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The Best is Yet to Come: Achieving Successful Implementation of PrEP is the Next Step in Ending the HIV Epidemic

HIV incidence has a disproportionate impact on gay, bisexual and other men who have sex with men (gbMSM). While only accounting for a small fraction of the Canadian Population (3-4%), gbMSM accounted for 60.9% percent of reported HIV cases in 2017.1 In fact, surveillance estimates suggest that gbMSM are more than 131 times more likely to acquire HIV than other Canadian men.2 Furthermore, intersecting identities and experiences place some subgroups of gbMSM at even greater risk. For instance, a cohort study co-led by Lachowsky of gbMSM running for the past 7 years in Metro Vancouver recently reported that Indigenous gbMSM are 55% more likely to report being HIV-positive than White gbMSM.3 Nationally, 34.5% of new HIV infections were among White individuals, 25.3% were among Black individuals, and 20.1% were among Indigenous individuals.1 Based on the 2016 Census, only 3.4% of the Canadian population is Black and only 4.7% is Indigenous.4 Previous studies have even shown that the diffusion and implementation of biomedical HIV preventions strategies tend to be less effective among gbMSM of colour5,6 – highlighting how multiple intersecting identities contribute uniquely to health inequities.7,8 Further complicating the matter, routes of HIV transmission differ based on ethnicity with Indigenous people accounting for 68.1% of HIV acquisitions through injection drug use.1

At the provincial level the British Columbia Centre for Disease Control (BCCDC) reports that gbMSM, Indigenous people identifying as First Nations, and people who use drugs (PWUD) are at the greatest risk for HIV acquisition.9 In fact, gbMSM account for 57.0% of new all HIV infections in BC.9 Among gbMSM, most new diagnoses of HIV occur in men born after 19809 and demographic shifts in new HIV diagnoses for gbMSM has been observed along ethnic lines with most recent reports show increasing incidence of HIV in Asian gbMSM.9 Together this evidence suggests that HIV is increasingly concentrated in sub-populations that may not be sufficiently engaged by existing health systems.

In 2009, the province of British Columbia piloted its Seek and Treat for Optimal Prevention of HIV/AIDS (STOP HIV/AIDS)10 program in Vancouver and Prince George. The aim of STOP HIV/AIDS was to evaluate the efficacy of Treatment as Prevention (TasP) – a strategy to reduce HIV morbidity, mortality, and transmission through engaging priority populations in efforts to improve HIV testing, linkage to HIV antiretroviral therapy (ART) and retention in HIV treatment.11 After two years of pilot testing, TasP was recognized world-wide and adopted as the predominant model for HIV prevention in the United States, China, and at the international level by UNAIDS.12 In December 2012, the British Columbia Ministry of Health, introduced its strategic framework for implementing best practices for HIV prevention across the province (From Hope to Health: Towards an AIDS-free Generation).13 Within this framework, gbMSM were identified as a priority population for health intervention, with Indigeneity, injection drug use, and rural residence being identified as key intersections.13 While the priority population framework obscures the underlying drivers of inequalities (e.g., racism, colonization, heteronormativity), it does provide a starting point for identifying individuals who should be considered when implementing programs and policies aimed to address HIV. Yet, over the two years following the introduction of the Hope to Health framework, HIV incidence increased 7.6% (5.2 cases/100,000 in 2012 to 5.6 cases/100,000 in 2014)14 and rates of new HIV cases among gbMSM have essentially stagnated. Acknowledging this, the BC Provincial Health Officer issued their 2014 Annual Report examining the drivers of the persistently high incidence of HIV among gbMSM.7 For the most part, the PHO’s report recommended a scale up of existing activities. However, they also called for the assessment of “pre-exposure prophylaxis (PrEP) as a prevention tool for gay and bisexual men in BC”.7 To our knowledge, this was the first public-facing document published by the Province with a recommendation favouring PrEP implementation. At the time, most people were unaware of Pre-Exposure Prophylaxis,15–22 despite major studies showing the efficacy of PrEP in clinical settings.23–26 Nevertheless, community-based organizations undertook a variety of knowledge mobilization activities to increase awareness of PrEP. For instance, the Health Initiative for Men launched their “Get PrEPed” educational campaign (www.getpreped.ca) and the YouthCO HIV & Hep C Society launched their “PrEP works, stigma doesn’t” social media campaign. Over the course of these campaigns, cohort data from the Vancouver-based Momentum Health study reported that PrEP awareness among HIV-negative gbMSM increased from 18% in 2012 to 77% in 2016.6 Yet, despite the four-fold increase in PrEP awareness, only 1.1% of respondents accessed PrEP by 2016. Indeed, without public funding, access to PrEP was limited to those willing to import the drug via online pharamacies (e.g. Vancouver’s Davie Buyer’s club), pay out-of-pocket premiums ($10,000/year), or pay for extended health benefits which covered the drug.

In early 2016, PrEP was approved for HIV prevention by Health Canada, and the Federal Non-Insured Health Benefits program (FNIB) made PrEP freely available to First Nations and Inuit people. Yet, uptake and awareness of PrEP under these programs was incredibly low – underscoring the reality that PrEP is vulnerable to implementation failures without a more active approach taken among patients and providers.27,28 A few months later, in late-2016, Vancouver Coastal Health (VCH) initiated a publicly-funded HIV PrEP program targeting HIV-negative partners of newly diagnosed people living with HIV. In 2017, Canadian researchers co-authored the Canadian Guidelines on the use of PrEP for HIV prevention.29 Aiming to raise awareness for PrEP and to urge for the wider scale-up of a publicly-funded PrEP program, the Community-based Research Centre (CBRC) held a community-led research summit in November 2017 hosting HIV-prevention experts from across Canada. In December 2017, the province of British Columbia announced that PrEP would be available through the BC Centre for Excellence’s in HIV/AIDS’s (BC-CfE) HIV Drug Treatment program (DTP), which is funded by the Ministry of Health through the B.C. PharmaCare program.30

Since January 1st, 2018 PrEP has been freely available through the BC-CfE’s DTP to all eligible individuals31 who are: (1) assessed as “high risk” of contracting HIV as per clinical criteria by a licensed physician or nurse practitioner; (2) HIV-negative based upon recent HIV testing; (3) enrolled in the BC Medical Services Plan (directly or through the First Nations Health Authority32) or has interim federal health coverage; and (4) confirmed as having adequate renal function. Unfortunately, the transition to the DTP has meant additional barriers to PrEP for First Nations people, and decreased access. Meanwhile, PrEP is available to Inuit peoples through prescribers and pharmacies without pre-authorization based on risk-status, as required by the BC-CfE.

Non-Inuit patients enter the BC PrEP program through a licensed physician or nurse practitioner who provides an HIV test and confirms eligibility. To meet eligibility requirements individuals must be diagnosed as high risk, which is defined as (1) having a score >10 on the HIV Incidence Risk Index for gbMSM (HIRI-MSM) scale;33 (2) previous repeat use of non-occupational post-exposure prophylaxis; (3) reporting an ongoing sexual relationship with a partner who has an unsuppressed viral load; or (4) diagnoses of syphilis or rectal bacterial infection in the past year. While these restrictions in eligibility reduce access to PrEP, particularly for non-gbMSM, these are based on both empirical studies and those assessing the cost-effectiveness of PrEP.34–36 If eligible, enrolment applications are submitted by prescribers to the BCCfE and 30-day prescriptions are filled. In the Metro Vancouver area, prescriptions are filled by St. Paul’s Ambulatory Pharmacy in downtown Vancouver. Primary care providers may request an alternative pick-up location, such as the physician’s office or a local pharmacy for those living outside of Vancouver. After HIV-negative serostatus is confirmed in follow-up testing, patients become eligible for 90-day refills. At each refill, participants are re-screened for eligibility.

While this program is revolutionary, the implementation of PrEP faces a number of barriers ranging from patient and provider awareness of PrEP to geographic barriers to care for rural and remote people. There is a need to understand these barriers, and more importantly identify the best practices in overcoming them. This will require significant investment and province-wide collaborations between researchers, community leaders, policy and decision makers, and public health leaders. However, if we can come together, then truly, the best is yet to come.

REFERENCES

1.           Public Health Agency of Canada. HIV in Canada, 2017 [Internet]. 2019 Feb [cited 2019 Feb 15]. Report No.: CCDR: 2018;44(12). Available from: https://www.canada.ca/en/public-health/services/reports-publications/canada-communicable-disease-report-ccdr/monthly-issue/2018-44/issue-12-december-6-2018/article-3-hiv-in-canada-2017.html

2.           Yang Q, Ogunnaike-Cooke, S S, Yan P, Rhemis R, Schanzer D. Comparison of HIV Incidence Rates Among Key Populations in Canada [Internet]. AIDS Poster Exhibition; 2014; Melbourne, Austrailia. Available from: http://pag.aids2014.org/Abstracts.aspx?AID=3904

3.           Gbolahan Olarewaju. Differences and similarities in measures of mental well-being by race/ethnicity among men who have sex with men in Vancouver, BC [Internet]. The Summit 2018; 2019 Nov 1; Vancouver. Available from: http://cbrc.net/update/11-2018/summit-2018

4.           Government of Canada SC. Census Profile, 2016 Census [Internet]. 2017 [cited 2019 Feb 15]. Available from: https://www12.statcan.gc.ca/census-recensement/2016/dp-pd/prof/index.cfm?Lang=E

5.           Card KG, Armstrong HL, Lachowsky NJ, Cui Z, Sereda P, Carter MA, et al. Belief in Treatment As Prevention and Its Relationship to HIV Status and Behavioral Risk. JAIDS J Acquir Immune Defic Syndr [Internet]. 2017 Oct 4 [cited 2017 Oct 13];Publish Ahead of Print. Available from: http://journals.lww.com/jaids/Abstract/publishahead/Belief_in_Treatment_As_Prevention_and_Its.96831.aspx

6.           Mosley T, Khaketla M, Armstrong HL, Cui Z, Sereda P, Lachowsky NJ, et al. Trends in Awareness and Use of HIV PrEP Among Gay, Bisexual, and Other Men who have Sex with Men in Vancouver, Canada 2012-2016. AIDS Behav. 2018 Jan 17;

7.           British Columbia Provincial Health Officer. HIV, Stigma and Society: Tackling a Complex Epidemic and Renewing HIV Prevention for Gay and Bisexual Men in British Columbia [Internet]. Provincial Health Officer’s 2010 Annual Report.; 2014. Available from: http://www2.gov.bc.ca/assets/gov/health/about-bc-s-health-care-system/office-of-the-provincial-health-officer/reports-publications/annual-reports/hiv-stigma-and-society.pdf

8.           Public Health Agency of Canada. Population-Specific HIV/AIDS Status Report: Gay, Bisexual, Two-Spirit and Other Men Who Have Sex With Men - Public Health Agency of Canada [Internet]. 2014 [cited 2015 Aug 4]. Available from: http://www.phac-aspc.gc.ca/aids-sida/publication/ps-pd/men-hommes/index-eng.php

9.           BC CDC. STI/HIV Annual Report [Internet]. Vancouver, Canada: British Columbia Centre for Disease Control; 2018. Available from: http://www.bccdc.ca/health-professionals/data-reports/hiv-aids-reports

10.        Gustafson R, Montaner J, Sibbald B. Seek and treat to optimize HIV and AIDS prevention. Can Med Assoc J. 2012 Dec 11;184(18):1971–1971.

11.        Treatment as Prevention [Internet]. BC Centre for Excellence in HIV/AIDS. [cited 2015 Oct 8]. Available from: http://www.cfenet.ubc.ca/tasp

12.        UNAIDS. 90–90–90 - An ambitious treatment target to help end the AIDS epidemic [Internet]. 2014 Oct [cited 2016 Sep 15]. Available from: http://www.unaids.org/sites/default/files/media_asset/90-90-90_en_0.pdf

13.        From Hope to Health: Towards an AIDS-free Generation [Internet]. British Columbia Ministry of Health; 2012 Dec. Available from: https://www.health.gov.bc.ca/library/publications/year/2012/from-hope-to-health-aids-free.pdf

14.        Reportable Diseases Data Dashboard [Internet]. British Columbia: British Columbia Centre for Disease Control; 2017 [cited 2019 Feb 15]. Available from: http://www.bccdc.ca/health-professionals/data-reports/reportable-diseases-data-dashboard

15.        Al-Tayyib AA, Thrun MW, Haukoos JS, Walls NE. Knowledge of pre-exposure prophylaxis (PrEP) for HIV prevention among men who have sex with men in Denver, Colorado. AIDS Behav. 2014 Apr;18 Suppl 3:340–7.

16.        Dolezal C, Frasca T, Giguere R, Ibitoye M, Cranston RD, Febo I, et al. Awareness of Post-Exposure Prophylaxis (PEP) and Pre-Exposure Prophylaxis (PrEP) Is Low but Interest Is High Among Men Engaging in Condomless Anal Sex With Men in Boston, Pittsburgh, and San Juan. AIDS Educ Prev Off Publ Int Soc AIDS Educ. 2015 Aug;27(4):289–97.

17.        Liu AY, Kittredge PV, Vittinghoff E, Raymond HF, Ahrens K, Matheson T, et al. Limited knowledge and use of HIV post- and pre-exposure prophylaxis among gay and bisexual men. J Acquir Immune Defic Syndr 1999. 2008 Feb 1;47(2):241–7.

18.        Mantell JE, Sandfort TGM, Hoffman S, Guidry JA, Masvawure TB, Cahill S. Knowledge and Attitudes about Pre-Exposure Prophylaxis (PrEP) among Sexually Active Men Who Have Sex with Men (MSM) Participating in New York City Gay Pride Events. LGBT Health. 2014 Mar 13;1(2):93–7.

19.        Young I, McDaid L. How Acceptable are Antiretrovirals for the Prevention of Sexually Transmitted HIV?: A Review of Research on the Acceptability of Oral Pre-exposure Prophylaxis and Treatment as Prevention. AIDS Behav. 2014;18(2):195–216.

20.        Lachowsky NJ, Lin SY, Hull MW, Cui Z, Sereda P, Jollimore J, et al. Pre-exposure Prophylaxis Awareness Among Gay and Other Men who have Sex with Men in Vancouver, British Columbia, Canada. AIDS Behav. 2016 Feb 16;

21.        Walters SM, Reilly KH, Neaigus A, Braunstein S. Awareness of pre-exposure prophylaxis (PrEP) among women who inject drugs in NYC: the importance of networks and syringe exchange programs for HIV prevention. Harm Reduct J. 2017 Jun 29;14(1):40.

22.        Doblecki-Lewis S, Lester L, Schwartz B, Collins C, Johnson R, Kobetz E. HIV risk and awareness and interest in pre-exposure and post-exposure prophylaxis among sheltered women in Miami. Int J STD AIDS. 2016;27(10):873–81.

23.        Grant RM, Lama JR, Anderson PL, McMahan V, Liu AY, Vargas L, et al. Preexposure Chemoprophylaxis for HIV Prevention in Men Who Have Sex with Men. N Engl J Med. 2010 Dec 30;363(27):2587–99.

24.        McCormack S, Dunn DT, Desai M, Dolling DI, Gafos M, Gilson R, et al. Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): effectiveness results from the pilot phase of a pragmatic open-label randomised trial. Lancet Lond Engl. 2016 Jan 2;387(10013):53–60.

25.        Molina J-M, Capitant C, Spire B, Pialoux G, Cotte L, Charreau I, et al. On-Demand Preexposure Prophylaxis in Men at High Risk for HIV-1 Infection. N Engl J Med. 2015 Dec 3;373(23):2237–46.

26.        Volk JE, Marcus JL, Phengrasamy T, Blechinger D, Nguyen DP, Follansbee S, et al. No New HIV Infections With Increasing Use of HIV Preexposure Prophylaxis in a Clinical Practice Setting. Clin Infect Dis Off Publ Infect Dis Soc Am. 2015 Nov 15;61(10):1601–3.

27.        Krakower DS, Mayer KH. The Role of Healthcare Providers in the Roll-Out of PrEP. Curr Opin HIV AIDS. 2016 Jan;11(1):41–8.

28.        Hankins C, Macklin R, Warren M. Translating PrEP effectiveness into public health impact: key considerations for decision-makers on cost-effectiveness, price, regulatory issues, distributive justice and advocacy for access. J Int AIDS Soc [Internet]. 2015 Jul 20 [cited 2019 Feb 23];18(4Suppl 3). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4509900/

29.        Tan DHS, Hull MW, Yoong D, Tremblay C, O’Byrne P, Thomas R, et al. Canadian guideline on HIV pre-exposure prophylaxis and nonoccupational postexposure prophylaxis. CMAJ. 2017 Nov 27;189(47):E1448–58.

30.        Ministry of Health. Preventative medication will protect people at risk of HIV. 2017 Dec 28 [cited 2019 Feb 15]; Available from: https://news.gov.bc.ca/releases/2017HLTH0114-002108

31.        Guidance for the use of Pre-Exposure Prophylaxis (PrEP) for the prevention of HIV acquisition in British Columbia [Internet]. Vancouver, Canada: British Columbia Centre for Excellence in HIV/AIDS; 2018 Sep [cited 2019 Feb 15]. Available from: http://cfenet.ubc.ca/publications/centre-documents/guidance-for-the-use-pre-exposure-prophylaxis-prep-prevention-hiv-acquisition

32.        Eligibility and MSP [Internet]. [cited 2019 Feb 15]. Available from: http://www.fnha.ca/benefits/eligibility-and-msp

33.        Smith DK, Pals SL, Herbst JH, Shinde S, Carey JW. Development of a clinical screening index predictive of incident HIV infection among men who have sex with men in the United States. J Acquir Immune Defic Syndr 1999. 2012 Aug 1;60(4):421–7.

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