HIV/AIDS prophylaxis in British Columbia

Last updated

In January 2018, the provincial government of British Columbia (BC) began providing individuals at high risk of HIV infection with pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) at no cost. [1] High risk individuals include men and trans women who have sex with men, people who inject drugs, and people who have sex with people living with HIV. [1] One year following this policy change, which is delivered as part of the British Columbia Centre for Excellence in HIV/AIDS (BC-CfE)'s Drug Treatment Program, almost 3,300 people have been prescribed with PrEP or PEP. [2]

Contents

The steps for obtaining PrEP in BC are as follows: speaking to a physician, getting some medical tests, enrolling and being given a prescription, and refilling the prescription. [3] The effort was undertaken to better support the UNAIDS "90-90-90: treatment for all" targets. [4]

HIV/AIDS in British Columbia

As part of the global HIV/AIDS epidemic, [5] BC experienced two distinct periods of rapid incidence growth rate. The first was in the 1980s among men who have sex with men, and the second was in the 1990s among injection drug users. [6] At its peak in 1987, the rate of new HIV diagnoses in BC was roughly 31 cases per 100,000 population. [7] The BC HIV incidence rate decreased thereafter and it was not until 2010 that the BC HIV incidence rate was less than the Canadian HIV incidence rate (7 per 100,000 population). [7] As of 2017, the rate of new HIV cases reported in BC was 3.8 per 100,000 population. [8]

Current state

As summarized in the BC Centre for Disease Control's Annual Surveillance Report, rates of new HIV cases differ based on location, gender, ethnicity, sexual orientation, and intravenous drug use. In addition to new HIV cases being highest in the Vancouver Coastal and Island Health Authorities, they were also highest among males, Caucasians (43% of new cases), gay, bisexual and other men who have sex with men (gbMSM), [9] and among people who inject drugs. [8] The dramatic decrease in new HIV cases among people who inject drugs is the main reason why the overall rate of new HIV cases has decreased. [8] With an incidence rate of 182 cases, [8] there are approximately 7,200 people living with HIV in BC. [10]

Policy effects

This policy has expanded access to preventative HIV medication in British Columbia. Individuals at high risk of contracting HIV can apply to receive PrEP no cost. The out-of-pocket cost of emtricitabine/tenofovir, a medication used to prevent HIV, was previously between $250 and $1,000 per month. [11] Because the BC-CfE was able to negotiate a lower price with manufacturers of generic versions of Truvada, [12] the program is able to offer the drug at no cost for high risk individuals. In its first six months, the program cost the BC government around $300,000. [13] Of the nearly 3,300 people being prescribed PrEP through this new policy, 98.4% are male, 0.5% are female, and 1.1% identify as transgender, unspecified, or another form of gender identity. [10] Provincial health authorities estimate that once the program has 5,000 participants, the rate of new HIV cases in BC will fall by 83% by 2026. [13]

Another positive consequence is an uptake in the number of PEP kits being used. Between 2017 and 2018 there was a 23% increase in the number of PEP kit initiations, bringing the number of kit initiations up to 400. [14]

There are also potential long-term savings to government through reduced healthcare costs. By preventing HIV infections, the BC government will save on the lifetime cost of antiretroviral therapy drugs and hospital costs for HIV/AIDS-related treatment. [15] In the German setting, investing in PrEP coverage has a projected savings of €5.1 billion Euros over a 40-year period. [16] In the United States, the medical cost savings for each case of HIV prevented is roughly US$229,800. [17]

Coverage in other areas of Canada

Other considerations

Safe sex

Since PrEP only protects against HIV and does not protect against blood-borne infections (e.g., hepatitis C) or other STIs (e.g., herpes, syphilis, chlamydia, gonorrhoea), [31] there is concern that increasing access to PrEP may increase rates of sexually transmitted infections by encouraging fewer safe sex practices like condom use. [32] [33] Others find evidence that suggests access to PrEP actually decreases the number of sexual partners and the number of men reporting unprotected anal sex. [34]

Barriers to access

Another policy consideration is potential barriers to access. Of current prescribers, 88% pick their medication up directly from St. Paul's hospital while 12% have the medication shipped to their physician's office outside of Vancouver. [35] While the bulk of the program participants live in Metro Vancouver, [2] there is ongoing concern that physician knowledge and access to primary care physicians in areas outside of Metro Vancouver are preventing access. To sign up for the program, a potential participant needs to have a physician submit a form on their behalf to the BC-CfE. Not everyone at risk of contracting HIV has a primary care physician or a physician they feel comfortable enough talking with about their sexual activity and previous drug use. [35] Also, some physicians refuse to fill out the prescription, citing process complexity or instead suggesting the person engage in fewer risky behaviours. [35]

Related Research Articles

Men who have sex with men (MSM) refers to all men who engage in sexual activity with other men, regardless of their sexual orientation or sexual identity. The term was created by epidemiologists in the 1990s, to better study and communicate the spread of sexually transmitted infections such as HIV/AIDS between all sexually active males, not strictly those identifying as gay, bisexual, pansexual or various other sexualities, but also for example male prostitutes. The term is often used in medical literature and social research to describe such men as a group. It does not describe any specific kind of sexual activity, and which activities are covered by the term depends on context. An alternative term, males who have sex with males is sometimes considered more accurate in cases where those described may not be legal adults.

Post-exposure prophylaxis, also known as post-exposure prevention (PEP), is any preventive medical treatment started after exposure to a pathogen in order to prevent the infection from occurring.

HIV/AIDS has been a public health concern for Latin America due to a remaining prevalence of the disease. In 2018 an estimated 2.2 million people had HIV in Latin America and the Caribbean, making the HIV prevalence rate approximately 0.4% in Latin America.

<span class="mw-page-title-main">Needlestick injury</span> Accidental puncture of skin causing contamination

A needlestick injury is the penetration of the skin by a hypodermic needle or other sharp object that has been in contact with blood, tissue or other body fluids before the exposure. Even though the acute physiological effects of a needlestick injury are generally negligible, these injuries can lead to transmission of blood-borne diseases, placing those exposed at increased risk of infection from disease-causing pathogens, such as the hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). In healthcare and laboratory settings globally, there are over 25 distinct types of blood-borne diseases that can potentially be transmitted through needlestick injuries to workers. In addition to needlestick injuries, transmission of these viruses can also occur as a result of contamination of the mucous membranes, such as those of the eyes, with blood or body fluids, but needlestick injuries make up more than 80% of all percutaneous exposure incidents in the United States. Various other occupations are also at increased risk of needlestick injury, including law enforcement, laborers, tattoo artists, food preparers, and agricultural workers.

<span class="mw-page-title-main">Emtricitabine/tenofovir</span> Drug combination for HIV/AIDS prophylaxis and treatment

Emtricitabine/tenofovir, sold under the brand name Truvada among others, is a fixed-dose combination antiretroviral medication used to treat and prevent HIV/AIDS. It contains the antiretroviral medications emtricitabine and tenofovir disoproxil. For treatment, it must be used in combination with other antiretroviral medications. For prevention before exposure, in those who are at high risk, it is recommended along with safer sex practices. It does not cure HIV/AIDS. Emtricitabine/tenofovir is taken by mouth.

<span class="mw-page-title-main">HIV/AIDS</span> Spectrum of conditions caused by HIV infection

The human immunodeficiency virus (HIV) is a retrovirus that attacks the immune system. It can be managed with treatment. Without treatment it can lead to a spectrum of conditions including acquired immunodeficiency syndrome (AIDS).

<span class="mw-page-title-main">Pre-exposure prophylaxis for HIV prevention</span> HIV prevention strategy using preventative medication for HIV-negative individuals

Pre-exposure prophylaxis for HIV prevention, commonly known as PrEP, is a form of medication used to prevent HIV infection, the cause of HIV/AIDS.

<span class="mw-page-title-main">HIV Prevention Trials Network</span>

The HIV Prevention Trials Network (HPTN) is a worldwide collaborative clinical trials network that brings together investigators, ethicists, community and other partners to develop and test the safety and efficacy of interventions designed to prevent the acquisition and transmission of HIV. HPTN studies evaluate new HIV prevention interventions and strategies in populations and geographical regions that bear a disproportionate burden of infection. The HPTN is committed to the highest ethical standards for its clinical trials and recognizes the importance of community engagement in all phases of the research process.

HIV/AIDS was first diagnosed in 1981. As of year-end 2018, 160,493 people have been diagnosed with HIV in the United Kingdom and an estimated 7,500 people are living undiagnosed with HIV. New diagnoses are highest in gay/bisexual men, with an estimated 51% of new diagnosis reporting male same-sex sexual activity as the probable route of infection. Between 2009 and 2018 there was a 32% reduction in new HIV diagnosis, attributed by Public Health England (PHE) to better surveillance and education. PHE has described an "outbreak" in Glasgow amongst people who inject drugs, and has campaigns targeting men who have sex with men in London and other major cities. London was the first city in the world to reach the World Health Organization target for HIV, set at 90% of those with HIV diagnosed, 90% of those diagnosed on HAART and 90% of those on HAART undetectable. The UK as a whole later achieved the same target. Under the Equality Act 2010, it is illegal to discriminate against someone based on their HIV status in the UK.

The history of HIV/AIDS in Australia is distinctive, as Australian government bodies recognised and responded to the AIDS pandemic relatively swiftly, with the implementation of effective disease prevention and public health programs, such as needle and syringe programs (NSPs). As a result, despite significant numbers of at-risk group members contracting the virus in the early period following its discovery, Australia achieved and has maintained a low rate of HIV infection in comparison to the rest of the world.

There is a relatively low prevalence of HIV/AIDS in New Zealand, with an estimated 2,900 people out a population of 4.51 million living with HIV/AIDS as of 2014. The rate of newly diagnosed HIV infections was stable at around 100 annually through the late 1980s and the 1990s but rose sharply from 2000 to 2005. It has since stabilised at roughly 200 new cases annually. Male-to-male sexual contact has been the largest contributor to new HIV cases in New Zealand since record began in 1985. Heterosexual contact is the second largest contributor to new cases, but unlike male-to-male contact, they are mostly acquired outside New Zealand. In 2018 the New Zealand Government reported a “major reduction” in the number of people diagnosed with HIV.

<span class="mw-page-title-main">HIV/AIDS in Canada</span>

HIV/AIDS was first detected in Canada in 1982. In 2018, there were approximately 62,050 people living with HIV/AIDS in Canada. It was estimated that 8,300 people were living with undiagnosed HIV in 2018. Mortality has decreased due to medical advances against HIV/AIDS, especially highly active antiretroviral therapy (HAART).

Discrimination against people with HIV/AIDS or serophobia is the prejudice, fear, rejection, and stigmatization of people with HIV/AIDS. Marginalized, at-risk groups such as members of the LGBTQ+ community, intravenous drug users, and sex workers are most vulnerable to facing HIV/AIDS discrimination. The consequences of societal stigma against PLHIV are quite severe, as HIV/AIDS discrimination actively hinders access to HIV/AIDS screening and care around the world. Moreover, these negative stigmas become used against members of the LGBTQ+ community in the form of stereotypes held by physicians.

HIV prevention refers to practices that aim to prevent the spread of the human immunodeficiency virus (HIV). HIV prevention practices may be undertaken by individuals to protect their own health and the health of those in their community, or may be instituted by governments and community-based organizations as public health policies.

Julio S. G. Montaner, is an Argentine-born 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, 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.

National AIDS Trust v NHS Commissioning Board, [2016] EWHC 2005 (Admin), was a court case before the High Court of Justice seeking judicial review regarding National Health Service funding for pre-exposure prophylaxis.

HPTN 083 is a 2016 clinical trial which compares cabotegravir injections with oral use of Emtricitabine/tenofovir as pre-exposure prophylaxis ("PrEP") for prevention of HIV/AIDS.

Margaret Denise Portman was a British medical doctor who specialised in sexual health. She was an advocate for pre-exposure prophylaxis medication (PrEP) to prevent new HIV cases.

Ready, Set, PrEP is a program of the U.S. Department of Health and Human Services (HHS) that provides free access to the HIV prevention medication PrEP for thousands of qualifying individuals. The program is a key component of Ending the HIV Epidemic: A Plan for America (EHE) initiative to expand access to PrEP and reduce new HIV diagnoses in the U.S.

Pre-exposure prophylaxis (PrEP), is the use of medications to prevent the spread of disease in people who have not yet been exposed to a disease-causing agent. Vaccination is the most commonly used form of pre-exposure prophylaxis; other forms of pre-exposure prophylaxis generally involve drug treatment, known as chemoprophylaxis. Examples include taking medication to prevent infection by malaria or HIV. In particular, the term PrEP is now synonymous in popular usage with the use of pre-exposure prophylaxis for HIV prevention.

References

  1. 1 2 Ministry of Health (December 28, 2017). "Preventative medication will protect people at risk of HIV". BC Gov News. Retrieved October 27, 2019.
  2. 1 2 Ministry of Health (March 7, 2019). "One year of preventing new HIV infections throughout BC". BC Gov News. Retrieved October 29, 2019.
  3. ↑ "How do I get PrEP?". Health Initiative For Men - HIM. 14 December 2017. Retrieved 2019-10-29.
  4. ↑ "90-90-90: treatment for all". www.unaids.org. Retrieved 2019-10-29.
  5. ↑ "Why the HIV epidemic is not over". World Health Organization
  6. ↑ McInnes, Colin W; Druyts, Eric; Harvard, Stephanie S; Gilbert, Mark; Tyndall, Mark W; Lima, Viviane D; Wood, Evan; Montaner, Julio SG; Hogg, Robert S (2009). "HIV/AIDS in Vancouver, British Columbia: a growing epidemic". Harm Reduction Journal. 6 (1): 5. doi: 10.1186/1477-7517-6-5 . ISSN   1477-7517. PMC   2662822 . PMID   19265531.
  7. 1 2 BC Centre for Disease Control (2018). "HIV in British Columbia: Annual Surveillance Report 2016" (PDF). Retrieved November 4, 2019.
  8. 1 2 3 4 BC Centre for Disease Control (2017). "HIV: Annual report" (PDF). BC Centre for Disease Control. Retrieved October 29, 2019.
  9. ↑ Hull, Mark; Edward, Joshua; Leah, Kelly (March 27, 2017). "PEP/PrEP Update - A BC Case Study" (PDF). CATIE: Canada's Source for HIV and Hepatitis C Information. Retrieved November 4, 2019.
  10. 1 2 Health (2019-03-07). "One year of preventing new HIV infections throughout B.C." news.gov.bc.ca. Retrieved 2019-11-05.
  11. ↑ Smith, Alex. "How to access PrEP without insurance in Canada (for $45 CAD per month)". Davie Buyers Club. Retrieved October 29, 2019.
  12. ↑ Penner, Derrick (2017-12-29). "B.C. to offer free HIV prevention treatment to high-risk individualspublisher=Vancouver Sun" . Retrieved 2019-11-05.
  13. 1 2 "Over 2,000 people in BC are now prescribed on new life-saving HIV prevention drug | News". dailyhive.com. Retrieved 2019-11-05.
  14. ↑ Health (2018-06-26). "Celebrating six months of success preventing new HIV infections throughout B.C." news.gov.bc.ca. Retrieved 2019-11-06.
  15. ↑ Adshade, Marina; Bell, Niko (January 7, 2018). "Governments should fund birth control, as they do HIV prevention". The Globe and Mail. Retrieved November 5, 2019.
  16. ↑ van de Vijver, David A M C; Richter, Ann-Kathrin; Boucher, Charles A B; Gunsenheimer-Bartmeyer, Barbara; Kollan, Christian; Nichols, Brooke E; Spinner, Christoph D; Wasem, Jürgen; Schewe, Knud; Neumann, Anja (2019-02-14). "Cost-effectiveness and budget effect of pre-exposure prophylaxis for HIV-1 prevention in Germany from 2018 to 2058". Eurosurveillance. 24 (7). doi:10.2807/1560-7917.ES.2019.24.7.1800398. ISSN   1560-7917. PMC   6381659 . PMID   30782266.
  17. ↑ Schackman, Bruce R.; Fleishman, John A.; Su, Amanda E.; Berkowitz, Bethany K.; Moore, Richard D.; Walensky, Rochelle P.; Becker, Jessica E.; Voss, Cindy; Paltiel, A. David; Weinstein, Milton C.; Freedberg, Kenneth A. (2015). "The Lifetime Medical Cost Savings From Preventing HIV in the United States". Medical Care. 53 (4): 293–301. doi:10.1097/MLR.0000000000000308. ISSN   0025-7079. PMC   4359630 . PMID   25710311.
  18. ↑ "PrEP Alberta | Finding Insurance Coverage". prepalberta. Archived from the original on 2019-10-30. Retrieved 2019-11-06.
  19. ↑ "HIV PrEP". www.rqhealth.ca. Retrieved 2019-11-06.
  20. ↑ Nine Circles Community Health Centre (2017). "Pre-Exposure Prophylaxis (PrEP) for HIV Prevention" (PDF). Retrieved November 5, 2019.
  21. ↑ AIDS Committee of Toronto. "PrEP in Ontario – Update for Community" (PDF). Retrieved November 5, 2019.
  22. ↑ Paré, Étienne. "Québec refuse de rendre gratuit un médicament essentiel à la prévention du sida". Le Journal de Montréal. Retrieved 2019-11-06.
  23. ↑ "La PrEP". www.rezosante.org (in French). Retrieved 2019-11-06.
  24. ↑ Ministry of Health and Wellness (July 20, 2018). "Government Adds HIV Prevention Drug to Public Health Plan". Government of Nova Scotia. Retrieved November 5, 2019.
  25. ↑ "Nova Scotia adds an HIV prevention drug to the pharmacare program after an increase of new infections | The Star". The Toronto Star. 20 July 2018. Retrieved 2019-11-06.
  26. ↑ "PrEP – AIDS New Brunswick | SIDA Nouveau-Brunswick" . Retrieved 2019-11-06.
  27. ↑ "Approval of the use of oral pre-exposure prophylaxis (PrEP) as a highly effective strategy to prevent the transmission of HIV". AIDS Committee of Newfoundland and Labrador. 2018-11-26. Archived from the original on 2019-11-06. Retrieved 2019-11-06.
  28. ↑ Yarr, Kevin (November 30, 2018). "Covering costs of HIV prevention drug 'just makes sense'". CBC News. Retrieved November 5, 2019.
  29. ↑ "PrEP access and coverage". www.catie.ca. Archived from the original on 2019-11-06. Retrieved 2019-11-06.
  30. 1 2 Toronto General Hospital, Immunodeficiency Clinic (2018). "Provincial/Territorial Coverage of ARV drugs for HIV prevention across Canada" (PDF). CATIE: Canada's source for HIV and hepatitis C information. Retrieved November 5, 2019.
  31. ↑ "Oral pre-exposure prophylaxis (PrEP)". www.catie.ca. Archived from the original on 2019-10-31. Retrieved 2019-11-06.
  32. ↑ Bond, Keosha T.; Gunn, Alana J. (2016). "Perceived Advantages and Disadvantages of Using Pre-Exposure Prophylaxis (PrEP) among Sexually Active Black Women: An Exploratory Study". Journal of Black Sexuality and Relationships. 3 (1): 1–24. doi:10.1353/bsr.2016.0019. ISSN   2376-7510. PMC   5512598 . PMID   28725660.
  33. ↑ Wise, Jacqui (2018-06-06). "Pre-exposure prophylaxis may increase risky behaviour when introduced, study finds". BMJ: k2514. doi:10.1136/bmj.k2514. ISSN   0959-8138. S2CID   46965502.
  34. ↑ Liu, Albert Y.; Vittinghoff, Eric; Chillag, Kata; Mayer, Kenneth; Thompson, Melanie; Grohskopf, Lisa; Colfax, Grant; Pathak, Sonal; Gvetadze, Roman; OʼHara, Brandon; Collins, Brandi (2013). "Sexual Risk Behavior Among HIV-Uninfected Men Who Have Sex With Men Participating in a Tenofovir Preexposure Prophylaxis Randomized Trial in the United States". Journal of Acquired Immune Deficiency Syndromes. 64 (1): 87–94. doi:10.1097/QAI.0b013e31828f097a. ISSN   1525-4135. PMC   3904758 . PMID   23481668.
  35. 1 2 3 "HIV pre-exposure drug approved for funding in B.C., but barriers remain". The Globe and Mail. Retrieved 2019-11-06.
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