[溫哥華本地新聞] AIDS: So close to a cure yesterday, research, crowded, office, always

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AIDS: So close to a cure

Vancouver at centre of research as AIDS turned from deadly epidemic to manageable condition
From a crowded office at Vancouver’s St. Paul’s hospital, Dr. Julio Montaner likes to track his progress, and the progress of the disease that for 30 years has been the focus of his life.
Keeping track keeps him optimistic.
“I can always look back and say yesterday we were here and it was bad, but today we are here and it’s better. I can see over there, we are going in the direction of things getting better and better all the time.”
Looking at his graphs, the rising and falling lines, it’s possible to see the transformation of a deadly, out-of-control AIDS epidemic into an illness that can be low-grade, manageable or even eradicated.
Eradication is still a dream but, for the first time since the identification of the HIV in 1983, researchers are guardedly using the word “cure” as if it were no longer a fantasy but a scientific possibility. Recent reports of “functional cures” and controlled remissions have raised much hope.
In May, a story broke that a Mississippi toddler born HIV-infected had been “functionally cured” after being treated aggressively with anti-retroviral therapy immediately after birth.
A group of 14 patients in France, dubbed the Visconti cohort, were “functionally cured” after starting anti-retro viral drugs within 10 weeks of infection, much earlier than when the medication is usually given.
Participants in the study were able to become “post-treatment controllers,” their bodies capable of keeping the virus at bay after coming off treatment, possibly because the virus had been dealt with so early after primary infection.
There is reason for excitement.
Made in Vancouver
Montaner’s strategy of “treatment as prevention,” or “TasP”, is already dramatically reducing levels of new infections.
By aggressively seeking out and treating everyone who is HIV positive with highly active anti-retro viral therapy (HAART), individual viral loads (the level of HIV in the blood) are lowered, transmission drops and the progress of the disease in a community can effectively be curbed or halted.
Montaner announced his research results at the 2006 International AIDS Conference in Toronto and international studies have since independently confirmed them.
“More people are living with the disease and less people getting infected,” said Montaner.
China, the United States, France and Brazil have adopted Montaner’s “treatment as prevention” strategy, which involves expanded testing in the general population, providing affordable or free HIV/AIDS medication, and creating support programs to encourage patients to keep taking them. (In Vancouver, Oak Tree Clinic is piloting an outreach program providing cellphones with free texting service to hard-to-reach women on the Downtown Eastside. Patients can easily ask for help if they need it, and case workers can check to see if they are staying on their drug regimen.)
Research shows that between 1995 and 2008, B.C. averted more cases of HIV than Ontario and Quebec combined and that the $15,600-a-year HAART treatment is much less than the cost of medical management of HIV infection, which averages $425,000 over a lifetime.
Although the cost of antiretroviral therapy drugs is heavily discounted for poor countries, the cost to middle-income countries such as Russia, Armenia and Malaysia is still prohibitive and only eight million of 15 million people who need the treatment are able to receive HAART in resource-limited countries.
Although TasP is endorsed by the World Health Organization guidelines, Canada lags. B.C. is the only province that has adopted the strategy, a situation Montaner has called “an embarrassment.”
Without political will, Montaner argues, an AIDS-free future remains a dream.
Montaner believes stigmas associated with sex, drugs and homosexuality still interfere with the federal government of Canada’s willingness to support the treatment as prevention program: “They have attached a value judgment to HIV that makes it very difficult to have a conversation. If it were breast cancer or a flu epidemic, it would be different.”
Cleaning out the hidden reservoirs of prejudice around the illness has been as difficult as rooting out the virus itself.
Montaner has grappled with the prejudice, discrimination and stigma of AIDS from the beginning.
When the Argentine-born respiratory specialist was a young post-doctoral fellow at St. Paul’s Hospital, reports started showing up about a new disease that was being identified in small groups of mostly young gay men.
“It was happening in California, it was happening on the East Coast and it was happening in Florida. We didn’t know if this was a real issue or some sort of mini-outbreak that was going to go away.”
He pauses.
“Little did I know that it was going to capture the rest of my life.”
In the early months and years, Montaner and other specialists worked hands-on with patients arriving with unusual and devastating life-threatening illnesses: pneumocystis carinii pneumonia, skin rashes, weight loss, cytomegalovirus. Some had been turned away from other hospitals, and sent to St. Paul’s in taxis.
The concentrated streaming of AIDS patients to one Vancouver hospital created a pressurized environment that transformed the Catholic-run hospital, and gave rise to a unique opportunity for study and research.
“At first our staff resented the actions of the other hospitals. But it turned out to be a good thing. It further focused our resolve, our intent, our attention. So HIV became an area of intense focus for us and led to very dramatic discoveries,” said Montaner.

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“It would be easy to write the history as if we were heroes and everyone else were villains. The truth is, we didn’t know what was happening. There was fear. There was concern. A lot of hesitation. For us it was a matter of urgency because it was something that was happening in our own midst. The epicentre of HIV-AIDS was in the West End. We couldn’t walk away from our neighbours.”

Facing down panic

John Ruedy, head of the department of medicine at St. Paul’s from 1978 to 1992, knew almost immediately he faced a growing emergency.

“There was panic throughout the institution, the nursing community, the administration,” he said. “No one knew how contagious this was. The majority of my staff were not very sympathetic to the issue, but there were outstanding exceptions.”

Among those were physician Alistair McLeod, respirologist Lindsay Lawson, nurse Irene Goldstone, hematologist Hilary Wass and gastroenterologist Linda Rabeneck, who formed the first AIDS care team.

The circumstances under which they worked — lack of funds, staff burnout, social stigma — were extreme and challenging. The hospital board was slow to apply for the funding they desperately needed, even as the numbers of patients were doubling every three months, Ruedy recalls.

“The board was very conservative. They didn’t want us to be known as an AIDS hospital.”

The fear was that other patients, the public, doctors, would not want to come to the hospital.

“It was the two nuns on the board that swayed everyone to go to the government and they came up with significant funding.”

When AZT, the first breakthrough drug, appeared in 1987, authorities were slow to approve it and even slower to fund it. Activists like Kevin Brown of the Vancouver Persons With AIDS coalition collected signatures, lobbied and led attention-grabbing protests. To the team at St. Paul’s, it was becoming clear the only way to widen access to drugs was through clinical trials. In 1989, Ruedy began to build the infrastructure of what would become the Canadian HIV Trials network.

Ruedy tapped Montaner to become the head of the new AIDS research program. Montaner accepted.

“I was a department of one,” he recalls.

Montaner wasn’t alone for long. Dr. Michael O’Shaughnessy, who worked for Health Canada in Ottawa and was chairman for the National Advisory Committee on AIDS, moved to Vancouver to help found the B.C. Centre for Excellence in HIV-AIDS in 1992. At that time the stigma around the disease was so great, people would turn away from O’Shaughnessy at cocktail parties when he announced, cheerfully, that he worked with HIV.

“I could clear a room.”

He can reel off stories about literally coming to blows in the hallways of the federal Parliament buildings with bureaucrats trying to block the trickle of money allotted to AIDS research.

“There was a fight over resources. Other branches of government undermined the federal centre for AIDS. … They’ll deny it, but I was there,” said O’Shaughnessy.

Researchers met similar resistance from B.C.’s socially conservative government, O’Shaughnessy recalls.

A near riot had erupted in the legislature over the Vander Zalm government’s announcement that patients would have to pay for AZT themselves, The drug could cost $10,000 a year.

O’Shaughnessy shakes his head in disbelief.

“How can you afford to pay thousands of dollars for a drug when you are so sick you can’t leave your apartment?”

When he joined the B.C. Centre for Excellence, his mandate was “to develop a system to get drugs to the people who needed them — for free.”

The strategy was research: “By setting up a study to measure outcomes, they could give out the drugs for free. That’s how it started.”

Like the AIDS quilts stitched by parents and friends, the Centre for Excellence was, in a way, handmade.

O’Shaughnessy recalls chasing birds out of the sixth floor of St. Paul’s with Montaner, Ruedy, McLeod, Goldstone and Dr. Marty Schector.

“There was nobody on the sixth floor, it was empty and full of crap and garbage.”

In 1992, B.C.’s Social Credit government gave St. Paul’s $1.7 million to establish the B.C. Centre for Excellence in HIV-AIDS. By then, attitudes were changing even among the most rigid conservatives.

“They had families. They had sons,” said O’Shaughnessy. “Behind closed doors, this was affecting everybody.”

Breakthrough

The year 1996 was, said O’Shaughnessy, “the watershed year.” Vancouver hosted the International AIDS conference where Montaner announced the dramatic results of his research: the triple drug therapy that could reduce the viral load in a patient’s blood, and the vital link between a reduced viral load and dramatically improved outcomes.

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“The sense of excitement was absolutely palpable. It was incredible. Within months mortality, death rates and progression to AIDS among people taking triple therapy was down to nothing. This happened in Vancouver,” said Montaner.

It was a fantastic story, but Montaner knew continuous aggressive action would be required to curb the epidemic.

“We had a moral and ethical obligation to bring treatment to the people. We started very aggressive new initiatives to go into the Downtown Eastside to treat people that until then others felt could not be treated; injection drug users, for example.”

Then another miracle. As Montaner and researchers monitored the impact of treatment in the community they saw the rate of new infections coming down.

“It didn’t make sense,” said Montaner.

Wouldn’t more people living with HIV mean more transmission? Montaner realized that because the treatment made bodily fluids free of virus, infection rates were lowered in individuals and in the community.

“Treatment is prevention,” he said.

Lessons learned

“The lesson learned is don’t exclude people,” said O’Shaughnessy. “That’s what happened to gay men. Then we repeated it with addicts. Native women. Native men. Street youth. It was exclusion and marginalization that set up the epidemic and there is no doubt about that. No doubt at all.”

If exclusion and marginalization set up the epidemic, HIV-AIDS still functions as a kind of divining rod that detects social issues that need to be addressed, whether related to sexuality or socio-economic status.

In B.C., HAART is free. In Ontario and Quebec, it is funded through both public and private insurance and access across Canada may vary according to socio-economic status.

Treatment or Cure

For O’Shaughnessy, the toll was intensely personal.

“My personal toll was my family. I was never there. Would I change it? I can’t. It was a good thing to do. I got a lot of knife wounds in the back, and lots of problems but I wouldn’t change it. We saved lives.”

He credits the activists.

“Gay men and addicts and natives and women were treated so poorly, but they said this isn’t right. And they changed things. They moved the agenda forward.”

If there is one lesson he has for young investigators and researchers: “When you think you know what you have to do, when your compass is telling you must do this, well damn it, just do it. Have the balls to do it.”

It’s personal for Montaner, too. From the start, he has been emotionally involved.

“When you deal day by day with patients that are so willing to take all the steps to deal with a disease that is so devastating, it’s a tremendous source of inspiration and energy and stamina.”

For Montaner, the battle to bring treatment to everyone, no matter their economic status, citizenship or lifestyle is both moral and ethical.

“All HIV does is bring the focus of light into the most needy populations so HIV forces us to deal with it,” he said, quoting Jonathan Mann, the late American physician whose efforts through the World Health Organization reframed the international AIDS crisis as a global human rights epidemic.

Montaner continues to be an outspoken advocate for those infected with HIV-AIDS around the world, and has called the Canadian government’s low funding of HIV-AIDS research, criminalization of intravenous drug users and lack of funding for global treatment “criminal neglect.”

And he’s nowhere near stopping.

“For HIV, you need to be very focused and you need to stay with it and you need to be able to bring people’s attention to it even when you are succeeding.”

Montaner can see the future, because he has seen the past. He was there when life expectancy after diagnosis was five to six months. A 20-year-old diagnosed today who receives and sticks to treatment can expect to live until age 73.

“What I can offer my children and the next generation is that if we continue to do what we’re doing, we can prevent morbidity, mortality and transmission by 90 per cent so it is a virtually AIDS-free world.”

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Dr. Julio Montaner, working in his office at St. Paul’s Hospital, has devoted nearly 30 years to AIDS research.