all witnessed, four decades into the epidemic, it’s pretty regular that every so often we get a vaccine-related announcement, a quasi-breakthrough, but unfortunately, we have not yet quite been able to arrive to ultimate success. And so we don’t have a vaccine for HIV. Neither a fully preventive vaccine nor a vaccine-like strategy that could cause a change in the core of the trajectory of the disease. Those efforts continue. That should keep us humble. As you know, overnight Johnson & Johnson interrupted their COVID-19 vaccine, they paused their vaccine trial because of the one incident of unexpected disease in a participant. Of course, it’s not clear if that was related to the vaccine or not, but while we are all optimistic that there will be a vaccine for COVID-19, and certainly the preliminary data looks very promising,

I think that testing and treating option that I outlined should be deployed regardless. In fact, even when we have a vaccine, because these elements will be complementary, synergistic, rather than antagonistic, and at the end of the day, let me remind you that if we had a vaccine today experts suggest that it would take in the order of two to four years, under the best circumstances, to reach global coverage that will be sufficient to limit the ongoing spread of COVID-19. Because at the end of the day, it doesn’t matter if we vaccinate everybody in British Columbia, if Alberta and Washington State are not vaccinated, we are in trouble just the same. So we need to be extremely careful how we proceed as we make assumptions regarding the potential contribution that a vaccine can have.

On that note, a comment here has been made regarding the fact that a prior speaker indicated that there is no precedent for a Coronavirus vaccine, which is true. And in fact, there is not even a clear understanding that post-COVID-19 disease now, individuals have lasting immunity. So all of that is up for grabs. It doesn’t mean that a vaccine cannot be more effective than the disease itself to produce reliable lasting immunity and there are certainly different kinds of immunity. Humoral immunity or cellular immunity that may play a role. So, the jury’s still out. We need to be, as I said earlier, humble about this and recognize that unfortunately, we don’t know what we don’t know yet. There are many questions that remain to be answered. And for that reason, it’s more urgent now than ever that we do not dismiss the strategies that we know are available and can work, namely testing and treating or management of individuals that are positive because that can decrease the burden of disease very quickly in quite a short order.

 


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