The challenge of accessing PrEP in Canada
I caught up with Michael Kwag, director of the Community Alliance project for Canada’s Community-Based Research Centre for Gay Men’s Health, to talk about the impact of PrEP for gay men in Canada.
What are some of the biggest health challenges that gay men in Canada are currently facing?
HIV and sexually transmitted infections such as gonorrhoea, syphilis, and HPV continue to affect gay men and other men who have sex with men in Canada at significantly higher rates compared to other populations. Gay men are 131 times more likely than other men in Canada to become infected with HIV.
Beyond sexual health, mental health - anxiety, depression, suicide - and substance use - alcohol, smoking, crystal meth - remain important health issues for many gay men in Canada, and often intersect with HIV and STI vulnerability. Despite significant social progress of LGBTQ communities in Canada, experiences of discrimination and harassment are commonly reported by gay men and other MSM in population health surveys.
How do gay men access PrEP in Canada?
It depends primarily on where you live, and in many cases, whether you have private health insurance. In Canada, healthcare is delivered by provinces, not the federal government, meaning each province has different systems for access. In British Columbia, and most recently in Saskatchewan, PrEP is fully covered by the provincial government for those at risk. In BC, PrEP is provided through a centralized HIV drug program which also covers HIV treatment and care. First Nations and Inuit people across Canada are also able to access PrEP through the Non-Insured Health Benefits Program.
In other provinces, such as Ontario, Quebec, and most recently in Nova Scotia, PrEP is covered through public pharmacare programs for those who are enrolled - mostly low-income, seniors, or people with disabilities. While this can help some with accessing PrEP, the deductibles can be prohibitive depending on your income, not to mention the significant time and energy required to enrol in these programs. For this reason, private health insurance remains an important mechanism for access for many gay men. Unfortunately, this leaves too many gay men without satisfactory options for PrEP access due to not having private drug coverage or being enrolled in public programs due to the high costs.
Other provinces such as Alberta are engaging in ongoing consultations with community and expert stakeholders to determine their province’s plan for PrEP access - for example, full coverage as in BC, or coverage via public, income-tested health insurance programs such as ON or QC. Another option that’s available to Canadians living by the US border is overseas drug importation through an online pharmacy via the US. Canada doesn’t permit direct mailing of drugs or medicines into Canada, but Canadians are allowed to bring up to a three-month supply of medications through the border. This offers a cheaper method to purchase PrEP outright, for approximately $50CAD per month compared to $200–250 CAD. But you have to live near the US border or be willing to drive great distances.
Is the availability of PrEP helping to reduce the rates of HIV transmission in Canada?
We don’t have enough data to answer that question definitively, at least not yet. Access to PrEP has improved significantly over the past 1–2 years, and we expect that current studies which are monitoring PrEP in Canada will report similar reductions in HIV incidence as seen in other jurisdictions which have scaled-up PrEP, such as London, UK, or San Francisco.
Do you encourage event-based or on-demand dosing for PrEP users?
Officially, no. Most Canadian protocols are based on daily use of PrEP, not on-demand. However, many front-line organisations and doctors are educating their patients about on-demand.
Does PrEP mean that the battle against HIV has been won?
No. We’re still in the early stages of getting PrEP more accessible and into the hands of those that need it. Much of the attention has been placed on first making PrEP more available and accessible - much work remains still in terms of ensuring there are effective and sustainable PrEP delivery models to get PrEP into the hands that need it the most.
Research shows that access to PrEP, and health care services more generally, is uneven, due to service barriers like stigma and cultural insensitivity often faced by people of colour, people living in non-urban settings, and other marginalised populations. While we remain confident that improved access and accessibility of PrEP will reduce HIV infections, we still have much more work to ensure our systems are equitable and effective, including emphasis on reaching the un-diagnosed.
Have the safer sex messages regarding condoms become superfluous?
No. Condoms have and continue to hold an important place in our safer sex toolkit. PrEP isn’t for everyone, and doesn’t protect against STIs like gonorrhoea and syphilis which remain prevalent infections among gay men in most urban networks. It’s also important to remember that not everyone can access PrEP - several provinces, including Canada’s most populous province Ontario, have gaps that make accessing PrEP challenging.
What the likelihood that the HIV virus will mutate or develop a resistance to PrEP?
Based on the current evidence, for which there have only been two reported cases globally of PrEP failure due to drug resistant HIV, we think the risk of acquiring HIV in those cases is exceedingly rare. However, more research on the prevalence of Truvada-resistant strains of HIV is needed.
Are we living in a post-HIV world?
In some ways yes, but in other ways, maybe not. We think it’s important to acknowledge that gay men’s health needs and interests span well beyond HIV, and that’s true for many HIV-positive and HIV-negative gay men. Biomedical advances in HIV treatment and prevention such as U=U and PrEP are markers of progress in our fight against HIV and our ability to manage it into our daily lives. Mental health issues such as body image, anxiety, and substance use are frequently listed as priority topics in community events, sometimes over HIV. Suicide took the lives of more gay and bisexual men in 2015 than HIV.
But despite all the progress with HIV prevention and treatment, we know that the stigma of HIV remains in the lives of both positive and negative men. We continue to learn from communities and populations who face ongoing barriers to accessing basic sexual health services such as HIV and STI testing, much less access to PrEP which remains a pipe-dream to many gay men in Canada depending on where they live and what their financial circumstances may be.
Does the health service in Canada have sufficient resources to meet the needs of gay men?
We believe it does, but much work remains in ensuring that the Canadian health system is appropriately equipped and funded to support the diverse needs of our communities. Even on an issue like HIV - which has taken centre stage in gay men’s health - the availability and accessibility of services, such as testing, let alone PrEP, varies markedly across the country, and often within cities and provinces.
Our attention to HIV has been well-justified, but also comes at the cost of not looking at gay men’s health needs more broadly - research on issues such as HPV and anal cancer among HIV-positive gay men suggest that significantly more resources and funding need to be invested into the health system to appropriate address population need.