In health, there are slogans that we repeat ad nauseam : “learn the lessons of history”, “make access to healthcare universal”, “acquire free medicines”. When it comes to HIV, we keep repeating them. And yet… The 24e International AIDS Conference opens in Montreal on Friday. His last visit here dates back to 1989. What a long way since then, of course.
We have witnessed unprecedented scientific success at lightning speed. In developed countries, triple antiretroviral therapy has made it possible, since 1996, for the life expectancy of people living with HIV (PLHIV) to be similar to that of HIV-negative people; the transmission of HIV from mother to child has almost disappeared and pre-exposure prophylaxis (PrEP) allows an HIV-negative person to reduce the risk of contracting HIV by 95% (PrEP is an antiretroviral), so much progress that eradicate HIV. And yet, can we claim victory?
How is it that, in Canada, approximately 15% of PLHIV are still unaware of their serological status (they are therefore not treated and can, without their knowledge, transmit the virus), that in Quebec, among people who have recently received diagnosis, nearly 60% have never had a previous screening and 27% have a CD4 cell count
These figures reflect a lack of awareness largely fueled by the scarcity of prevention campaigns and the abolition of sex education classes. These shortcomings, linked to budget cuts, have had effects whose magnitude has not been measured. Catching up on the delay will require long-term work, the benefits of which are immediately invisible. Just like the establishment of a warmer reception system for migrants in the medical network, often associated with the institutional milieus of the country of origin and their repression, and which hinders access to care and services.
The problems faced by migrants are even more complex. Not all benefit immediately from the RAMQ or the interim federal health program (IFHP). Doctors see them, we manage to find drugs thanks to compassionate programs, but it is difficult to carry out blood tests without exceptional collaboration, because the centralized laboratories refuse samples that do not include a RAMQ identifier. These migrants certainly do not have the means to access the private sector, so their support remains sub-optimal. This is a public health responsibility that remains to be fulfilled.
Free
Given the scale of these challenges, there are however means that have very short-term effects. It is high time that governments use them. Treatment for sexually transmitted and blood-borne infections (STBBIs) — chlamydia, gonorrhea, LGV and syphilis, in particular — is free in Quebec. This program provides free prescription drugs to treat them.
Why isn’t HIV treatment free? In North America, HIV affects men who have sex with men more than the general population. Are we to understand that there is a link? Is it because HIV is a chronic disease and treatment is long term? However, the number of PLHIV in Quebec remains limited (approximately 17,000) and the costs are limited, compared to the impact of new infections.
Since 2008, we know that a person with an undetectable viral load cannot transmit HIV sexually: undetectable = untransmissible. In Quebec, for some, contributing to the RAMQ represents a challenge. Making treatment free and accessible to PLHIV would be a responsible public health gesture. Free drugs would have avoided treatment discontinuations during the COVID-19 pandemic due to loss of income.
Post-exposure prophylaxis (PEP) helps prevent the transmission of HIV to an HIV-negative person who has been exposed to the virus. Antiretrovirals must be taken within 72 hours of potential exposure for four weeks. Free STBBI treatment also applies to people who have had contact with an affected person. And the same goes for the abortion pill. So many measures that no one questions, rightly. So why isn’t PEP free?
Finally, why is it that PrEP, which is effective like a vaccine, is underutilized? Out of ignorance, out of fear of talking about sexuality on the part of the doctor or the patient, but also because of its cost. At present, 15% of patients on PrEP have had to stop taking this treatment for financial reasons. And this unfortunate situation, Public Health must take responsibility.
The 24e International AIDS Conference will restore visibility to this forgotten epidemic. The next few days will show whether decision makers opt for concrete and rapid action or whether they are content to be satisfied with the progress made so far. If we are to defeat HIV by 2030, as advocated by UNAIDS, let us take the necessary steps to succeed. For this, national, provincial and municipal political will as well as that of Public Health are essential.