For Dr. Julio Montaner, this week's closure of the dedicated AIDS ward at St. Paul's Hospital in Vancouver carried double-edged symbolism.
The director of the B.C. Centre for Excellence in HIV/AIDS helped shape the pioneering treatments that have cut AIDS cases so sharply that the ward is no longer necessary. But he remains frustrated that B.C.'s proven strategy, dubbed treatment as prevention, isn't being adopted elsewhere in Canada.
He blames Ottawa for failing to lead the fight against what he considers a national epidemic.
“I have written to the prime minister or the health minister every year starting in 2006 and outlined the progress that we have made," Montaner said in an interview with Yahoo Canada News.
"All I get is a form response, thank you but no thank you. This is a matter we’re leaving to provincial jurisdiction.”
The explanation doesn't wash, Montaner said. HIV/AIDS is a national problem and Ottawa has not hesitated in the past to provide guidelines and support to the provinces for other epidemics such as SARS and serious influenza outbreaks.
But when it comes to HIV/AIDS, "they find the subject matter toxic" and the main at-risk groups – gay men, sex-trade workers, injection-drug users – "somehow difficult to deal with."
“Canada has made, in my opinion, a value judgment that these people don’t count and they are basically letting the fire burn and hope it’s going to extinguish itself," Montaner said.
"I’ve got news for you. The only way HIV is going to extinguish is we do the right thing, and we’re not doing the right thing at the national level.”
[ Related: Treatment triumph changes B.C. hospital's AIDS ward ]
Health Minister Rona Ambrose was unavailable to comment on Montaner's view. But Health Canada spokeswoman Sylwia Krystzton said via email that Ottawa has stepped up in the fight against HIV/AIDS.
In the current fiscal year alone, she said, the government has earmarked $86.7 million for the federal initiative to address HIV/AIDS and a program to develop an HIV vaccine. The Conservative government has invested more than $500 million to support HIV/AIDS research since 2006, she said.
The number of newly diagnosed HIV cases reported in 2012 was the lowest since statistics started being kept in 1985, with a drop of almost eight per cent in 2012 compared with the previous year, Krystzton said.
The Conservative government is used to this kind of hammering from Montaner, arguably one of Canada's top experts in HIV/AIDS. The Argentine-born doctor has been a thorn in its side for almost a decade.
Some of the mutual antipathy no doubt springs from Montaner's defence of the Insite supervised drug-injection site on Vancouver's Downtown Eastside, which the Conservatives tried unsuccessfully to shut down.
But Montaner can't understand why the government cannot see the cost savings evident in promoting the B.C. strategy – more than $3 million per 100,000 population in lifetime expenses in B.C. alone – that could be replicated elsewhere in Canada.
“Let’s be clear, all of your biases, passions and anything else aside, this is a no-brainer," he said.
“I think the public should get outraged that we have a made-in-Canada solution that has become the standard of care around the world but has failed to take traction in Canada because the government is paralyzed.”
St. Paul's, on the edge of Vancouver's West End "gay village," was a battleground for two decades as AIDS ravaged the nearby community, the worst-hit in Canada. At its height, the disease was killing one person a day in the province.
But the number of AIDS cases has dropped so dramatically in B.C. that the ward, which was known only as 10C to minimize its stigma, is being revamped. It now will treat patients living with the long-term effects of HIV infection, as well as those suffering from chronic diseases related to drug addiction, such as hepatitis.
The treatment-as-prevention strategy couples the province-wide availability of HIV testing with speedy administration of anti-HIV triple-drug therapy (known as HAART) to HIV-positive patients.
The goal is to reduce their viral load to near undetectable levels. It essentially removes the disease's death sentence, reduces the likelihood of needing treatment for HIV-related complications and lessens the chance of HIV transmission, especially mother-to-child.
The strategy has been responsible for an 80 per cent decline in AIDS cases and in HIV-related deaths between 1996 and 2012, according to the B.C. Centre for Excellence in HIV/AIDS. The incidence of new HIV diagnoses is down by two thirds.
The increased testing boosted the number of reported HIV cases by more than 50 per cent during that period, with the number of patients receiving HAART soaring to 700 per cent.
In 2010, 114 people presented with AIDS-related illnesses. Last year, the number was down to 40.
Contrasting with B.C.'s experience, the centre's analysis of Health Canada data from 1995 to 2011, HIV diagnoses declined only slightly in central and eastern Canada, and actually increased in Saskatchewan and Manitoba. Montaner noted the increases in the Prairie provinces were largely among First Nations people, whose health care falls under federal responsibility.
According to Montaner, the B.C. strategy has been adopted by a number of U.S. jurisdictions, as well as countries such as France, Brazil, China and Sierra Leone.
It's also accepted as the standard of care by UNAIDS, the UN agency devoted to combating the disease worldwide. Its executive director, Michel Sidibé, attended this week's shut-down of Ward 10C, and Montaner has just been appointed UN special adviser on HIV/AIDS treatment.
Health Canada's Krzyszton said the government supports comprehensive approaches to HIV, from education, testing and treatment "tailored to individual provinces/territories' epidemiology and context.
"The Government of Canada facilitates the sharing of information nationally, however, decision on treatment and the delivery of health care services fall under the jurisdiction of provinces and territories," she said via email.
The federal Public Health Agency's recently released HIV screening and testing guide "offers flexible and adaptable approaches to normalize HIV screening and testing for a range of care providers and settings and is another tool that provinces and territories can use in their delivery of HIV related services."
Montaner's career as an HIV/AIDS crusader was largely accidental. He came to Canada in 1981 to complete his studies in respiratory medicine with plans to become a specialist in the field like his late father, a recognized expert in Latin America.
Many of the patients he saw in the early eighties suffered from pneumocystis pneumonia, a normally manageable fungal lung infection that was the main killer of patients afflicted with HIV, still a mystery virus at the time. Once the link to HIV was established, Montaner saw the direction of his career.
“It became clear that if I wanted to do something meaningful, this was where most of the problem was and I knew as much about this as anybody else," he said. "I was given the opportunity and basically that distracted my attention for a little bit, for the last 25 years."
The work led him outside the strictly medical boundaries, seeing the disease's other social, economic and political elements, he said.
"It really became a passion of me to try to do something to try to eliminate what was the worst epidemic in our history," said Montaner.
"I’m happy to tell you that in my academic life I have seen the beginning of an epidemic in British Columbia and I now see the end of an epidemic. I have every intention to just see the end of it before I’m done.”
(Photos courtesy the Canadian Press)