Note: In the coming weeks, we will be updating this section to reflect the addition of PrEP to Alberta's Public Drug Benefit Plan. All updates will be complete before changes are implemented on September 1, 2018.
Based on the findings of both surveys and the recent developments related to PrEP access across Canada, we have developed the following recommendations as it relates to PrEP access and delivery in Alberta:
No. 1: Public Funding
Alberta (Government of Alberta, Alberta Health Services) should begin funding PrEP as an HIV prevention tool for Albertans deemed eligible by current medical guidelines:
The cost of one month of Truvada in Alberta, which until recently was the only version of TDF/FTC approved by Health Canada for use as PrEP, is approximately $1,000. This puts PrEP far out of reach for most Albertans, particularly those most vulnerable to HIV infection.
And although a small portion of those who have sought coverage for PrEP have been successful, the vast majority have not, leaving access to the medication contingent on whether or not an individual has the financial means to absorb its high out-of-pocket costs. In some cases, even those who have been able to access PrEP report taking the medication less frequently than as prescribed to make their prescription last longer because of high out-of-pocket costs such as expensive co-pays. This can decrease the effectiveness of PrEP as an HIV prevention tool.
Barriers such as these render PrEP inaccessible to those who do not enjoy the privileges of a high disposable income and/or a premiere private health insurance plan. This creates an unfortunate reality where an individual`s ability to access a highly effective HIV prevention tool, and thus their vulnerability to HIV infection, rests squarely on their socioeconomic status.
Therefore, to ensure that access to PrEP is equitable and not based upon an individual's financial means, we strongly urge the provincial government to start publicly funding PrEP for those deemed eligible based on current medical guidelines as soon as possible.
We recognize some of the challenges in doing this, particularly given the past inability for various jurisdictions to negotiate a price for Truvada as PrEP that would make the provision of publicly funded PrEP feasible from an economic perspective. However, with Health Canada’s recent approval of four generic versions of TDF/FTC, three of which are already approved and marketed for use as PrEP, it is increasingly likely that the government will be able to access TDF/FTC for use as PrEP at a much lower cost than would have been previously possible.
These generic versions of TDF/FTC have been used as PrEP by various jurisdictions throughout the world, including Australia, through the EPIC NSW Study, which aims to enroll approximately 3,700 MSM from the state of New South Wales, and most recently by BC with its decision to publicly fund PrEP, with the province specifically stating:
"In August 2016, the Common Drug Review recommended PrEP for coverage, contingent in part on a lower price for the drug Truvada being secured. This condition has been met through the availability of generic Truvada." - ("Preventative medication will protect people at risk of HIV")
With the condition of reduced price having been met through the availability of generics, increasing the ability of jurisdictions to deliver PrEP in a cost-effective manner, it is also important to consider the potential long-term impact of PrEP delivery on HIV rates, as well as the savings associated with preventing new infections and related treatment costs.
Over the past year, we have seen significant decreases in the rates of HIV infection amongst MSM across the globe in jurisdictions with expanded PrEP (see here, here, and here). These successes, combined with the increased effectiveness of other new prevention technologies, have led various cities, states, and countries throughout the world to commit to the virtual elimination of new HIV infections within the next several years. Expanded PrEP access is recognized as a crucial component of their strategies to achieve that goal (see here).
We are at a crucial point in our response to HIV, wherein ending new HIV infections is not just a lofty aspiration but, instead, an achievable goal. Therefore, it is important not to view PrEP in isolation or through a short-term lens. Instead, PrEP should be viewed through the lens of the province's overall response to the HIV epidemic, which when employed strategically alongside other combination HIV prevention interventions, can lead to the virtual elimination of new HIV infections and the lifelong costs associated with treating them.
In 2018, Albertans should not have to travel south of the border – which they are – to access a widely-endorsed, highly effective HIV prevention option. Nor should they be deprived of a medication they are eligible for based on current medical guidelines because of how much money they have (or don't have) in their bank account. It runs counter to the province's commitment to health equity.
With BC's recent decision to publicly fund PrEP, all three of Canada's most populated provinces (Ontario, Quebec, and BC) provide some form of public funding for PrEP. Now, with the significantly reduced cost of securing PrEP and the mounting evidence of its effectiveness, there is no reasonable excuse for Canada's fourth most populated province not to follow suit.
No. 2: Prescribing Authority and Access Points
The provincial government must 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.):
The CADTH Canadian Expert Drug Committee, in its final recommendation on the reimbursement of TDF/FTC for use as PrEP, recommended that the drug be reimbursed when prescribed as PrEP to adults at a high risk of HIV infection if two conditions are met:
That the price be reduced – a barrier discussed in the first recommendation of this report.
That PrEP be “provided in the context of a sexual health program by a prescriber experienced in the treatment and prevention of HIV-1 infection.”
Most stakeholders can agree on the first of the two recommendations, as the pricing for Gilead’s Truvada (the only version of TDF/FTC approved for use in Canada at the time of the report's writing) made public reimbursement of TDF/FTC as PrEP infeasible for most jurisdictions. However, the response to the second has been more divided, with the Canadian HIV sector pushing back strongly against it.
It is true that for many non-specialist physicians and allied healthcare professionals, the existence of PrEP and the evidence of its effectiveness might not be something they have been made aware of throughout their daily practice and standard professional development. Throughout our findings, respondents clearly indicated significant gaps in knowledge and understanding among healthcare providers about PrEP itself and the process through which an individual can obtain a prescription and subsequent coverage.
Because of these gaps, individuals seeking PrEP are often placed in situations where they are responsible for retrieving information about the medication, educating their healthcare provider about the drug and related guidelines, and then advocating for themselves in the face of opposition to obtain a prescription that they are clearly eligible for based on current medical guidelines.
Even if they are successful, they are often left without adequate support from their healthcare provider to navigate the complex pathway towards obtaining PrEP coverage, instead relying on community-based organizations, word-of-mouth from peers, and their own intuition to piece together some way to successfully obtain coverage though their private insurer. This process generally involves the individual having to go back and forth between their physician, their private insurance plan, and Alberta’s Specialized High Cost Drug Plan before they are able to receive a decision from their private insurer as to whether or not PrEP will be covered – with no guarantee of a positive result.
However, restricting prescribing authority to Infectious Disease Specialists or physicians with experience providing care for HIV-positive patients is not the answer. In a province already experiencing challenges in early linkage to care and treatment for those diagnosed with HIV, restricting prescribing authority in such a manner would drastically limit the prescriber pool, creating a bottleneck effect and leading to an increased burden on physicians already highly burdened by caring for those living with HIV and other chronic infections.
Given the ongoing monitoring for HIV, STBBIs, and drug tolerability, prescribing physicians must be willing to engage patients in care for as long they take the medication. It is not feasible to expect a small subset of physicians to take on this responsibility alongside their current caseload, particularly given the high interest in PrEP demonstrated by community members.
Limiting the prescriber pool would likely have other unintended negative impacts as well. For example, there are many individuals currently taking PrEP who received their prescription from their family doctor. What potential interruption might they experience if they are no longer able to receive a PrEP prescription from this provider?
It is recommended that PrEP be provided within the context of comprehensive sexual health care. This is to ensure that physicians engage patients in ongoing discussions about their sexual health to determine if PrEP is still the best HIV prevention option for them, to provide necessary education related to the prevention of other STBBIs, and to ensure they receive necessary adherence support. What happens if this provider is no longer eligible to prescribe PrEP and perform necessary follow-up with their patient? What might be lost through the fracturing of this relationship and how might that impact patient outcomes?
The potential inequities that might be faced by rural Albertans who are interested in accessing PrEP must also be considered. If decisions are made to restrict prescribing authority to Infectious Disease Specialists, who work almost exclusively out of urban centres, accessing PrEP could become virtually impossible for some.
So, how do we ensure a prescriber pool which is both adequately knowledgeable about PrEP and also sizeable enough to handle the expected patient-load? This brings us to the second part of the above recommendation. Instead of restricting the prescriber pool, measures should be taken to expand access to PrEP by educating non-specialist physicians and allied health professionals about PrEP, by supporting patients in navigating the complex process to access PrEP, and through enabling the delivery of PrEP in non-traditional settings such as community pharmacies or outreach sites known to serve high prevalence populations. By taking these measures, the discussion surrounding a knowledgeable vs. sizeable prescriber pool does not have to be either/or but can instead be both/and.
Finally, for those who are concerned about sacrificing quality by expanding the prescriber pool, it should be noted that primary care providers have already been prescribing PrEP throughout the world for years – including in Alberta. Several jurisdictions that provide publicly funded PrEP through various models of delivery such as Australia, Ontario, and BC - who no doubt have an interest in monitoring PrEP delivery and its impact - enable PrEP to be prescribed by non-specialist physicians. Alberta should follow their lead. At a time when the provincial government is repeatedly asking Albertans to adopt safer sexual health practices, we should be making life easier for those who identify such practices and seek to adopt them, not create unnecessary burdens for them and the healthcare providers that care for them.
No. 3: Community Engagement
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:
Given the varied components and inherent complexity involved in the development and implementation of a publicly funded PrEP delivery model, both Alberta Health and Alberta Health Services must demonstrate an ongoing, tangible commitment to meaningful and transparent collaboration. However, to ensure that such a collaboration results in a model which is acceptable to those for whom it is intended and results in high uptake, it is crucial to engage communities at an elevated risk of HIV infection.
Many of these communities, particularly gay, bisexual, and other men who have sex with men (GB-MSM), have been at the frontlines of the global push for the expansion of PrEP access; participating in trials, raising awareness in the media, creating step-by-step online access guides, and lobbying governments to fund PrEP as an HIV prevention intervention. Because of these sustained contributions to the PrEP movement, communities most vulnerable to HIV infection, and the organizations that serve them, hold valuable insights about PrEP and the collective knowledge, attitudes, and preferences their communities have about it.
These insights are particularly important given the diversity of these populations. For example, consider GB-MSM, who have been early leaders in the PrEP movement. As per our survey findings, this population has already demonstrated high awareness of and interest in taking PrEP. This likely indicates that the most significant barriers to PrEP uptake amongst GB-MSM are not knowledge or interest but instead the exorbitant costs of the medication, the lack of healthcare provider knowledge and support as it relates to prescribing PrEP and completing ongoing monitoring and follow-up, and the complexity of navigating the PrEP coverage pathway.
Conversely, other populations in Alberta who are at an elevated risk of HIV infection might face different barriers to access. For example, some indigenous individuals who are insured through the Non-Insured Health Benefits program offered by the First Nations and Inuit Health Branch (FNIHB) are able to access Truvada for use as PrEP free-of-charge, a fact many individuals appear to have been unaware of until recently. Service providers who work with African, Caribbean, and Black communities in Canada have also reported low levels of PrEP awareness within their communities.
Given that the needs of Albertan subpopulations at increased risk of HIV infection are so different in relation to PrEP access and uptake, a one-size-fits-all approach to the delivery of publicly funded PrEP will surely leave some individuals and communities behind. Therefore, Alberta Health and Alberta Health Services must come together with individuals belonging to each of these communities – and the organizations that serve them – to develop and implement a publicly funded PrEP delivery model that will work for all who could benefit from this important HIV prevention intervention.
PrEP provides an opportunity. An opportunity to demonstrate that Alberta is serious in its fight against HIV. A chance to demonstrate that the government believes that all Albertans are of value and deserve equitable access to care, positive health, and wellbeing. And a chance to lead by accepting evidence on its face, rejecting unfounded bias, and making sound public health decisions for the benefit of the people of this province.
We recognize the challenges presented in attempting to provide publicly funded PrEP in Alberta. However, we cannot, with the one hand, admonish those most vulnerable to HIV infection for not taking positive steps to protect their sexual health, but then, with the other, block access to a prevention tool that, for some, presents their best opportunity to prevent HIV infection. Yet, for each Albertan who has attempted to access PrEP, in response to the call that they make responsible sexual health decisions, this is the contradiction they are faced with.
Although it is difficult to quantify, in a province which reported more than 280 new HIV infections in 2016, it is hardly speculative to presume that there are some Albertans who have acquired HIV whose infections could have been prevented if they had access to publicly funded PrEP.
Therefore, we urge the government to move swiftly to address this issue. We ask, in doing so, that the government take these recommendations into consideration when exploring options to expand PrEP access. Furthermore, given the profound impact decisions related to PrEP access could have on numerous communities within the province, and the complexity in finding options that adequately balance public health concerns and cost, we implore the government to work closely alongside healthcare professionals and key community stakeholders, like the EMHC, who are able to provide key insights into PrEP, its expansion, and the communities who need it most.
We all share the same goal: to prevent new HIV infections and to help Albertans of all backgrounds have equitable opportunity to experience optimal health and wellbeing. By working collaboratively toward the expansion of PrEP access, together, we can achieve this.