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Tuesday, 3 January 2012

HIV progress in Canada – A great public health success story to start the New Year

What better issue to celebrate the New Year with than what is the number one new public health story of the last few decades and a celebration of Canadian public health.

Far too many of those active in public health can remember the initial postings of the unusual new immunodeficiency syndrome that was first identified in San Francisco in 1981 with viral identification in 1983.  The disease has killed over 25 Million people, and still kills about 2 Million per year.  There are currently an estimated 35 Million infected persons living with HIV worldwide, about 2/3rds of these in Africa.  The secondary impact is the loss of a significant proportion of young adults and the development of a generation of 14 Million African youth who have been orphaned by the disease. 
This posting is less about the tragedy of the disease which is not to be understated; it is not about the epidemiology and transmission as a sexually transmitted, blood borne or perinatal infection; nor about the disease process, social impact or treatment; – you can be readily directed to thousands of resources including Wikipedia.  This posting is about celebrating the accomplishments of a generation of public health contributors from Canada.
From an unknown clinical syndrome that was quickly identified as mostly fatal over about 10 years, to within 30 years to being a disease where the life expectancy in Canada under treatment is potentially similar to non-infected persons is nothing short of remarkable.
There are an estimated 65,000 infected Canadians, with an estimated incidence of about 3,000 cases annually.  Roughly half are men who have sex with men (MSM), and 20% amongst intravenous drug users (IDU).   Somewhere around one-third are attributable to heterosexual transmission, roughly equally divided between persons from countries with high HIV prevalence and those where transmission likely occurred within Canada amongst second or more generation populations. 
The embedded figure speaks to incidence over time by risk categorization, for which several notable observations need to be made.   The initial rapid decrease in incidence in MSM began to rebound in the early 2000’s.  The incidence in IDU has decreased in parallel with other indicators of overall IDU use suggesting protection as much by changing drug use habits (eg. shift to cocaine inhalation from heroine injection) as to the focus on safer injection practices.  The final notable observation is the steady increase in persons acquiring infection through heterosexual transmission. The hidden statistic is that Aboriginal populations are currently carrying twice the burden of illness incidence as non-Aboriginal Canadians.  The full story is available at HIV epidemiology in Canada

The main focus of the celebration is the consistent success that Canada has contributed to fighting HIV.  Likely there more and perhaps some of you would like to add to the list so we can edit it in celebration of great national accomplishments.
1.       Identification and synthesis of one of the first antiviral medication 3TC by Bernard Belleau of McGill who then went on to established BioChem Pharm
2.       Dr. Mark Wainberg of McGill numerous contributions including:
a.       the mechanism of effect of 3TC
b.      postulating and proving resistance development of HIV to antivirals and
c.       co-leader on HAART triple therapy
d.      President of the International AIDS Society
3.       Dr. Rafik-Sekaly and the team of the Université de Montreal who furthered considerably the knowledge about the immune response to HIV infection.
4.       Dr. Julio Montaner’s now at UBC and the BC Centre for Excellence in HIV, momentous contributions including:
a.       collaborating on the triple therapy HAART approach,  
b.      innumerable trials on improving the effectiveness on antiviral therapy delivery in hard to reach populations
c.       past president of the International AIDS Society
d.      recent contributions on the public health benefit of reducing viral loads to undetectable levels as a method of prevention of transmission (“STOP HIV/AIDS” “Treatment as Prevention” project). The combined efforts of this group are demonstrating that HIV incidence can be reduced and can currently claim multiple year reductions since 2003/04 a remarkable 40% reduction BC 2010 STi and HIV statistics  and for all provinces see Table 6B HIV incident cases by province to 2009 
5.       Dr. Frank Plummer at PHAC and the National Microbiology Laboratory and his innumerable contributions that extend back to the early-80’s.
6.       Many researchers who have looked at the question of reducing transmission in communities, or increasing effectiveness of reaching therapy into hard-to reach populations.
7.       The notable contributions of Steven Lewis as UNAIDS ambassador and advocate for AIDS reduction in Africa.
8.       Dr. Kate Hankin’s work at the epidemic onset within Canada and then with UNESCO. 
9.       Numerous Canadian teams that have been involved in addressing specific questions of a global health nature, predominately but not exclusively in Africa.
10.   The recent announcement by Dr. Chil-Yong Kang at University of Western Ontario of a new HIV vaccine candidate for human trials is hopefully the next step on the ladder of great Canadian contributions.   

Every list suffers from the risk of incompleteness and your contributions are nominations are welcomed (drphealth@gmail.com).  

Canada is the 35th most populous country, with only 1/2 % of the global population, yet Canada’s contributions to research, control and treatment of HIV/AIDS is consistently in the top 4-6 countries on an absolute level and rivalling any country on a per capita basis.  Now isn’t that a Canadian public health success to celebrate?  

Check out some of the disparate sources that list a few of the innumerable Canadian contributions. 

Centre of Excellence on HIV/AIDS Centre of Excellence BC  

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