Changing my mind on treatment as prevention

Published: March 11, 2013

Editor Bob Leahy used to be a strong opponent of treatment as prevention and all it stood for. But times change and there has been a sea change in his view. Now he’s a treatment as prevention supporter. Find out what it was that changed his mind.

One hundred and eighty degree turns happen in a variety of ways. Sometimes we seize the steering wheel of our lives and in one fell swoop travel along an opposite path.  Other times, we take the turn slowly, one degree at a time, gradually realizing the path we are on leads nowhere and we need to go off in radically new directions. That’s been the case with my realizing that most of my once fervently held objections to treatment as prevention, in 2013, make much less sense than they once did.

Why? In the last decade, our knowledge of disease progression has changed as has how much we know about the impact of ART on our ability to transmit the virus. But treatments have changed too, and so has my own willingness to look at both sides of the argument, to weigh them against each other and to make informed choices which recognize, above all, a shifting environment.

As well, the realist in me tells me that when it comes to HIV prevention, the status quo isn’t working. I respect those who work in the prevention community. But, to be blunt,  those who continue to play with the same old tricks – plugging condom use when we know the limits to their efficacy in real life situations, trying to effect behavioural change with the odd stray missile thrown at the social determinants of health  – are playing in the wrong sandbox. Let’s not fool ourselves. None of these things will stop the epidemic. We need new tools.

Enter my new friend, treatment as prevention.

Accepting it as a valid, in fact necessary, tool hasn’t been a slam dunk.  My early introduction to it left me decidedly unimpressed.  At the Canadian AIDS Society (CAS) eight years ago I echoed the concerns of the Quebec caucus who first bought the issue of treatment as prevention to the floor, concerned at the notion of people being put on treatment without informed consent and with no demonstrable benefit to their health. If memory serves me I moved a motion that was approved at a CAS AGM condemning treatment as prevention – and in fact was instrumental  in drafting a highly critical position paper when I was subsequently elected to the CAS board.

Fast forward a few years. I was still a treatment as prevention doubter in January 2012 when, through my work for, I nervously picked up the phone to talk with Dr Julio Montaner, the distinguished former head of the International AIDS Society, now heading the British Columbia Centre for Excellence in HIV/AIDS.  Montaner is of course a leading expert on, and advocate for, treatment as prevention. His arguments though, have not persuaded all in the HIV/AIDS movement, notably many people living with HIV/AIDS.

Going in to that long conversation with Montaner, which you can read in two parts here and here I had real reservations as to whether treatment as prevention was ethical or even good for people living with HIV, yet alone effective. I’ll get to how I’ve processed those issues since, but let me first say a few words about Montaner.

Full text of article available at link below –

Leave a Reply