A state in Australia has cut new HIV infections by 25 percent in less than two years. San Francisco has a new goal to reduce transmission of HIV by 90 percent by 2020. A London clinic (in the U.K.) cut new infections by 90 percent in just three years.
Pre-exposure prophylaxis, or PrEP, is a new tool that appears to be making a major impact on reducing new HIV infections. Jurisdictions around the world have demonstrated that incorporating PrEP into standard HIV prevention could potentially eradicate HIV. But in Ontario, only a small percentage of people who could benefit from PrEP are using it.
What is PrEP and how do people use it?
Rather than treat HIV, PrEP prevents the virus from being transmitted. PrEP is typically a combination of two drugs that have been used for HIV treatment for years: tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC). PrEP is usually taken as one pill a day during periods of a person’s life when they are engaging in activities that put them at an elevated risk of acquiring HIV (such as sex without a condom, or sharing injection drug equipment). PrEP can cause minor side effects such as gastrointestinal upset and headaches, which usually dissipate, and may cause bone thinning (however, this is unlikely to cause an increased risk of fractures). The most serious adverse effect is impairment of kidney function, which is rare and usually normalizes if the medication is stopped or changed.
PrEP is highly effective at preventing HIV. Kevin Woodward, an infectious disease specialist and associate professor of medicine at McMaster University, says that “in people who take [PrEP] every day and don’t miss doses, [the] quoted rate of efficacy is probably greater than 99 percent.” This was demonstrated in the iPrEx study.
Who can benefit from PrEP?
James Owen, an HIV primary care physician at St Michael’s Hospital in Toronto, says, “PrEP is for anyone who is HIV-negative but at high risk of acquiring HIV. This can include men who have sex with men, transgender women, people who use IV drugs and some other at-risk populations.” He goes on to say that PrEP may not be indicated for every person in these groups, and that starting PrEP is an “individualized [decision], taking into account the patient’s own preferences, behaviours and the overall prevalence of HIV within their community.” Guidelines have been established in several jurisdictions, including Canada, in an attempt to advise physicians as to who could benefit from PrEP and should be offered it. However, critiques of these guidelines have raised concerns that some women and people from African, Caribbean and Black (ACB) communities would not be offered PrEP as per the guidelines, when in fact they could benefit.
When it comes to the individual benefits of PrEP, Ryan Lisk, director of community health programs at the AIDS Committee of Toronto (ACT), says that PrEP is an “an effective prevention option, whether condoms are being used or not.” Lisk is open about his own use of PrEP and says, “I like PrEP in that the onus is on me. [It’s] my proactive attempt at doing what I need to manage my health.”
Paul MacPherson, an infectious disease specialist at the Ottawa Hospital who runs a PrEP clinic, has found that PrEP allows his patients to “[engage] in sexual activity with less anxiety.” Lisk agrees and says that PrEP “reduces that anxiety and allows me to have the kinds of sex that I may want.”
HIV infections and PrEP in Ontario
Despite current prevention efforts, the number of new HIV infections each year in Ontario has not decreased significantly over the past decade, and there are still nearly 900 new diagnoses each year.
PrEP was approved for use as an HIV prevention tool by Health Canada in 2016. Recent studies by Tan et al. estimate that about 4,000 people in Ontario are using PrEP, but that at least 30,000 could benefit from it. Therefore, only about 13 percent of people who could benefit from PrEP are actually using it.
Other jurisdictions have been able to distribute PrEP to much larger proportions of their populations. In New South Wales, Australia, a targeted role-out of PrEP estimated that around 3,300 gay men were at risk and could benefit from PrEP. In just eight months, 3,700 at-risk gbMSM started on prep, and there was a 25 percent reduction in HIV infections in the following 12 months.
Mark Hull, an infectious disease specialist at St. Paul’s Hospital in Vancouver and researcher at the British Columbia Centre for Excellence in HIV/AIDS (BC-CfE), estimates that since January 2018, when PrEP started to be universally funded for anyone at high-risk for HIV in B.C., about 4,000 people (which amounts to a larger percentage of B.C.’s population than of Ontario’s) have been using it. Hull thinks that in addition to universal funding, sexual health clinics played an important role in distributing PrEP by accepting it as “part of their new mandate.” Already B.C. is forecasting that 2019 will have the lowest number of new HIV infections recorded since 2003. By promoting PrEP and other HIV prevention strategies, the BC-CfE has a goal to essentially eradicate HIV in B.C. within a decade.
Barriers to accessing PrEP in Ontario
Awareness of PrEP
MacPherson thinks a key barrier to people accessing PrEP is a lack of awareness. In some communities, such as some ACB and Indigenous communities, this has been shown to be especially concerning, and may be related to stigma, inequities in health care access and health education, and other disparities.
When it comes to government and public health initiatives to increase awareness of PrEP, Woodward thinks “there’s been a lot of missed opportunity,” and that there should be a “massive, massive public health intervention.” He thinks Ontario is far behind jurisdictions such as New York City, where the public health authorities have made major pushes to increase PrEP uptake among groups at risk for HIV.
When asked about the government’s role in promoting PrEP across Ontario, a spokesperson for the Ministry of Health and Long-term Care (MOHLTC) replied: “The Ministry supports a community-based response to HIV in Ontario and funds many community-based organizations across the province that raise awareness of PrEP and all methods of effective HIV prevention.” The MOHLTC also mentioned that a “series of forthcoming resources will work to increase the overall profile of PrEP in Ontario and system capacity for delivering it. They include a PrEP clinic locator, education modules and risk assessment supports, and will become available through the Ontario HIV Treatment Network’s website.”
However, Woodward is concerned that because of announced plans to consolidate the province’s 35 public health units into 10, “programs that we had started to work on with some of the public health units have been put on hold.” He feels that PrEP is often “put on the backburner.”
Perception of HIV risk
“Assessing your own risk for HIV is something that people do quite badly,” says Hull, and there are studies supporting this. Individuals who could benefit from PrEP may not even consider it an option, and this may be exacerbated by the stigma that PrEP is for people who engage in promiscuous and risky sexual behaviours, or is purely for gay men. MacPherson has heard of people declining PrEP because they think it’s for “sluts.” Lisk has heard the term “Truvada whore.”
Some PrEP providers in B.C. and Ottawa are trying to reach people who may benefit from PrEP through existing sexual health services. If a person comes for STI testing, for example, there is an opportunity to assess whether they would benefit from PrEP, discuss the option, and link them to the appropriate services.
Accessing a health care provider
Finding a health care provider who is knowledgeable about HIV and PrEP is another challenge. Woodward says: “If I’m somebody who’s interested in PrEP, and I live outside the GTA, it’s not very easy to figure out where to go.” He thinks “this is really a primary care intervention,” and “you don’t need an infectious disease specialist to give PrEP.”
And yet, says Owen, PrEP is still mostly prescribed by specialists. He hopes that “one day every family doctor [will] be able to, first, identify their patients who are at high risk of acquiring HIV, and second, prescribe HIV pre-exposure prophylaxis when it is indicated.” However, he acknowledges that “it will be an ongoing challenge to reach practising family physicians, and to support them in learning about PrEP.” In some cases, he says, it may be on the patients themselves to “offer suggestions for resources that a family doctor can review.”
Truvada, the most common brand-name form of PrEP, costs close to $1,000 per month in Ontario. Generic TDF/FTC, which costs about $220 per month, has been available since September 2017.
There are several routes through which Ontarians can get at least partial drug coverage. Currently, the major gaps in coverage for Ontarians are the same as for most drugs: people between 25 and 65 who don’t have private insurance, or for whom it is inadequate, and who are ineligible for provincial or federal drug programs.
Due to recent changes to OHIP+, people younger than 25 are not eligible for public drug coverage if they have access to a private drug plan, regardless of how much that plan covers. In addition, if a young person is uncomfortable discussing HIV prevention with their family, they may not be able to use their family’s insurance plan, while still being ineligible for OHIP+ based. This concerns Lisk, who points out that young people are a high risk group for HIV infections.
Still, says Woodward, “realistically, there are very few people in Ontario [for whom] we cannot get coverage or they cannot afford [PrEP].” But Lisk thinks that while coverage may be available to most Ontarians, many people are not aware of it or how to access it. This can be a deterrent to seeking PrEP in the first place, especially for people who think the price tag is $1,000 per month. Woodward agrees and thinks that the “perception… that [PrEP] is too expensive” is a major barrier.
While increasing awareness of coverage programs could theoretically improve PrEP access, other jurisdictions have shown success by providing PrEP free to anyone who meets criteria for being at a high risk for acquiring HIV. Hull thinks universal funding for PrEP in B.C. played a major role in increasing PrEP uptake rapidly. However, he recognizes that the health system also needs knowledgeable health care providers and targeted public awareness and education campaigns to improve PrEP access.
When asked about the possibility of funding PrEP for all Ontarians, the MOHLTC outlined the current programs available to aid drug funding for Ontarians and stated: “We are aware of the PrEP access programs that have recently been implemented across Canada and will analyze their results as they become available.”
The future of HIV in Ontario
British Columbia and Australia have shown that if PrEP is made a priority, HIV infections could be reduced drastically in a short period of time, and could potentially lead to its total eradication. Time will tell if Ontario will join these jurisdictions.