Note: In the coming weeks, we will be working with AHS and Alberta Health to update this section to reflect the Alberta Government's expansion of public PrEP coverage, as announced by Premier Notley on September 1, 2018.
In 2016, 282 new HIV infections were reported in Alberta, with men who have sex with men (MSM) accounting for nearly 40% of all new infections. In February 2016, Health Canada approved Truvada, a Gildead-manufactured version of emtricitabine/tenofovir disoproxil fumarate (TDF/FTC), for use as HIV Pre-Exposure Prophylaxis (PrEP) - which has been demonstrated to be nearly 100% effective at preventing new HIV infections if taken daily as prescribed.
Historically, the expansion of PrEP access has been limited by exorbitant costs, preventing most jurisdictions from offering publicly funded PrEP. The lack of public funding and challenges obtaining coverage through private insurers has made PrEP access challenging for those who cannot afford to pay for PrEP out-of-pocket. Recently, two generic versions of TDF/FTC have been approved for use as PrEP by Health Canada and are currently marketed nationally by their manufacturers. The ability to secure generic versions of PrEP have led to recent decisions by BC and Ontario to publicly fund the drug, joining Quebec which has done so for the past several years.
Despite this recent progress and the fact that jurisdictions with expanded PrEP access have seen significant decreases in new HIV infections, particularly amongst MSM, Alberta has not yet made a commitment to the delivery of publicly funded PrEP. This has rendered PrEP inaccessible to many Albertans who are unable to pay for PrEP out-of-pocket.
To help move necessary dialogue regarding increased access to PrEP in Alberta forward, throughout the summer and fall of 2016, the Edmonton Men’s Health Collective (EMHC) conducted two surveys aimed at gauging the attitudes, experiences, and preferences of Alberta gay, bisexual, trans, and queer (GBTQ) men relating to PrEP use and access in the province.
Both surveys were available online only through Google Forms and promoted through social media platforms, including Facebook and Twitter. The first, much shorter survey, available for response from June 9 to June 27, 2016, received 372 on-target responses and collected only quantitative data from respondents. A univariate analysis method was applied to survey data to produce descriptive statistics. Survey results were used to inform the design of a second, more extensive survey to explore the topic further.
The second survey, available for response from September 29 to October 7, 2016, received 161 on-target responses and collected both quantitative and qualitative data from respondents using a concurrent nested survey design. A mixed methods approach to analysis was used, with a univariate analysis method applied to quantitative data to produce descriptive statistics and a thematic analysis being applied to qualitative data to identify key themes presented in the data.
High awareness of, interest in taking, and eligibility for PrEP but low uptake:
In the first survey, 85% of respondents had heard of PrEP before completing the survey, 46% were eligible for PrEP based on the draft Canadian PrEP/nPEP guidelines, and 59% indicated they would be interested in obtaining a PrEP prescription if there were no out-of-pocket costs. An additional 30% would consider obtaining a PrEP prescription under the same circumstances.
In the second survey, 81% of respondents had heard of PrEP and felt they had a good understanding of what it was; followed by an additional 17% who had heard of PrEP but did not feel they understood it well. Within the HIV-negative cohort, 56% indicated being “Very Interested” in obtaining a PrEP prescription, the highest measure on the scale. Finally, 66% of HIV-negative respondents indicated being eligible for PrEP based on current guidelines. Despite this, two-thirds of respondents who tried to access PrEP were unsuccessful, with only 6% of the total HIV-negative cohort taking PrEP at the time of the survey. Of those who attempted to access PrEP, 70% attempted to obtain coverage for the medication but only 1/3 were successful in obtaining any reimbursement.
Inadequate Healthcare Provider Knowledge and Lack of Clarity regarding the PrEP Access Pathway:
Participants who tried to access PrEP (n=31) were asked to quantify the clarity of the process on a scale of 10, with one as the lowest ranking. Nearly half of respondents who had tried to access PrEP (13 out of 31) gave the process the lowest clarity ranking. Approximately 84% of all respondents gave the process a score of five or lower. When asked to rate the knowledge level of the provider they spoke to about PrEP, on a scale of 10, with one being “Not at All Knowledgeable” and ten being “Very Knowledgeable,” nine respondents rated the provider’s level of knowledge at a score of one and nearly half (15 out of 31) rated the provider’s level of knowledge at a score of three or lower.
The government bears the bulk of the responsibility in funding PrEP:
In the first survey, 53% of respondents indicated that the government should fully fund PrEP, with no out-of-pocket payments required of the individual; 41% felt the government should provide partial coverage for PrEP, with the rest being paid through private insurance or out-of-pocket. Only 1% of respondents felt it should be paid for 100% out of pocket.
In the second survey, respondents highly favoured coverage options in which the government carried the majority of the burden in funding PrEP as opposed to those in which individuals were expected to shoulder the burden. For example, 68% found it “Very Favourable” that PrEP be 100% funded by the government, with just 3% finding that funding model “Unacceptable.” Conversely, just 1 % of respondents found it “Very Favourable” that the individual would pay 100% out-of-pocket for PrEP, with another 87% finding that scenario “Unacceptable.”
Based on these findings, the EMHC makes the following three recommendations:
1) Alberta (Government of Alberta, Alberta Health Services) should begin funding PrEP as an HIV prevention tool for Albertans deemed eligible by current medical guidelines.
2) The provincial government should not create barriers to PrEP access by limiting prescribing authority to infectious disease specialists or physicians providing care to HIV-positive patients. Instead, measures should be taken to expand access to PrEP by educating non-specialist physicians and allied health professionals, supporting patients in navigating the complex process to access PrEP and enabling the delivery of PrEP in non-traditional settings (e.g. community pharmacies, outreach sites, etc.).
3) The development and implementation of a publicly funded PrEP delivery model must be a collaborative effort involving Alberta Health, Alberta Health Services, and communities disproportionately impacted by HIV.
To learn more about the findings from both surveys and to read in-depth explanations behind each of the above recommendations, access the other sections of this report below: