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August 16, 2006
IAC: Diary of a Doc (Part Two)
by Lloyd Bailey, MD
August 16, 2006—Julio Montaner must have been a populist politician in a previous life. He has all the prerequisites: uncommon good looks, a sexy baritone voice, charisma that’s off the charts and a “Treatment to the People!” philosophy. His talk opening the plenary session at the International AIDS Conference this morning brought to mind the “chicken in every pot” rhetoric common among 1930s populist politicians in my home state of Louisiana.
I first heard Dr. Montaner was planning this talk last week when I was interviewed for the POZ article “If HIV Meds Grew on Trees” by Nicole Joseph. While I understood the technical argument of greatly reducing HIV transmission by placing “everyone” on treatment, I was apprehensive that such a scenario might be coercive and infringe upon individual rights.
But there was no such coercion in Dr. Montaner’s presentation today. Instead, he made a convincing argument based on solid facts. First, that HIV medicines are becoming progressively easier to take, with fewer pills, the availability of once daily dosing and improving side effects. And then that studies of mother-to-child HIV transmission and discordant couples are showing a direct relationship between lower HIV viral loads and lower transmission risks. Among the couples, for instance, HIV transmission rates approached zero for those individuals with viral loads less than 400.
Dr. Montaner was especially good at approaching the current tug of war between treatment versus prevention. Which should take precedence? His conclusion: Treatment is an effective prevention strategy.
His focus was not on treating individual patients who are not officially “ready” for meds but on significantly increasing treatment funding in both the developed and developing world. His message was clear: treatment is cost effective and makes good economic sense. By taking individuals off of waiting lists and putting them on treatment, hundreds of new infections could be averted each year.
Using a series of charts to illustrate his argument, he showed that if HIV treatment rates approached 100%, transmission would decline dramatically over time. For every dollar spent today on meds, $2 would be saved—because of all the infections averted. In 45 years (assuming near 100% compliance to treatment), the global incidence of HIV infection could be reduced 70 fold, from about 40 millions individuals worldwide to less than one million.
Dr. Montaner closed his talk by acknowledging that these outcomes were theoretical and fit most neatly into a model where meds were free, safe, and non-toxic—a reality that’s not likely anytime soon. He also acknowledged the challenges of drug resistance, hidden epidemics, individual rights and logistics.
However, he said, the reality of dramatically improved HIV treatments and clear-cut evidence that meds are cost effective and synergistic with prevention efforts demands a closer look at this strategy.
Dr. Montaner closed his talk this morning with just the sort of forceful image you’d expect from an effective populist politician. In this case, he presented a sign commonly seen in the London subway system that had been altered rather creatively. Instead of “Mind the Gap,” his sign said “Fund the Gap.”
Lloyd Bailey, MD, practices at the Spellman Center at St. Vincent’s Midtown Hospital in New York City. Also check out his IAC dispatches from August 15 and 18.