In the three decades I have worked in the field of HIV prevention and treatment, I’ve never seen a breakthrough quite like it.
It’s not a vaccine. It’s not a cure. But it could mean the end of the HIV epidemic as we know it.
The science is simple. When people living with HIV take their medication as prescribed on an ongoing basis, the virus can be suppressed to levels so low that it can no longer be detected in blood tests. And when it’s undetectable, doctors and scientists now agree, it’s intransmissible. Let me repeat that: a person on effective HIV treatment can’t pass it on to a sexual partner.
Ever since the breakthrough of combination antiretroviral therapy was announced at the International AIDS Conference in 1996, we have seen these medications transform the reality of living with HIV. An HIV diagnosis, once considered a death sentence, is now seen by many health-care providers as a chronic, manageable condition. Modern treatments have given people with HIV a new lease on life, and a young Canadian diagnosed with HIV today can expect to live as long as his or her HIV-negative peers, with prompt diagnosis and treatment.
And now we know that these medications have an additional benefit: the partners of those on effective HIV treatment are not at risk of infection. It’s opened up possibilities once considered unthinkable for couples with one HIV-positive and one HIV-negative partner, such as conceiving and having a baby, and sharing intimacy without the fear of passing on a virus. It’s now all possible, if a person living with HIV has access to effective treatment.
These benefits extend to all of us, whether we are living with HIV or not. Mathematical projections have shown that if enough people living with HIV are diagnosed and start treatment by next year, the prevention benefits of treatment could mean the end of the HIV epidemic in just over a decade. This requires three targets to be met by 2020: 90 per cent of HIV-positive people diagnosed, 90 per cent of those diagnosed accessing treatment, and 90 per cent of those on treatment having the virus suppressed (90-90-90).
This is a game-changer, and other countries have already taken advantage. In the United Kingdom, which has an HIV epidemic and health-care system similar to our own, a combination of testing and treatment efforts brought the country above the 90-90-90 threshold one year ago. Even some low- and middle-income countries, including Botswana, Cambodia, Eswatini and Namibia, reached the global targets way ahead of Canada.
Why have we been punching below our weight? HIV treatment works for almost everyone who can access it and takes it as prescribed. In Canada, the two most significant bottlenecks are at the diagnosis stage — first, getting people tested, and then linking those diagnosed with HIV to treatment and care. And these are the most urgent bottlenecks to address, as all HIV infections originate from people who either don’t know they have the virus or aren’t on effective treatment.
Despite the lauded accessibility and universality of Canada’s health-care system, we have many barriers that make it difficult for people to get tested and start treatment. And these obstacles hit hardest the communities most affected by HIV in our country.
While Canadian service providers have developed creative strategies to encourage people to get tested, regulatory hurdles and inertia have slowed the adoption of more innovative and effective technologies and approaches.
Seventy-seven countries have adopted policies that allow for HIV self-testing, meaning a person can administer an HIV test on their own, similar to a home pregnancy test. Health Canada has not yet approved HIV self-testing.
Dried blood-spot testing, another testing approach which has shown promise for rural, remote and Indigenous communities, is only offered for diagnosing HIV in limited settings, such as research projects.
In one piece of good news this year, Health Canada will now allow for rapid finger-stick HIV tests to be administered by non-clinical service providers such as counsellors and peers — but this comes years after other countries made similar tests available over the counter to anyone who wanted them.
Yet by far, the most significant barrier to Canada achieving global targets for HIV epidemic elimination is linking people to treatment once they are diagnosed. According to the latest estimates from the Public Health Agency of Canada, 19 per cent of Canadians diagnosed with HIV are not accessing treatment. Compared to all other G7 countries that have published figures on this measure, Canada ranks last.
What sets us apart? For one, we are the only high-income country in the world with a public health-care system that lacks a country-wide pharmacare program. In some provinces and territories, Canadians without private insurance can access HIV medication through a patchwork of public drug plans and patient assistance programs. But navigating these programs can be a hurdle in itself, and many public drug plans charge premiums, deductibles and co-payments. Canadian case studies have shown that higher co-payments result in fewer prescriptions filled, more hospitalizations, and greater costs to the health-care system.
Expanding our public health-care system to include pharmacare from coast to coast would streamline drug coverage across the country, make prescription medication as accessible as public health-care services, and achieve the buying power and efficiencies necessary to keep out-of-pocket costs to patients low. In Canada, HIV treatment is already offered free of charge in four provinces and two territories, and research from British Columbia has proven that this is cost-effective — thanks to the health-care savings generated from improved quality of life and the prevention of future infections.
But expanding treatment access would not only ensure that Canadians with HIV can live long and healthy lives. Countries like ours — and countries unlike ours — have rolled out free HIV treatment programs at a national level, and they are already seeing significant reductions in new HIV infections.
So with one year left for Canada to catch up to the rest of the world, what are we waiting for?
Laurie Edmiston is executive director of CATIE, Canada’s source for HIV and hepatitis C information.