Photo by John Donne
Deep inside the maze of offices in the West End’s St. Paul’s Hospital, Julio Montaner has been leading a global revolution to stop the spread of HIV/AIDS. For the past four decades, the Argentinian-born doctor has been at the forefront of finding treatments for the infected and reaching others before they suffer the same fate.
Having helped create the world’s most effective HIV treatment therapy and spearheaded a campaign for point-of-care testing for at-risk groups, Montaner’s research has helped save countless lives, from Vancouver's Downtown Eastside to sub-Sahara Africa.
The director of the British Columbia Centre for Excellence in HIV/AIDS and past-president of the International AIDS Society, Montaner has been well recognized for his work—most recently, he was awarded the prestigious Albert Einstein World Award of Science. He is now pushing countries to adopt the Vienna Declaration, which calls on governments around the world to decriminalize drug users and remove barriers to effective HIV prevention, treatment and care.
But despite his many accomplishments, the extremely passionate and vocal Montaner has been involved in a long-running feud with Prime Minister Stephen Harper’s Conservative government over the fate of Vancouver’s safe-injection site, its decision to expand jail cells and the lack of funding to tackle the disease.
Montaner recently sat down with Megaphone in his small St. Paul’s Hospital office and discussd the purpose of the Vienna Declaration, his fight to help the Downtown Eastside control its HIV/AIDS rates, and how Canada and the world needs to refocus its energy on HIV treatment before the crisis spirals out of control.
Megaphone: Vancouver city council recently endorsed the Vienna Declaration. What do you think that means for the city?
Julio Montaner: Vancouver has been at the forefront of trying to develop evidence-based policies to help us to deal with the drug addiction problem and HIV, so I think it’s only a natural development that city council made a clear statement where their heart and their brains lie.
I contrast that with the attitude of the federal government, which, in my opinion, is highly neglectful, irresponsible, dogmatic and trenchant on hypocritical principles that are not supported by evidence. The same day that we launched the Vienna Declaration, we received a letter from the Ministry of Health saying they are not even prepared to consider the Declaration because it did not meet the guidelines of the government. For [the federal government] to tell me that we’re not embracing it because it doesn’t fit our policies, well that’s exactly the reason why we’re having this discussion.
Having said so, Toronto, Victoria and Vancouver have endorsed the Declaration, which are [cities] in direct contact with the consequences of drug addiction and everything that contributes to the crisis that we have in the inner cities. Our ivory tower politicians, who are up in the sky and not even aware of what the realities are like on the front lines, have no difficulty telling you they are not interested because they have no idea what they are talking about.
MP: There is a great deal of support from the city, the province and even the local police for Vancouver’s safe injection site, Insite, and yet the federal government is still pursuing the case in the Supreme Court to have it shut down. What impact do you think it would have in Vancouver if it did get shut down?
JM: It would be beyond my ability to comprehend how anybody in his or her right mind would choose to defy the evidence and ask for the closure of Insite. I don’t think for a moment that the local authorities, the provincial authorities or the medical community will be willing to support a recommendation from the federal government to close the site. You know, we have had unanimous support from professionals at all levels of the health care spectrum throughout the country [and] the support of every Liberal government within the province of British Columbia. I had repeated discussions with the Premier, with the [provincial] Minister of Health, the mayor, all of who repeatedly have encouraged us to continue the fight to do the right thing based on the evidence.
Never have the representatives of the federal government been able to point out [any] true evidence demonstrating the harms of the site or demonstrating the ill effects of the site. They have based their assertions on ill-conceived third-party reports that were generated through fraudulent action of individuals within the RCMP.
We need more of these sites in Vancouver, in British Columbia, in the rest of the country, and only when we do that are we going to be able to harness a full potential of action for the benefit of those infected, for the benefit of those at risk and for the benefit of the community at large.
Photo by John Donne
MP: Suppose there was an order to close the site. Would you recommend that people ignore that order?
JM: I don’t discount the possibility of civil disobedience at a large scale if there was an attempt from anybody to close Insite at anytime in the near future. I don’t want to say that I’m promoting it or that I am recommending it, but I have to tell you I don’t see how a health care provider in good conscience could withdraw services that has now been demonstrated to save lives based on some sort of political ruling.
We have demonstrated decreased mortality associated with the use of Insite; we have demonstrated decreased morbidity—that is, people don’t get sick as much; we have demonstrated increased cessation of drug use. I mean, what else do you want? At the same time we have shown that the site is associated with decreased loitering and decreased disturbance in the environment where the site is located.
I mean ethically, morally, scientifically, economically I cannot conceive an argument why the site should be closed, so let’s hope that smart people, well-informed people, arrive at the right decision.
MP: In 2007, the United Nations reported that the Downtown Eastside had a Hepatitis C rate of just below 70 per cent and an HIV rate of approximately 30 per cent. What needs to be done to get a hold on these numbers?
JM: The epidemic in the Downtown Eastside has already matured. The likelihood that we’re going to prevent a lot more HIV in that first cohort of people, that opportunity is gone. Now, given the dynamics of drug use, there are always new entries into the drug use environment. The important thing to realize is that if we address the issue of harm reduction and anti-retroviral therapy to all those that are eligible for it within that community, and for that matter within the whole province, then we would have the best possible opportunity to reduce the likelihood of HIV transmission.
In order to do that we need a comprehensive outreach strategy. We call it “Seek, Test, Treat and Retain” (STTR), which means: if you are not accessing the services, we need to access you. The problem is that there is a large proportion of people on the fringes who are involved in risky activities that could lead to HIV, but they don’t somehow identify themselves as being in a high-risk situation, who are the ones that are the hardest ones to reach. Now, there may be elements of socioeconomics or mental health or homelessness, or there may be various other complicating factors, but what we need is an aggressive strategy to get to those individuals if we are going to control the epidemic.
There is always a tension in our society regarding the competition for these very scarce dollars. So whenever we propose, ‘Well, let’s have a mass testing campaign’, people start arguing, ‘Who do we take money from?’ At the end of the day it comes down to an issue of cost-effectiveness and what we have argued is that investing on testing and treating people with HIV is highly cost effective to the point that you are generating a return on the investment that is not just related to the health outcomes of the person that is infected, but is actually related to the prevention of the progeny of HIV infection that that person would have derived.
MP: Despite issues with the federal government, Canada is seen as very progressive around the world. Some American states don’t even allow needle exchanges. What do you hope the Vienna Declaration can do globally?
JM: All my life I’ve been reluctant to praise myself for being better than the worst. The reality is that the United States has an abominable track record when to comes to dealing with substance use problems. They have a law and order approach, which unfortunately is a very easy thing to sell to the uninformed public, and all it has done is enrich the operators of correctional facilities. You can scare people very quickly into believing that if I put everyone in jail it solves all your problems.
The federal government in Canada is now proposing to expand the number of jails for unreported crime, which is I find it absolutely incredible. The statistics show that crime is going down, but they say unreported crime is going up.
Obviously they are stating the facts as they see it because they have a conviction that is basically ideologically motivated.
I think our expectation with the Vienna Declaration is that it’s going to generate a dialogue, a debate around what is a proper policy for progressive societies today in dealing with harm reduction. The fact that Vancouver, Victoria and Toronto have now aligned themselves formally behind the Vienna Declaration [means], sooner or later, it will create the kind of momentum for these discussions to be brought up to the attention of the federal government. The evidence is here, the cities that are dealing with the problems are asking for this because this would be a better use of our resources. We don’t need more jails; we need more supervised injection sites. If we do that, we will need even fewer jails.
MP: UN AIDS recently reported that there were 2.6 million HIV infections around the world in 2009, which were 20 per cent fewer than the late 1990s. While it’s great progress, the report also said the issue is still ‘halting’ and ‘fragile’. Do you think people have gotten too complacent on this issue?
JM: I think we have to look at the UN AIDS figures and conclude that some progress has been made. The figures show that we can deliver on our promise to stop the epidemic if we have the resources. There was a hope that by 2005 they would put 3 million people on treatment and that eventually there would be universal access to treatment, care and prevention by 2010. This was a commitment by the G8. The truth is that by 2005, it never happened. It took until 2007 to get 3 million people in treatment. As a result of that we’ve been behind all along.
I find it objectionable, if not highly irresponsible and hypocritical, that the G8 met in Canada [last] year and basically decided to change the agenda to maternal and child health issues, and forgot about the AIDS pledge. There is no apology or even commentary as to how we’re going to catch up on this. They pretend that they’re going to deliver on maternal and child health when, in Africa, 30 per cent of the women are infected with HIV.
We seem to look at the problem of HIV as if it was remote and we don’t care about it. To be perfectly honest with you, if the HIV crisis was not affecting racial minorities, people with drug-use problems, or homosexual men, our leaders would feel a lot more sympathy and empathy for this problem. They have applied their judgement: these lives are expendable. Well, they’re not expendable. If we don’t solve the AIDS crisis, our children, and the children of our children are going to be burdened with an AIDS mortgage that’s only going to get worse.
With all the implications that it has for human security and for the stabilization of the globe which is something that, 30 years from now, we’re going to regret that we didn’t stop this when we could have. And our data shows, if we do the right thing, we can do it.
MP: According the UN AIDS, while more people are getting access to treatment the number of people around the world with HIV has increased to 33.3 million, which is the highest its ever been.
JM: The number of people we’re treating is growing but not as fast as the epidemic is growing. The problem is if we don’t get ahead of the number the curves will continue to grow separately so that the number of people in need will continue to outpace our ability to deliver.
We can see the future and the future says if we have a society where 30 per cent [of the people] are infected with HIV, that country is not stable. In South Africa, the GDP is suffering because of AIDS—the economy is being compromised. How can you protect the integrity of a society when you reach a critical mass of people infected with HIV? People are dropping like flies, and that’s what people need to understand.
MP: Your critics, including former Minister of Health Tony Clement, have claimed that you have drifted away from being a scientist into being an activist. What is your response to those kinds of accusations?
JM: The reason why “Dr. Montaner”, as [Tony Clement] said it, “has drifted into an advocacy role”, is because I have the profound conviction that when you do clinical and public health research and your data is clear, transparent and definitive, you have an obligation to inform the public and decision makers regarding the next steps that need to be taken, particularly to address the epidemic situation of HIV and drug addiction.
The more those policy makers refuse to accept the facts, the greater my responsibility to educate the public and the decision makers. So, my crusade, to disseminate this knowledge, is a fundamental next step in this kind of work.
My answer to the federal government is that they can say whatever they want but my credentials speak for themselves. The problem we have is that their credentials are also transparent and they’re perfectly clear: they are not about evidence, they’re not about public health, they’re simply about continuing to rule this country based on an ideology that unfortunately is not congruent with the needs of the patients that we’re trying to serve.