Ending AIDS as a pandemic is very possible and can be done using our made-in-Canada Treatment as Prevention (TasP) strategy, a disease elimination strategy pioneered by the BC Centre for Excellence in HIV/AIDS (BC-CfE). UNAIDS has embraced the ambitious goal of ending the AIDS by 2030, and this has now been formally endorsed within the United Nation's Sustainable Development Goals agenda. On World AIDS Day, UNAIDS will be calling for the world to achieve: "Zero new HIV infections. Zero discrimination. Zero AIDS-related deaths."
In October of this year, The Economist stated, when it comes to targeted disease elimination, "the biggest prize might be AIDS itself." AIDS, the disease caused by HIV, meets the criteria for disease elimination in an infectious illness reliant on human-to-human transmission:
1. An effective intervention is available, in the form of highly active antiretroviral therapy (HAART);
2. There is wide scientific consensus that immediate use of HAART following HIV infection prevents disease progression to AIDS and premature death and, secondarily, virtually abolishes the chances of forward transmission of the virus;
3. There is global normative consensus recommending widespread HIV testing and immediate offer of HAART to those who are HIV infected; and
4. There is a sound roadmap to meet this goal, namely the UN 90-90-90 Target, which proposes by 2020 at least 90 per cent of people living with HIV globally should be aware of their infection, at least 90 per cent of them should have access to high quality HAART regimens, and at least 90 per cent of them should achieve sustainable suppression of their HIV infection, and in so doing, by 2030, will lead to a 90 per cent decrease in AIDS morbidity and mortality, as well as HIV incidence globally.
Over the last decade with the implementation of TasP in BC, with the unwavering support of the provincial government, the number of AIDS-related deaths has dropped by over 80 per cent and the number of new HIV cases has dropped by over 65 per cent. This has been unprecedented within Canada, where HIV and AIDS remain far from controlled.
Moreover, investing in a TasP strategy and it's related 90-90-90 Target drives better individual outcomes, better public health outcomes and promotes health care sustainability. According to research from the BC-CfE, over the next 25 years, the implementation of TasP in BC will save over $65 million. Similarly, implementing the strategy in South Africa would save up to 5.5 million lives and US$28.7 billion within forty years. And the return on the investment becomes very attractive, very quickly, as UNAIDS predicts a 15-fold return on the investment over five years.
Expanding treatment broadly, including hard-to-reach and often-stigmatized populations such as injection drug users, creates a more efficient, less-siloed approach to health care. It also helps to reduce discrimination. A concerted approach to meeting the needs of hard-to-reach populations, such as injection drug users, has proven markedly effective in reducing the impact of HIV and AIDS in BC. With the use of aggressive harm reduction strategies - including the expansion of needle exchange, opioid substitution therapy, observed therapy programs, peer navigators, medicalized heroin, and supervised injection sites to support the expansion of HIV testing and HAART access in this community - the province has seen a nearly 90 per cent decrease in AIDS morbidity and mortality, and HIV incidence among this group.
Further, the fundamentals behind the TasP strategy, as part of a disease elimination strategy, can be applied to other infectious diseases, including Hepatitis C Virus (HCV). Globally, approximately 200 million people (about three per cent of the world population) are currently infected with HCV, including about 240,000 in Canada. In 2012 there were over 10,000 new cases of HCV reported in Canada and it has been estimated over 40 per cent of people living with chronic HCV are unaware they are living with the virus. We need to urgently deploy a widespread HCV testing campaign across Canada and facilitate access to lifesaving therapy. As the HIV TasP strategy demonstrates, the approach of saving money by restricting access to HCV testing and treatment is draconian, short-sighted and counterproductive.
With the recent return of a federal Liberal government to science and evidence-based policymaking, Canada has a unique opportunity to reclaim a leadership role it relinquished almost a decade ago. Central to this would be to implement TasP and adopt the UN 90-90-90 Target as a national HIV/AIDS strategy.
Next, the new federal government should endorse and champion the UNAIDS campaign to have this made-in-BC, Canada, strategy adopted globally. This represents a unique opportunity for our country to take much deserved credit for a major global health care contribution.
However, this is not just about testing or making treatment available to those in need. For almost a decade, Canada has inappropriately dealt with most at-risk populations, including: marginalizing commercial sex workers, preventing the establishment of supervised injection facilities, criminalizing drug possession, and criminalizing HIV exposure (even in the absence of HIV transmission or even HIV transmission risk). It is time for the laws of this land to be revised in order to work in synergy with, rather than against, public health efforts. We trust this is high on the agenda of the newly installed Trudeau government.
This World AIDS Day we welcome a new era of evidence-based decision-making at the federal level. This will serve to deliver on the promise of ending AIDS within our generation. We have the means, and we have the road map, we just need the political will. The time is now: Canada is back in the business of defeating AIDS domestically, and providing global leadership to end AIDS by 2030.
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