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More comprehensive national ART program needed in Canada

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An expanded national antiretroviral therapy program in Canada may have decreased community plasma HIV viral load, particularly among injection drug users in British Columbia, according to study findings.

Julio Montaner, MD, of the British Columbia Center for Excellence in HIV/AIDS in Vancouver, Canada, presented the results at the 17th Conference on Retroviruses and Opportunistic Infections in San Francisco. “Who knows what is going to happen in ensuing years, but for now things are going reasonably well with the program,” he said.

Montaner presented findings from a prospective ecological study that detailed the effect of expanded ART coverage on community plasma HIV viral load and transmission among two cohorts of injection drug users.

“New diagnoses of HIV substantially decreased following the first expansion of ART in 1996,” Montaner said. “During the second phase, which lasted from about 2000 to 2004, there was a substantial increase in people on ART and a downward expansion of new HIV diagnoses.”

Between 2004 and 2009, the number of individuals assigned to ART in British Columbia increased to about 5,000, and a second decrease in new diagnoses was observed (P=.001).

“If you put the whole story together, you have rapid uptake of ART and a reduction in new HIV diagnoses,” Montaner said.

At the end of 2007, a decrease of about 50% in new HIV diagnoses among injection drug users was observed. That same year, the proportion of injection drug users with HIV who had plasma HIV RNA levels greater than 1,500 copies/mL, which the researchers used as a surrogate for high community plasma HIV viral load, decreased steadily from about 50% from 2000 to 2004 to about 20% in 2009 (P<.001).

“Drug resistancehas been decreasing steadily over time,” Montaner said. “Every year since 1994, the number of tests in the province has gone up. The number of undetectables has been growing significantly.”

Montaner also noted that rates of other STDs such as chlamydia, gonorrhea and syphilishave “gone in the wrong direction.” He said that this may indicate that risk behaviors have not been changed, which makes the progress of the ART program more remarkable.

“We cannot establish a causal relationship between the program and the results because it is an ecological study,” he said. “But evidence in favor of expanding ART is quite compelling. An argument could be made for a more aggressive rollout.” — by Rob Volansky

Montaner J. #88LB. Presented at: 17th Conference on Retroviruses and Opportunistic Infections; Feb. 16-19, 2010; San Francisco.