by David Johnston
At the start of the AIDS crisis two decades ago, a promiscuous Air Canada flight attendant named Gaetan Dugas, then living in Montreal, was dubbed Patient Zero by the U.S. Centres for Disease Controls (CDC).
Dugas, who died in 1984, saw his reputation reach mythic proportions after he was sexually linked by the CDC to 40 of the first 248 gay men who died of AIDS in the U.S.
Ever since the CDC issued its first bulletin about AIDS 20 years ago this month, Montreal has figured prominently in the mythology of AIDS and in key developments in the treatment of the disease.
In 1989, a fledgling local drug firm, Biochem Pharma, reported promising results of a proposed new AIDS drug, 3TC.
Today, 3TC is the most widely prescribed AIDS drug in the world.
In recent weeks, Montreal has once again been attracting international attention among AIDS researchers as evidence has emerged showing the incidence of new HIV infections in Montreal is much lower than it is in other major industrialized cities where rates have as much as tripled in the past three years.
Since 1996, there has been a dramatic decline in AIDS mortality as 3TC and other new AIDS drugs have come into wide use. In 1996, 1,036 Canadians died from AIDS-related complications. Last year, only 126 died. But as AIDS deaths have declined, the rate of new annual HIV infections has grown in most major cities, leading researchers to believe that decreasing fear of dying from AIDS has produced a wave of safe-sex fatigue.
But one city stands out as an anomaly: Montreal.
Two weeks ago in Toronto, a team of Montreal researchers presented a paper at a Canadian Association for HIV Research conference showing the rate of new HIV infections among gay men in Montreal has held relatively steady in recent years at around 0.6 per cent.
That is to say, six in every 1,000 HIV-negative gay men are becoming HIV-positive from one year to the next.
By contrast, conversion rates in other large cities has been much higher.
It's 20 in every 1,000 in Toronto and in Vancouver. In some U.S. cities, the rates are even higher.
``It really does seem that the number of new infections in Toronto and Vancouver and other cities is higher than it is here,'' said Dr. Mark Wainberg, director of the McGill University AIDS Centre, located in the Jewish General Hospital. Wainberg is also past president of the International AIDS Society, a scientists' group.
It was Wainberg's McGill AIDS laboratory on Cote St. Catherine Rd. that did the testing on 3TC that confirmed the drug's effectiveness in suppressing replication of the HIV virus. BioChem, formed in 1987, had brought Wainberg 300 different potential AIDS drugs for testing before company representatives arrived one day holding a sample of 3TC. All 300 previous drugs had proved ineffective. 3TC was different. ``We said, `This one looks like winner,''' Wainberg said.
This was in early 1989, five years after Gaetan Dugas, the so-called Patient Zero, had died of AIDS-related kidney failure. A native of the Quebec City suburb of L'Ancienne Lorette, Dugas was living in Montreal in the early 1980s when CDC researchers in Atlanta had begun flying him down for interviews in order to help understand early patterns in the transmission of the disease.
On June 5, 1981, the CDC published a 553-word article in its weekly newsletter about a rare parasitic lung infection that had shown up in Los Angeles. It had infected five young homosexuals, three of whom had also shown symptoms of a mysterious collapse of their immune systems.
More reported cases started appearing in Los Angeles, New York and other large cities. Researchers called the mysterious illness GRID, Gay-Related Immune Deficiency, and interviews with people suffering from it helped researchers link Dugas sexually to nine of the first 19 GRID cases in L.A., and ultimately 40 of the first 248 cases in the U.S. A CDC statistician calculated the odds of it being purely coincidental and ``figured that the chance did not approach zero - it was zero,'' wrote Randy Shilts in his 1987 book about AIDS, And The Band Played On.
The Montreal HIV-infection data presented two weeks in Toronto was tabulated by a team of researchers affiliated with the Omega Cohort study, which is an ongoing look at the sexual practices of 1,500 HIV-negative gay men in Montreal. It's a huge sample size, considering 1,500 is a standard sample size for national public-opinion polling in Canada.
For the Omega study, the 1,500 men are tested for HIV every six months, as well as asked to fill out a questionnaire providing updated information about their sexual practices. One question that is asked is: have you had unprotected anal sex in the previous six months with someone whose HIV status you don't know, or with someone who is HIV-positive? Omega has found about 17 per cent of respondents admitting to such unsafe sex, compared with 30 per cent in similar studies in other cities.
At face value, this suggests safe-sex practices are more prevalent in Montreal, and that's why infection rates are lower. But there are comparative problems between Omega and the other studies. The ongoing Vancouver study, called Vanguard, classifies a man who is having unprotected anal sex with a regular partner who is HIV-negative as someone who is engaged in unsafe sex. The Omega study doesn't.
Joanne Otis, one of the Omega researchers, has retabulated the Omega data to compare apples with apples and found under the Vanguard definition of what constitutes safe and unsafe sex, the Omega figure of 17 per cent rises to 33 per cent. This suggests little, if any, difference in safe-sex practices between Montreal and Vancouver, or for that matter between Montreal and other cities with 30-per-cent rates.
So what explains Montreal's lower infection rate? (The Montreal and Vancouver rates are, in fact, only estimates, because Quebec and British Columbia are the only two provinces in which doctors aren't obliged to report knowledge of a new HIV infection to public-health authorities. But the estimates have been shown to be reliable. According to the statistical standard deviation, Montreal's estimated 0.6-per-cent rate could actually be as low as .45 or as high as .75, still well below Toronto's real rate of 2 per cent, or 20 in every 1,000.)
Otis thinks there's a very simple explanation for Montreal's lower infection rates: better AIDS-prevention programs here than other cities.
``In Toronto since 1996, prevention work has disappeared,'' she said. ``We've seen that in other cities, too. Vancouver. American cities.''
Sero Zero, a Montreal HIV-prevention group, has 10 workers who go directly into Montreal's dozen bathhouses catering to gay men.
Gay bathhouses are rarities elsewhere: Montreal has more bathhouses than the rest of Canada combined. New York City has two or three, according to local gay men. Last year, Sero Zero, funded principally by the federal and provincial governments, distributed 700,000 condoms in the dozen Montreal bathhouses.
``Twenty years ago, you wouldn't have seen a condom in a Montreal bathhouse; now, people are more prudent,'' said Jocelyn Boulianne, receptionist at the Oasis bathhouse in the Gay Village that straddles Ste. Catherine St. E. between St. Hubert and Papineau Sts. With a sauna, steambath and whirlpool, and 110 rooms where gay men have consensual sex, it is the largest bathhouse facility in Montreal.
Dr. Rejean Thomas, president of the Clinique Medicale l'Actuel in the Gay Village, thinks it's an urban myth that gay men in Montreal are any ``wiser, smarter'' than gay men elsewhere when it comes to safe sex. He said he expects the next round of figures on HIV-infection incidence will show a sharp increase in Montreal rates.
``I've become very discouraged in the last couple of months,'' said Thomas, who ran unsuccessfully for the Parti Quebecois in the 1994 provincial election. ``We're seeing syphilis again in this clinic for the first time in 10 years. We also have an outbreak of anal gonorrhea going around, and just yesterday I had an 18-year-old CEGEP student come in who told me he had had unprotected anal sex 10 times in the past year. That is something I would never have heard two or three years ago.''
In the late 1990s, as drugs like 3TC produced sharp declines in AIDS mortality, some gay publications in the U.S. began promoting a return of ``barebacking'' practices - i.e., anal sex without condom use.
``In parts of the U.S., and recently in England and Europe, elements in the gay community have been advocating unsafe-sex practice as a right, in terms of enjoyment of life,'' said Wainberg of the McGill AIDS laboratory.
At the same time, said Otis, drug companies in the U.S., which are allowed greater advertising freedom than their Canadian counterparts, have been aggressively promoting the effectiveness of drug treatment of AIDS, and created ad campaigns trumpeting an imminent discovery of an HIV vaccine.
As a result of these U.S. influences, said Otis and Thomas, the image of AIDS is changing among gays. A ``preventable'' disease is morphing into a ``treatable'' disease, they said.
``Fear of death is a very powerful motivator, and it's not at all surprising that when people are no longer looking at certain death from HIV, their views about unsafe sex are going to change,'' said San Francisco public-health director Dr. Mitchell Katz in 1999.
Claude Cyr, a worker with Sero Zero, said the English-French language barrier has probably shielded many francophone Montreal gays from outside barebacking and pharmaceutical propaganda.
But as the social history of Quebec has shown, the barrier
is not impervious to new ideas for very long.
For more information, contact:
Bonnie Devlin
Vanguard Project Coordinator
608 - 1081 Burrard Street
Vancouver, BC, Canada, V6Z 1Y6
Tel: (604)806-8306
Fax: (604)806-9044