The Hour is Blue

From the Archive: Dr. Julio Montaner and the Revolution in HIV Treatment

This live interview was first broadcast in April 2012 on my former radio show, Prof Talk, on CiTR 101.9 FM at the University of British Columbia in Vancouver, Canada.

Dr. Julio Montaner is a University Killam Professor of Medicine at UBC, Executive Director and Physician-in-Chief of the BC Centre for Excellence in HIV/AIDS, and Head of HIV/AIDS at St. Paul’s Hospital. He is widely recognized as one of the fathers of highly active antiretroviral therapy, or HAART, and later pioneered Treatment as Prevention, using effective HIV treatment not only to prevent illness and death but also to stop transmission.

It was such an honour to interview Dr. Montaner in 2012, and it has been especially meaningful to return to this conversation fourteen years later and finally offer it a full transcript.

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The Blue Hour, hosted by Farha Guerrero, airs live every Tuesday at 2 p.m. PT on CiTR 101.9 FM at the University of British Columbia in Vancouver, Canada.

Transcript

Transcript lightly edited for clarity and readability while preserving the substance and natural rhythm of the original live conversation.

Farha: Hello and welcome to Prof Talk.

There's no question we know a lot more about AIDS today than in years past. It was once believed that HIV, if transmitted, meant a sure and relatively rapid death. But today, so much of that thinking has changed.

Today I have the extraordinary pleasure of having one of the top AIDS researchers in the world right here in the CiTR studio.

Dr. Julio Montaner is the Director of the British Columbia Centre for Excellence in HIV/AIDS, the Chair in AIDS Research and Head of the Division of AIDS in the Faculty of Medicine at UBC. He is also the past President of the International AIDS Society.

His recent research has been primarily focused on the implementation of the Seek and Treat for Optimal Prevention of HIV/AIDS initiative, which will utilize HIV treatment as an HIV prevention strategy in BC. The initiative seeks to drastically decrease HIV-related morbidity and mortality in the province.

Dr. Julio Montaner joins me now here in studio at CiTR. Thank you, Julio, for coming in today.

Julio: Thank you, Farha.

Farha: You were born and raised in Argentina, and we were talking about that before we started. You came to Canada in 1981, fresh out of medical school.

You're now one of the top AIDS researchers in the world. Tell us about this incredible journey.

Julio: It's been nothing but an exceptional, life-changing story.

I was privileged to grow up in Buenos Aires, a city that I love, a country that I also love very much. I had every intention to stay in Buenos Aires and be, hopefully, a mover and shaker in the health care field back at home. My dad was a very prominent physician, and so I had a fair bit of inspiration coming that way.

At the same time, because of the privileged situation that I had, I wanted to earn my stripes, so to speak, elsewhere. I was looking for a place where I could train and really forge my career before I could claim my seat next to my dad and hopefully have an impact back at home.

I went to a number of places looking for mentors, and everywhere I was received by a friend of my father. It was something a little bit disappointing. I was trying to escape his umbrella, and I realized his umbrella was much bigger than I anticipated.

It wasn't until I met Professor Hogg from UBC at St. Paul's Hospital that I managed to get an opportunity to train somewhere where my dad was actually not known. So, really escaping his area of influence, I came to Vancouver.

I was very fortunate that I was coming to a great place, both academically and in every other respect. Within months of arriving here, one step at a time, my life was changing in front of my eyes.

It was three months into it that Professor Hogg came back to me and said that he was planning to offer me the opportunity to stay for another year, at a time when I didn't even know what I was doing. It was very early on. I was flattered, and I decided that I would do that.

Shortly thereafter, he started to talk to me about how important it would be that I complete my training based on Canadian standards so that I could go back home and really be well formed and grounded and have a real impact.

Little did I know that while all of this was happening, I met my wife, Dorothy, and that was late in 1981 already. So everything was falling apart in front of my eyes.

At the same time, there was an epidemic brewing that I knew nothing about. In fact, I didn't even know I was getting involved with it.

My original focus was respiratory medicine because pneumonia, very severe, lethal pneumonia, was the main reason why people with HIV were falling ill and eventually dying. I became interested in this problem.

Lo and behold, we came up with a strategy. We managed to treat it effectively to prevent death. By 1985, I was immersed in HIV 100 percent, and there was no turning back.

Farha: You've often been described as someone who's incredibly passionate about the work that you do. Do you think that's why you've been so successful in your career?

Julio: I think what happens is that you feed from the people that you're working with. You feed from the energy that you receive from the patients that you're working with.

Being Latin also helps. I bring a bit of a different level of emotion to the stuff that I do.

I've always been very socially minded. I was very perturbed back at home with inequalities and disparities in terms of social issues, and that always troubled me quite a bit.

As I became involved in HIV, I wasn't totally aware of all of the issues. This was a totally new world for me. But feeding from the energy that my patients brought to the table, I picked up where they left off and tried to champion their issues.

How can you not be passionate and committed when so many young people put their lives on the line to help you find the answers to the sometimes very important, life-changing research that we've been able to conduct here? That has been a huge motivation.

Then, as you learn more and further appreciate the insights that you have gained and the tremendous contribution that knowledge can make to society, you appreciate what I call the implementation gap.

All of the stuff that we know we could do, and we are not doing because of indifference or political apathy, or simply the fact that there are preconceived biases and notions that preclude us from doing the right thing, all of that feeds you even further.

My whole professional life has evolved into one of science, but also activism, in trying to close that implementation gap so that hopefully we can all benefit from implementing to the maximum everything we know, so that we can have, as soon as possible, an AIDS-free generation.

Farha: Right now there are more than 33 million people affected with HIV, and most of them are in sub-Saharan Africa. Although there is no cure for AIDS, it's no longer considered a death sentence, mostly because of greater access to these antiretroviral drugs.

Tell us about how you helped to create a triple-drug therapy that's now the gold standard treatment for HIV today.

Julio: With all due respect, because I don't mean this in a bad way, I look at my work as being a combination of good luck, fortunate insights, dedication, hard work and commitment.

I don't think that I'm smarter than anybody else or that I know something unique that nobody else knows. It's a matter of drawing parallels between what you know and what you're trying to solve.

Most of the work that we have done in HIV draws directly from the experience of tuberculosis, which is the area that my father was working in back at home.

I tried to adapt a lot of the stuff that my dad was working with onto the field of HIV. There were a lot of parallels in my mind all along.

I remember back in the day having these discussions with him about the fact that maybe earlier treatment would be more useful, and maybe combining drugs might be the way to go.

We started to do more and more of those clinical trials and research.

Eventually, because this particular drug was being abandoned by the Americans because they felt that it was not good enough, I had the opportunity to test this new drug, Nevirapine, as part of a triple-drug combination therapy, a novel approach at the time. It had not been used before.

In a very exploratory way, we were able to secure funding from Boehringer Ingelheim, the company that had that drug, to help us do this research. The company was so disconcerted by the lack of success in the previous trials that they were ready to dump the whole thing.

I said, "No, no, no, let's do this."

It took a lot of work and a lot of convincing, but we managed to convince them, and we started this pilot study.

A year later, in December 1995, one of the senior virologists in Canada, Mark Wainberg, a good friend of mine from the Jewish General Hospital in Montreal, called me aside. He was doing the virology for our study.

He said, "Julio, there's something wrong with your study because all of a sudden we don't seem to be able to grow the virus."

In retrospect, I could rewrite history and say that we had tremendous insight and we planned the discovery of triple therapy. But the reality is, we were trying this and that and the other thing, and we were lucky on this particular one.

At the time that we were lucky that the virus was not growing, we actually were not sure if it was a therapeutic success or if we had messed up the whole thing. So a new set of experiments was done.

We confirmed in December 1995 that triple therapy, given de novo to people who had never been treated and who were infected with HIV, could suppress the replication of the virus.

By stopping the replication of the virus, immunity was allowed to recover and therefore prevented the immune deficiency-related complications. In other words, it prevented death and allowed people to live longer.

In 1996, when we announced these results at the Vancouver conference here in town, we were able to tell the world, look, there is a new way to do this.

If we treat people with triple therapy, we will transform HIV from a rapidly progressive lethal disease into a chronic, manageable condition.

It wasn't perfect right away, but we were pretty close to being right 100 percent.

Very soon, triple therapy became the standard of care, and within months death rates in British Columbia almost melted in front of our eyes.

It was the most traumatic experience of my life.

Farha: Over the course of this time, arguably millions of lives have been saved.

Julio: Highly Active Antiretroviral Therapy, which we now know is the standard of care for the world, is based on the triple-drug combination that we unveiled in Vancouver in 1996.

Of course, there were a number of others who contributed to this new knowledge. But collectively, this group of investigators had the privilege of bringing something that was truly transformational.

The fight then became to make it so that HAART could be embraced in the south of the world, where the epidemic was really thriving.

Ninety percent of the cases were in the south of the world, where less than 10 percent of the people had access to medication. It was a very challenging situation, and it was difficult for us coming from the north to argue that the south should be doing this when resources were a problem.

But at the end of the day, we got the World Health Organization to rally behind it. We got funders to rally behind it, and the so-called 3x5 program was instituted.

The aim was to have three million people on antiretroviral therapy by 2005. It was a very modest aim. At the time, people felt that it was something that would never happen.

It took a bit longer. By 2007, three million people were on antiretroviral therapy, and we now have nearly tripled that number.

All in the south of the world, saving lives, saving families, putting people back on their feet, back to work, and really making a huge difference.

Is it enough? It's not enough.

But have we begun to change the nature of the epidemic and the course of the epidemic? Yes, we have. So we need to work harder now.

Farha: This therapy can drive the viral load of people living with HIV to undetectable levels, making the risk of transmitting the virus to partners extraordinarily low.

How does this treatment reduce the amount of virus in the bodily fluids of someone with HIV infection?

Julio: What happens is that when you stop the replication of the virus, the sort of vacuum cleaner that we all have within ourselves, the reticuloendothelial system, starts cleaning up the virus that you have circulating.

It takes a few weeks, but at the end of the day, within a period of about three to six months, the virus in your blood becomes undetectable.

You basically shut down viral replication, you clean up the virus that was present, and as long as you're taking the medication properly, there is no longer detectable virus in your blood.

As that's happening, the virus also becomes undetectable in other biological fluids, whether it's semen, cervical-vaginal fluid, rectal mucosa, you name it.

As a result of that, we hypothesized a number of years ago that if the amount of virus in a biological fluid was the main driver of HIV transmission from one person to another, regardless of the setting, whether it's mother-to-child transmission, injection drug use transmission or sexual transmission, it's always the same.

The more virus in the infected person, the higher the likelihood that you're going to transmit.

If that is the case, the opposite should be true.

Less virus, less transmission.

And no virus, hopefully, could mean that the likelihood of transmission would go down to almost a negligible level.

We came out with the statement back in 2006. It was a fairly controversial situation.

It ended up being a Lancet paper and a plenary at the International AIDS Conference in Toronto.

It so happened that we were changing governments in Canada from the Liberal to the Conservative government, so that brought me more than a few enemies in the federal government as well.

But at the end of the day, I'm happy to tell you that, thanks to the unwavering support of the government of British Columbia, we were able to explore this issue at a population level in BC.

We demonstrated that by expanding the coverage with antiretroviral therapy among people infected with HIV, not only were we able to decrease morbidity and mortality, putting people back to work and keeping them at home, but we were also able to control transmission of HIV.

In BC today, thanks to the use of the treatment, we have virtually eliminated mother-to-child transmission of HIV.

Secondly, we have had a 60 percent reduction in the number of new HIV diagnoses, from a high in the order of 900 prior to 1996 to the current level, 2010 being the last figure that I have for you, of 301 diagnosed cases.

If you can imagine, that means that every year we're sparing ourselves some 600 or so new HIV infections. The trend continues to improve.

We are dramatically decreasing morbidity and mortality. We are keeping people employed. We are keeping people at home.

We are protecting the family.

And at the end of the day, we're saving money.

There is nothing here that you could say, "I don't like."

Farha: This is remarkable.

In order for these programs to be implemented effectively and successfully, we need to deal with other issues that affect people who are most at risk with HIV, and that's where the challenge comes.

Last year, Science and Time named this treatment, the Treatment as Prevention model, the Breakthrough of the Year for 2011.

How did that make you feel?

Julio: To be perfectly candid, we've been asking for this to be named the Breakthrough of the Year for close to a decade. But finally it came.

No, just kidding.

What precipitated the international community to finally truly embrace Treatment as Prevention was that the Americans completed a randomized controlled trial involving heterosexual couples, sexually active couples where one person was HIV-positive and the other was not.

These couples were sexually active. They were counselled to use condoms and the like.

But over and above that, they were randomly assigned, half of them to do nothing else, the other half to receive HIV treatment immediately.

The HIV-infected member of the couple was told, look, in your situation we wouldn't typically recommend treatment. I'll remind you this is for Africa, so usually they use treatment very late for our liking.

They took advantage of that delaying of treatment in the African context, for the most part, and said, we're going to give you treatment earlier to see what it does primarily to HIV transmission.

Interestingly, by treating people early, they showed a decrease of 41 percent in morbidity and mortality.

The study was able to show again that earlier treatment is significantly better for the person who is infected.

But over and above that, what they showed was a 96 percent reduction in HIV transmission.

Ninety-six percent.

It doesn't get much better than that.

The statistic was derived from one case of HIV transmission among the serodiscordant HIV couples that received treatment. That transmission event occurred within days or weeks of starting the treatment.

The treatment did not have a chance to become active.

As I said earlier, it takes a few days or weeks, maybe a few months sometimes, for the virus to become undetectable.

If you start the treatment, the treatment doesn't protect you from transmitting until it takes full effect in, say, three to six months.

What that means is that if you allow the treatment to become effective, truly it becomes nearly 100 percent effective.

This is huge because it now says that the decision of whether or not to deliver on the promise of an AIDS-free generation is on us.

We have no excuses.

We don't need to wait for a vaccine.

We don't need to wait for a cure.

We don't need to wait for the second coming of Jesus.

We have the tools and we have them here.

And if we don't do it, it's because we don't want it.

If our political leaders deliver on the promise, which has been made at the highest possible level at the United Nations, including the Government of Canada, to deliver on universal access to care, treatment and prevention for the south of the world, we will stop HIV.

We haven't because they promised it, but they didn't put the money in to do the trick.

Farha: And that's what you always say, that we have to stop writing guidelines and really start implementing them.

Julio: Right.

I've been at the forefront of writing guidelines all my life. To be perfectly honest, I have tremendous respect for the guidelines and tremendous respect for the process behind them, the science behind it and everything else.

But if I take my scientific hat off for a minute and tell you the truth, we could stop writing guidelines today.

We could stop making promises today.

Deliver on the guidelines that we have and the promises that we have already made.

If we do that, we will have a different world within our lifetime.

Farha: Are you optimistic?

Julio: I've always been optimistic, but more than optimistic, I am committed to make it happen.

I will do whatever it takes to make my contribution meaningful to this fight.

And if I have to face Mr. Harper face to face, I will do it.

Farha: Besides meeting these politicians, what is really your next big project with your current research?

Julio: My ambition in the short term is to demonstrate at the field level, using the province of British Columbia as the major laboratory opportunity that we have in front of us, that by fully exploiting this strategy we can drive HIV to very, very low levels.

Both at the individual level in terms of disease progression and mortality, which we're doing already, and also at the societal level by stopping transmission.

My second priority is to address all of the determinants of HIV that we can possibly address, whether it is the decriminalization of drugs, the normalization of HIV care and testing, the normalization of the commercial sex work trade, so that we can have a society where we can approach these issues in a much more constructive way.

We made a lot of progress with the fight for recognition of the gay people in our community.

We are not finished with that, but if we could bring all of the rest of the pieces of the puzzle to that kind of level of functioning, that would be great.

Finally, what I want to do is show that the approach that we have used for HIV in terms of the quasi-elimination of an epidemic can actually be exported to other areas of medicine.

Currently, I am promoting the extrapolation of our work to the area of hepatitis C, for example, where we honestly believe that if we use the seek-and-treat approach, finding people infected, treating them appropriately and aggressively, we can actually control not just the HIV epidemic, but many other such epidemics that are affecting our world.

Farha: It's been such an incredible pleasure to have you here, and thank you so much for taking the time out of your very busy schedule to be here with us.

Julio: Thank you very much.

Farha: I've just been speaking with Dr. Julio Montaner, the Director of the British Columbia Centre for Excellence in HIV/AIDS.

You are listening to Prof Talk on UBC CiTR 101.9 FM in Vancouver and via live web streaming on CiTR.ca.

Thank you for listening today.

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