The biggest barrier to ending HIV is interrupting transmission, and we are never going to be able to do that with any one intervention; we are never going to be able to do it all with PrEP.. We will never interrupt transmission by treating everybody either, because some people don’t know their status… Ending HIV is going to take a comprehensive effort.
The CDC estimates that 1 in 4 gay and bisexual men are likely eligible for PrEP. And with the recent Canadian draft guidelines, it is pretty reasonable to expect that a lot of gay men living in Edmonton could be eligible for PrEP. Would you say that in 2016 we can really say that we are providing quality and effective care to queer men if we don’t ensure that PrEP is available as a sexual health intervention? And, if PrEP is an essential sexual health intervention, should it be covered by the government in the same way that other STI treatments are covered?
First of all, PrEP is available right now – it is only available to people that have private insurance, because it is not publicly funded, and and the cost, currently, is prohibitive. That may change as these drugs become generic. The question that you are really getting at, is should this particular preventive intervention be paid for in a single-payer health system?
You have to look at all the competing demands within the health system. If you take it from a public health standpoint, this is an opportunity for the health care system to actually improve the health of the population, to prevent new infections and the costs associated with those infections. They could look at it as a potential cost-saving measure. In that regard, I think I would have a tough time saying as a public health official, that funding PrEP was not worth it. But, we’ve also got for example, cancer care, pediatric cardiac surgeries, and all of these other things that the government has to pay for. The government has to look at where that money is most effectively used. On an individual basis, there is no doubt that PrEP is a good thing to do for people who are at risk, but you have to define who those people are and you have to put your resources where you are going to get the most return on your investment.
If jurisdictions across Canada start adopting PrEP in an organized fashion, they are going to have to start with some fairly restrictive criteria, that define a very high risk population. There will need to be early successes with those populations to show administrators that it does have an impact, and that there aren’t any compensations in the system that are bad (for example, that there is no increasing risky behaviour, and no increase in drug resistance) be able to show these things, and then roll out PrEP to a wider population. I think there is absolutely every expectation that a PrEP trial should be done for a very well defined population; as for whether it should be more broadly available to any gay man who is HIV negative and who wants it, we are not there yet.
You talked about risk compensation, and that has been a major point of discussion around PrEP. Now that it has been rolled out in various real world contexts, there is a question of whether or not we will see an increase in higher risk behaviour. Is this something you are concerned about, and if risk compensation does become a problem, how do you think we can address that?
Having the major trials out of France, Quebec, and the UK, it doesn’t look like it is as big a problem as people thought it was going to be. I think it behooves us, if this becomes a public health program, to monitor for risk compensation, and to do that both by talking to the patients about their behaviour, talking to the public about their behaviour, and also monitoring from a laboratory standpoint for drug resistant virus.
Monitoring for risk compensation has to be built into a PrEP program, but is it a reason not to go ahead with the program? I don’t think so. I think we would have to address the problem of compensatory risky behaviours if and when it occurs, and really target the areas where we identify that it is happening. We would have to look at it if and when it started to happen, and make sure we have mechanisms in place for detecting it very early.
Recently, CATIE updated their statements on condoms, treatment as prevention, and PrEP, saying that all three, when used effectively, can reduce sexual transmission of HIV by 90% or more. Do you agree that we should be viewing all three of these prevention options equally? Why or why not?
I think it is irrelevant whether you view them equally, but they have to come as a package. Their relative contributions and value might be different, but every study that we’ve done has been looking at these as a package. People like the Danes, who have had successes, they don’t look at which component is most likely the biggest contributor, they have the bundle of treatment as prevention, PrEP, aggressive counseling, testing and treating, and condom use. I don’t think you can separate them out.
If we do see PrEP become affordable and widely accessible in Alberta, what are your thoughts on who should be able to prescribe it? Should people be required to see an Infectious Disease specialist? Should it be available at the STI centre? Or through general practitioners? How do we ensure, if GPs are prescribing it, that they are prepared not only to prescribe it, but also do monitoring and follow up?
I think you have to split up the frontline people from the people administering and monitoring a program; I think you need a certain amount of public health or ID expertise in order to set up an appropriate program, and to make it self sustaining and to make monitoring for risk compensation effective. As far as the people on the front line doing the counselling, ordering laboratory tests, prescribing medications, and doing the follow ups, there is not a lot of ID expertise required. I can see nurse practitioners, interested primary care providers, and Infectious Disease specialists all being involved in this. I would like to see a PrEP program have access to interdisciplinary health care professionals, like social workers, counsellors, and pharmacists. It is important to have links established if we decide that people are going to be on these medications for 5 or 10 years, to monitor for side effects.
On Ending HIV
Now that we know that people that take their HIV medications regularly and have undetectable viral loads have almost no chance of transmitting HIV, and that people who adhere to a daily regimen of PrEP have almost no chance of contracting HIV, do you think that we now have the tools to end HIV, once and for all?
In the developed world, yes. Elsewhere in the world where the bulk of HIV lives, maybe not. For example, in Denmark, there is a very aggressive testing and treatment program, that their gay men in the country are very engaged with, and they have very high coverage with anti-retroviral therapy rates for HIV positive individuals, with suppression rates of over 90%. In the last 10 years, they have seen, with treatment as prevention, a real impact on their epidemic.
What they found is that a program is only as good as the information that you have. People have to know their HIV status, and then PrEP is the icing on the cake, so to speak, that will allow people who are not already infected to avoid becoming infected and perpetuating the epidemic. So in, for example, Western European and North American countries, I think ending HIV is possible with a combination approach, but achieving that level of coverage in developing countries, as well as getting enough engagement, is going to be really, really tough.
What is our most significant barrier to ending HIV?
Human nature, I think. This is a virus that is transmitted through sexual behaviour and sexuality is integral to being a human. I don’t see people abstaining from sex to end an epidemic. It’s not going to happen. The biggest barrier to ending HIV is interrupting transmission, and we are never going to be able to do that with any one intervention; we are never going to be able to do it all with PrEP, because we will never attain 100% coverage, as some people won’t perceive themselves as at risk or bother obtaining PrEP. We will never interrupt transmission by treating everybody either, because some people don’t know their status, and of the people that we recommend treatment for, some people take it and some people won’t.
Ending HIV is going to take a comprehensive effort; we are going to have to reach a critical threshold, after which we can start to see some decline in new infections, and once we get to that point, the decline becomes self-sustaining. But, we have to get past the threshold of new infections, to the point where we start to see the rate of infection declining rather than unchanging or increasing. Maybe another barrier is the compartmentalization of all of our current resources. Maybe it is that testing and counselling are separate from the treatment, which is separate from the public health interventions, which is separate from the STI treatment. Perhaps we just need a more comprehensive approach.
The Money Shot
If you could tell the GBTQ community one thing, what would it be?
Look after yourselves, and know what looking after yourself means. It is all you can do. Nobody else is going to do it for you.
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