Written by: Dr. Jared Walters (he/him) and Dr. Matthew Numer (he/him)
Edited by: Zahra Taboun (she/her).
“As of right now, we have all the tools necessary to eradicate new HIV infections”.
Pre-exposure prophylaxis (PrEP) is that tool that can eradicate new HIV infections. PrEP is a once daily pill that when taken properly is over 99% effective at preventing HIV infection (1). HIV spreads through the body by replicating itself in white blood cells. PrEP prevents the infection of HIV by blocking the virus from being able to enter and replicate within the white blood cells and thus prevents the HIV virus from developing in your body (2). For populations who are at higher risk of being infected by HIV, such as intravenous drug users and sexually active LGBT2SQ men, PrEP can be a life changing and saving drug. Access to the drug, however, for most Canadians is still limited and far too expensive for most to afford.
Health Canada approved PrEP in 2016, but the annual out of pocket cost for an individual is nearly $3000 (3). Six provinces and territories – British Columbia, Alberta, New Brunswick, Prince Edward Island, Northwest Territories and Nunavut – provide PrEP for free, the other provinces such as Nova Scotia do not. In 2018, following a spike in new HIV cases in Nova Scotia, which saw the number of new cases double, the province added PrEP to its list of covered drugs by the provincial pharmacare system. But, pharmacare in Nova Scotia is not free or universal, those enrolled must first apply to be accepted and still pay for part of the drug’s cost and make an annual co-payment. This is simply not enough; a comprehensive sexual health plan is needed in Nova Scotia that includes funding for universal coverage and sexual health clinics, and increased awareness of PrEP to at-risk populations, racialized communities, and medical practitioners to tackle HIV.
Under the current pharmacare system in Nova Scotia, PrEP is not widely accessible to the populations who need it most.
Under the current pharmacare system in Nova Scotia, PrEP is not widely accessible to the populations who need it most. In the first five months of PrEP in pharmacare, only nine people were approved (4). Data from other provinces clearly shows that making PrEP free both drastically improves the amount of people taking the drug and reduces new HIV cases. British Columbia saw new HIV cases drop to a record low following universal coverage of PrEP and expect to see an 86% reduction of new HIV cases by 2026 (5). Comparatively, Ontario, where 77% of PrEP users pay for the drug themselves, has not had a reduction in new HIV cases (3). Furthermore, when Alberta provided PrEP for free, they saw usage of the drug jump from 6% to 15% in LGBT2SQ men between 2018-2019. In the same period when Nova Scotia added PrEP to pharmacare, usage from LGBT2SQ men only increased from 8% to 9% (6). The men surveyed in this study also stated that in Nova Scotia, cost of the drug was the largest barrier to access. Data clearly shows that making PrEP free increases its use and has an immediate impact on reducing new HIV cases.
While the cost of the drug for an individual can be expensive, it is significantly cheaper than HIV treatment. The cost to provide the drug to 500 people in Nova Scotia, would cost at most $1.5 million a year. The province already spends over $6 million in HIV/AIDS treatment each year. Each new HIV case can cost $3.1 million over the course of an individual’s lifetime to treat and Nova Scotia currently averages 15-17 new HIV cases each year (7). Funding of universal PrEP coverage makes economic sense to the over stressed Nova Scotia Health Authority both as a short- and long-term financial investment.
Funding of PrEP, however, is just part of a much needed comprehensive sexual health plan as funding of sexual health clinics and awareness are also essential. Alongside daily use of PrEP, regular three-month STBBI testing is also important to make sure the drug is working effectively. Regular and affordable STBBI testing is not always available in the province. In Nova Scotia, where over 50,000 people are currently waiting to be assigned a family doctor, many LGBT2SQ men do not have access or feel comfortable getting regular STBBI tests from a family physician. The Halifax Sexual Health Clinic is the only place in mainland Nova Scotia that offers anonymous STBBI testing. This overburdened and underfunded clinic cannot keep up with testing demands of the public (8). Further, research shows that these types of clinics are preferred by the LGBT2SQ population to receive testing and seek access to PrEP (6). Funding of this and other clinics is an important step in reducing HIV and other STBBIs.
A comprehensive sexual health plan is needed in Nova Scotia that includes funding for universal coverage and sexual health clinics, and increased awareness of PrEP to at-risk populations, racialized communities, and medical practitioners to tackle HIV.
Lastly, PrEP is a relatively new drug and as a result, awareness of its existence and benefit is key. Data shows that awareness of PrEP in LGBT2SQ populations is increasing year after year, but there is still a portion of at-risk populations that are unaware of this drug. Likewise, knowledge of PrEP is growing in medical communities, but many primary care physicians and nurses are still not aware and rely on the patient to be knowledgeable (9). Educational interventions for doctors about PrEP along with universal coverage can have a major impact in HIV reduction in Nova Scotia (10).
As well, research in British Columbia and Ontario show that racialized groups, such as Indigenous and Black communities were not targeted in PrEP awareness campaigns and overall have less knowledge of the drug despite being communities with higher HIV infection rates. Knowledge of PrEP needs to be targeted more towards these underserved communities to have a greater impact on HIV reduction.
Nova Scotia, along with the rest of Canada has the tools and ability to effectively eradicate new HIV infections and funding, access, and education need to be the focus of a comprehensive sexual health plan for the province.
References:
1. Anderson, P., et al. (2012). Emtricitabine-tenofovir concentrations and pre-exposure prophylaxis efficacy in men who have sex with men. Science Translational Medicine, 12(4), 151. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3721979/
2. McPhee, J. (2019, December 2). NDP, AIDS coalition push Nova Scotia to cover preventative drug. Saltwire. https://www.saltwire.com/halifax/news/local/ndp-aids-coalition-push-nova-scotia-to-cover-preventative-drug-383346/#.XeW6qulcaiU.facebook
3. Cooke, A. (2021, April 15). Why an HIV prevention drug isn’t getting into the hands of those who need it most. CBC News. https://www.cbc.ca/news/canada/nova-scotia/ns-pharmacare-prep-hiv-prevention-drug-1.5984438
4. d’Entremont, Y. (2018, November 28). Advocates, NDP implore Nova Scotia government to cover HIV-prevention drug. Toronto Star. https://www.thestar.com/halifax/2018/11/28/advocates-ndp-implore-nova-scotia-government-to-cover-hiv-prevention-drug.html
5. B.C. Ministry of Health. (2018) Celebrating six months of success preventing new HIV infections throughout B.C. https://news.gov.bc.ca/releases/2018HLTH0065-001291
6. Community-Based Research Centre. (2021) Sex now survey. https://www.cbrc.net/ourstats
7. Canadian AIDS Society, (2011) The Economic Cost of HIV/AIDS in Canada. http://www.cdnaids.ca/wp-content/uploads/Economic-Cost-of-HIV-AIDS-in-Canada.pdf
8. Chiu, E. (2018, September 27). Doctor shortage forces Halifax clinic to cut STI testing despite growing need. CBC News. https://www.cbc.ca/news/canada/nova-scotia/sti-hiv-testing-halifax-sexual-health-clinic-funding-1.4841002
9. McGinn, S. (2016, November 29). “Highly effective” HIV prevention drug still hard to access for Canadians at risk. CUSJC. http://cusjc.ca/finch/2016/11/29/highly-effective-hiv-prevention-drug-still-hard-to-access-for-canadians-at-risk/
10. Sinno, J., Doria, N., Cochkanoff, N., Numer, M., Nyeydli, H. & Tan, D. (2018) Attitudes and Practices of a Sample of Nova Scotian Physicians for the Implementation of HIV Pre-Exposure Prophylaxis. HIV/AIDS – Research and Palliative Care, (13), 157-170.
