Each year, the 1er December marks World HIV / AIDS Day. 2021 also marked the 40e anniversary of the emergence of HIV. On June 5, 1981, 40 years ago, the Morbidity and Mortality Weekly Report The U.S. Centers for Disease Control reported five patients, young gay and previously healthy men, with life-threatening pneumocystis pneumonia, an infection rarely causing serious illness in healthy adults. Although named AIDS in 1982 (acquired immunodeficiency syndrome), this new disease will continue to be associated with gays for several years, wearing nicknames all more stigmatizing than each other, such as GRID (Gay Related Immune Deficiency) or even “gay plague”.
During these forty years, despite the absence of an HIV vaccine, we have witnessed exceptional scientific successes. In developed countries, despite the arrival of triple therapy in 1996, which allowed the life expectancy of people living with HIV (PLHIV) to equal that of HIV-negative people, the almost total disappearance of HIV transmission from mother-to-child or pre-exposure prophylaxis (PrEP is a medication that an HIV-negative person can take to reduce the risk of contracting HIV and is effective up to 95%) so much ? Certainly, but only in part.
Inequities between developed and developing countries persist in more than one respect in health. Here, have we done the maximum in the fight against HIV? We must note that in Canada, about 15% of PLHIV do not know their HIV status (so they do not have access to treatment and can transmit the virus). In Quebec, among those newly diagnosed, nearly 60% had never been tested before, which illustrates unacceptable shortcomings in HIV testing.
The lack of a prevention campaign is certainly not unrelated to this. It is also this lack of awareness which, insidiously, fuels discrimination against PLHIV, groups vulnerable to HIV, and undermines efforts to fight this epidemic which is not over.
It is no wonder that in 2021 UNAIDS chose the slogan End inequalities. End AIDS. End pandemics. What is amazing is that history repeats itself and that no lessons can be learned from it. With HIV, we understood that an epidemic cannot be reduced to a virus and that ignoring social injustices is synonymous with failure. Respect for rights improves the overall health of patients, as we know. If this knowledge had been applied years ago, society would have been better able to respond to COVID-19.
Global approach
Yet the holistic approach to health has been in vogue for some time. But there seems to be a gulf between theory (right thinking) and understanding its implementation on the ground, on the front line. The holistic approach requires growing resources in an urban setting, which brings together prevalent vulnerabilities. This is the case for LGBTQ2 + and migrant communities, the homeless, drug addicts, sex workers, people who have gone through a gender transition, incarceration, etc. In this 1er December 2021, let’s take a moment to reflect on the care of PLWHIV and people vulnerable to HIV.
Consultations with communities affected by several vulnerability factors are more complex, more frequent and take more time. PLWHA over the age of 50 constitute the majority of cases in Quebec. They present several co-morbidities (diabetes, cardiovascular diseases, cancer, etc.) which require further monitoring. These are not standard cases. Also more frequent are the visits of patients on PrEP who must see a doctor every three months for check-ups. The vast majority of these patients (over 75%) go to sexual health clinics rather than seeing their family doctor, either because the family doctor is uncomfortable prescribing PrEP or because ‘he is not comfortable talking about sex. These are not standard cases either. Finally, mental health difficulties, already present in the population before 2020, worsened significantly during the pandemic and will not disappear overnight, let alone in vulnerable communities.
The care of HIV – and people at risk – by family physicians is a model that sets Quebec apart and that many countries, including France, envy us. This model now faces decisions and restrictions that run counter to the fight against HIV. It would be bad to lose him. Not everyone is equal in health. We knew it 40 years ago, HIV proved it, COVID-19 reminded us. Patient care is different depending on the region, the arrondissement and the vulnerabilities. The holistic approach has been proven to work, so let’s adapt the resources accordingly. This is what we do in our clinics with the means at hand.
The retirements will result in hundreds of orphaned PLHIV. Who will take care of it in the Montreal region? The government must hear the needs and become more involved. Adding human and financial resources is crucial. Forty years later, it is time to recognize that HIV is a sexually transmitted infection and to ensure free drugs associated with it, in terms of treatment or prevention (PrEP).