As the US Quits the Global HIV Fight, Canada Can Step Up

Developing and impoverished countries around the world have, until recent cuts, depended on U.S. funds for HIV testing, treatment and prevention.

“UNAIDS ran a questionnaire for the main countries affected by HIV to try and understand how weak their stocks of antiviral therapy, HIV prevention and HIV testing were,” said Dr. Julio Montaner.

“All will run out by the end of the summer,” he said.

Montaner is the executive director and physician-in-chief of the BC Centre for Excellence in HIV/AIDS and the head of the HIV/AIDS Program at St. Paul’s Hospital in Vancouver.

While U.S. funding cuts have created a crisis, they have also created an opportunity for Canada to step up as a global leader in the fight against HIV, Montaner said.

To do this, he said, Canada must double its HIV funding, scale up B.C.’s HIV strategy to a national level, and decriminalize HIV.

Doubling Canada’s HIV funding

Doubling Canada’s HIV funding will encourage other wealthy countries to do the same and help cover the “50 to more than 60 per cent” loss in funding for health programs caused by U.S. cuts, Montaner said.

“Either we pay now or we pay later,” he said. “And if we pay later it’s going to cost more — not just in money, but in death and instability. AIDS will devastate economies and it will generate more conflict.”

In an email to The Tyee, Health Canada said that in 2024-25 the federal government invested $99.5 million in ongoing annual funding to address sexually transmitted diseases and blood-borne infections in Canada.

Health care is generally the jurisdiction of provincial and territorial governments, but multiple layers of government and community organizations work collectively to address sexually transmitted diseases and blood-borne infections.

The federal government also spends $26.4 million annually to support short-term projects through its HIV and Hepatitis C Community Action Fund and $7 million annually through its Harm Reduction Fund to help reduce HIV and hepatitis C among people who use drugs, the Health Canada email said.

Internationally, Canada is a founding donor to the Global Fund to Fight AIDS, Tuberculosis and Malaria, the email said, and has given $4.9 billion since its inception in 2002. Health Canada said the global fund provided 28 per cent of “all international financing for HIV programs,” and that discussions “are ongoing” for how much Canada will contribute this year.

How BC’s strategy was built

Montaner moved to Vancouver from Argentina in 1981 to do a fellowship in respiratory medicine.

“Gay men, predominantly from the West End, were dropping like flies in the emergency department with pneumocystis pneumonia,” he said. At the time, no one knew how to treat pneumocystis pneumonia or what was causing it.

These men were some of Vancouver’s first AIDS victims, and their care marked the beginning of Montaner’s nearly 45-year-long career at the forefront of fighting the global HIV pandemic.

Montaner would go on to build B.C.’s HIV strategy around making treatment and prevention widely available for everyone in the province, regardless of whether or not they were covered by the Medical Services Plan, and bringing HIV treatment and prevention to highly marginalized populations instead of waiting for them to seek help.

Montaner says that if Canada adopts and funds that strategy and encourages it and funds it on the global stage, it will become a global HIV leader.

Montaner helped discover a way to treat and prevent the pneumonia and switched his focus to virology to work on a treatment for HIV — which he discovered in 1996.

Combining AZT, ddI and NVP, or zidovudine, didanosine and nevirapine, was “the first time that you could shut down the replication of the virus. And when you did that, the immunity recovered,” Montaner said. “Death after 1996 started dropping and death from AIDS was starting to be reasonably well controlled.”

It would be a couple of years before they realized treatment was also decreasing an infected person’s viral load, which meant they weren’t spreading HIV.

“The more people we treated, the less infections there were,” Montaner said.

“When we modelled that mathematically we found that for every one per cent increase in treatment coverage, you have a one per cent decrease in HIV incidence or new infections.”

Montaner could also map out what’s known as an “H mortgage,” which shows that the faster a government worked to test and treat HIV cases in a given population, the sooner a government would start to benefit from having productive, healthy citizens rather than paying for sick, unproductive or dead citizens.

It’s just like paying off a mortgage, Montaner said, except the benefits have exponential growth.

That’s because protecting people from catching HIV today means protecting generations to come from the spread of the virus.

Realizing that was “a game-changer,” Montaner said.

Scaling up BC’s approach

With treatment made widely available, AIDS-related deaths dropped by two-thirds in B.C. between the mid-1990s to 1999, Montaner said.

The final one-third of patients needed a little extra help because they were highly marginalized or didn’t know how to navigate the health-care industry, he said.

“So we brought the services to the people… and the death rate in B.C. virtually disappeared,” he said.

This was part of the Treatment as Prevention strategy, which Montaner helped create in 2006. It ran as a pilot project in 2008 and expanded in 2010, after which deaths related to HIV-AIDS dropped to fewer than five per year.

This strategy took B.C. from having one of the highest number of HIV diagnoses in Canada in 1995 to having one of the lowest by 2023, Montaner said.

Treatment as Prevention could be scaled up to end the AIDS pandemic by 2030, he said.

Montaner defines ending the AIDS pandemic by “having a minimum of a 90 per cent decrease in morbidity related to AIDS, in AIDS deaths, and new HIV infections.”

To get there, by 2020 the world would need 90 per cent of people living with HIV to be diagnosed, 90 per cent of the diagnosed to be on antiviral treatment, and 90 per cent of those on treatment to have viral suppression, meaning they’re not contagious.

By 2025 those targets would need to increase to 95-95-95, he added.

The target of 90-90-90 by 2020 was adopted by the federal government and the UN in 2015. In 2021, both updated their goals by adopting the target of 95-95-95 by 2025. Both targets were first proposed by the BC Centre for Excellence in HIV/AIDS.

As of 2023, around 86 per cent of people living with HIV had been diagnosed, 89 per cent of them were on treatment and 93 per cent of those on treatment weren’t contagious, he said.

That’s a lot of progress made over the last several decades, Montaner told The Tyee.

However, the fight is far from over, especially because it seems unlikely that the United States, under President Donald Trump, will be reinvesting in HIV treatment and prevention any time soon.

“To have these guys, overnight, throw it all into the garbage without even realizing or acknowledging that, in doing so, they’re throwing into the garbage the investments of the last 30 to 40 years,” Montaner said.

“I think this is criminally negligent.”

Montaner pointed to Prime Minister Mark Carney’s speech in which he said that “if the United States no longer wants to lead, Canada will.”

Carney was speaking about trade, but it could be applied to HIV leadership too, Montaner said.

Strengthening Canada’s strategy; decriminalizing HIV

Montaner said he’s spoken with Carney about how Canada has an “obligation” to clean up its domestic HIV strategy if it wants to step into a global leadership role.

He said the national strategy can be improved by following B.C.’s lead in five areas.

First, Canada needs to make medication for prevention and treatment free for anyone in the country.

Second, Canada needs to enhance its genetic monitoring of HIV-AIDS to better identify clusters of cases and to tailor treatment for those clusters.

Third, there needs to be a national policy for harm reduction so, for example, people can access sterile equipment to use drugs.

Fourth, Canada needs to enhance social and medical support for marginalized populations, like the unhoused.

And finally, Canada needs to decriminalize HIV.

Legally, people are required to disclose they are HIV-positive to sexual partners. But if a person is taking treatment and their viral load is suppressed, they are not contagious, Montaner said.

These laws discourage people from getting tested and fuel stigma and misinformation, he said.

Acting globally will help Canada protect its citizens domestically, Montaner added.

“If we don’t help them, their infections are going to overwhelm us,” he said.