Julio S. González Montaner (born April 13, 1956) is an Argentine-Canadian physician, professor and researcher. He is the director of the British Columbia Centre for Excellence in HIV/AIDS, the chair in AIDS Research and head of the Division of AIDS in the Faculty of Medicine at the University of British Columbia and the past-president of the International AIDS Society. He is also the director of the John Ruedy Immunodeficiency Clinic, and the Physician Program Director for HIV/AIDS PHC. He is known for his work on HAART (Highly Active Antiretroviral Therapy), a role in the discovery of triple therapy as an effective treatment for HIV in the late 1990s, and a role in advocating the "Treatment as Prevention" Strategy in the mid-2000s, led by Myron Cohen of the HPTN 052 trial.
Early life and career
Montaner was born in Buenos Aires, Argentina in 1956, the son of Julio González Montaner, a pulmonary specialist. His father initially doubted that Montaner would follow in his footsteps, but after entering medical school, he developed a passion for medicine. He received an M.D. with Honours from the University of Buenos Aires in Argentina in 1979.
Montaner originally planned on following his father's career in pulmonary medicine, and accepted an invitation to do a one-year post-doctoral fellowship at the University of British Columbia in 1981 in the Pulmonary Research Laboratory, which was directed at the time by James C. Hogg. His initial research focused on animal models of acute lung injury. Montaner initially planned on returning to Argentina after completing his fellowship. After meeting his future wife at St. Paul's Hospital in the early 1980s, he decided to remain in Canada. He completed his residency at the University of British Columbia in the Department of Internal Medicine and Respiratory Medicine and was appointed Chief Resident for the Department of Medicine from 1986 to 1987.
Montaner then joined the faculty at St. Paul's Hospital/University of British Columbia in Vancouver, British Columbia, in 1987. John Ruedy, at the time the head of the Department of Medicine at St. Paul's Hospital, invited him to run the new HIV department that was being established in response to the emerging AIDS crisis. Ruedy appointed him as the director of the AIDS Research Program and the Infectious Disease Clinic in 1989. Montaner's shift to HIV research began when he encountered AIDS patients with Pneumocystis carinii pneumonia while completing his training in pulmonary medicine. He encountered the opportunity to test AZT monotherapy for HIV as part of his work on PCP, which sparked an interest in HIV research.
Montaner was the only member of the HIV department at St. Paul's Hospital when it was first founded. He became the founding co-director of the Canadian HIV Trials Network in 1990 with Martin Schechter. In 1992, he was joined by Michael O’Shaughnessy to found the B.C. Centre for Excellence in HIV/AIDS in 1992.
Montaner was appointed a National Health Research Scholar of Canada (NHRDP) from 1988 to 1998. In 1996, Montaner presented the results of his pioneering research on triple therapy to treat HIV infections at the XI International AIDS Conference in Vancouver, creating new standard for HIV drug therapy. In 1997, he was appointed a Professor of Medicine at the University of British Columbia.
Montaner served as the president of the International AIDS Society from 2008 to 2010, and as of 2013, continues to serve as an elected member of the Council of the International AIDS Society after his term as president ended. As of 2013, he also serves as the director of clinical activities at the BC Centre of Excellence in HIV/AIDS, a professor of medicine at UBC, physician program director for HIV/AIDS PHC and continues to serve as the director of the John Ruedy Immunodeficiency Clinic at St. Paul's Hospital.
Montaner is the editor of the B.C. Centre Therapeutic Guidelines and oversees its Drug Distribution Program. In 2002, he was awarded the $1 million Distinguished Researcher Award in HIV.1 He was awarded the Avant-Garde Award of $2.5 million over 5 years, from the National Institute on Drug Abuse of the National Institutes of Health, in support of the "Seek and Treat for Optimal Outcomes and Prevention in HIV & AIDS in IDU (STOP HIV/AIDS)" strategy of treatment as prevention in 2010.
Research Respiratory medicine research
As a post-doctoral fellow and resident, Montaner's research was initially focused on respiratory medicine. He participated in and led a series of studies on the role of adjunctive corticosteroids in treating Pneumocystis carinii pneumonia (PCP) patients. PCP is an opportunistic infection commonly found in AIDS-stage HIV positive patients and was one of the major killers of HIV-positive patients at that time. Montaner and his colleagues found that oral corticosteroid treatment administered early to AIDS patients experiencing their first moderate to severe P. carinii pneumonia episode prevented early deterioration and improved oxygen saturation, a key indicator of survival in PCP patients. Montaner and the study's co-authors found that only 5.6% of the patients given Prednisone (a corticosteroid) reached the study-end point of a 10% decrease in oxygen saturation compared to 42.1% of the patients on the placebo drug. The Prednisone group also demonstrated increased long-term exercise tolerance, another indicator of long-term survival.
As a result of this study, Montaner was one of the first doctors to implement the strategy of treating PCP patients with steroids. The approach of treating immunosuppressed patients with steroids, which are anti-inflammatory drugs, was unorthodox at the time but Montaner pursued this strategy as he "believed [HIV] was a matter of immune dysregulation as much as suppression.". Montaner and his colleagues published their findings in Chest in 1989 and the Annals of Internal Medicine in 1990. Montaner's research and similar findings from other pulmonary researchers at the time led to the release of a consensus statement from a NIH-University of California Expert Panel recommending the treatment of HIV-positive PCP patients with corticosteroids.
HIV/AIDS research
Montaner has authored over 450 publications on HIV/AIDS dating back to the late 1980s. After he was appointed the director of the AIDS Research Program and the Immunodeficiency Clinic at St. Paul's Hospital; Montaner focused his research on antiretroviral therapy and HIV treatment regimes.
Triple therapy (HAART)
His research in the mid-1990s contributed to the development and implementation of anti-HIV triple-drug therapy (HAART). At the XI International AIDS Society-USA (IAS-USA) Conference in 1996, Montaner presented the findings of the INCAS group, which consisted of HIV-positive cohorts in Italy, Netherlands, Canada, Australia and the United States. The INCAS group's initial findings were that treating HIV-1 positive adults with a combination of three drugs (nevirapine, didanosine and zidovudine) resulted in a greater decrease in viral load than a combination of two drugs. He also announced an association between decreased viral load and improved outcomes, as well as decreased mortality. The study also reported a decrease in viral load of less than 20 HIV RNA copies per mL of blood in some patients in the triple therapy group. The study was conducted as a 52-week double-blind study on 151 antiretroviral-naïve HIV-positive patients that had never had a record of an AIDS-defining condition. This discovery was adopted as part of the antiretroviral treatment guidelines by the IAS and is the basis of the modern-day HAART treatment regimen. Montaner said about the discovery: "The sense of excitement was absolutely palpable. It was incredible. Within months, mortality, death rates and progression to AIDS among people taking triple therapy was down to nothing. This happened in Vancouver."
In 1998, the results of the INCAS randomized double-blind clinical trial examining a combination of Nevirapine, Didanosine and Zidovudine as treatment for HIV-positive patients was published in the Journal of the American Medical Association. This paper reported the data initially presented by Montaner and his colleagues at the XI IAS Conference. The paper demonstrated their findings of a greater decrease in plasma HIV-1 RNA (an indicator of HIV viral load) in patients treated with the combination of the three drugs as opposed to patients treated with a regimen of only two of the drugs, which was the standard of care in the mid 1990s. The percentage of patients in the triple drug therapy group with a viral load below 20 copies per mL after 52 weeks of treatment was 52%, compared to 12% for patients in the zidovudine plus didanosine group and 0% for the zidovudine plus nevirapine group (P < 0.01). The trial demonstrated that a triple therapy regimen of nevirapine, didanosine and zidovudine given as a combination reduces viral load among HIV-1 positive adults significantly more than a combination of two of the drugs.
Drug resistance
Montaner and his colleagues at the BC-CfE have conducted research on the development of drug resistance to triple-drug therapy cocktails. In 2005, Montaner and his colleagues published a study in The Journal of Infectious Diseases characterizing the development of antiretroviral resistance among a cohort of 1191 initially antiretroviral-naïve HIV positive British Columbians. The results indicated that a high baseline plasma viral load, poor adherence and the inclusion of non-nucleoside reverse-transcriptase inhibitors (NNRTIs) in the initial drug cocktail were all predictors of development of antiretroviral resistance. Montaner was coauthor on Robert Hogg's paper demonstrating that resistance to NNRTIs resulted in greater mortality than the development of resistance to protease inhibitors. Montaner and the BC-CfE continue to focus research efforts on multi-drug resistance and its predictors.
Treatment as prevention strategy (TasP)
Montaner was also central in the creation and implementation of the Treatment as Prevention strategy (TasP). The Treatment as Prevention strategy is based on the premise that administering HAART to all medically eligible HIV positive individuals will decrease transmission rates. In 2006, Montaner, Robert Hogg, and colleagues at the B.C. Centre for Excellence in HIV/AIDS published an article in The Lancet promoting early and global access to HAART treatment as a strategy not just to decrease mortality and progression to AIDS, but also as a method of reducing HIV transmission. HAART treatment has been found to reduce viral load to undetectable levels in the female genital tract, semen and blood. Montaner et al. suggested that this would therefore decrease transmission risk, based on studies of significant decreases in mother-to-child transmission with the use of HAART. Montaner and his colleagues presented evidence from multiple clinical trials and cohort studies showing reduction in HIV transmission among sero-discordant couples with the use of HAART, as well as regional negative correlations between increased HAART access and use and HIV transmission rates.