Accessing HIV post-exposure drugs

Gay men in Vancouver will soon have expanded access to a drug therapy that can prevent them from becoming HIV-positive after exposure to the virus.

Next month the Ministry of Health and the BC Centre for Excellence in HIV/AIDS (BC-CfE) will implement an 18-month pilot project called non-occupational post-exposure prophylaxis (nPEP).

Right now PEP treatments, which are initiated within 72 hours of exposure to HIV and cost between $1,000 and $1,500, are publicly funded only for victims of sexual assault or people exposed to the virus in the workplace. Under nPEP the government will cover the costs for treatments following other high-risk exposures to HIV, such as unprotected sex and intravenous drug use.

“Non-occupational post-exposure prophylaxis will be rolled out in the next few weeks,” confirms Dr Val Montessori, co-chair of the therapeutic guidelines committee at BC-CfE. “If the individual is assessed as having been in a high risk situation, nPEP, which includes three medications active against HIV, will be prescribed. A physician is the only one who can prescribe these HIV medications. The cost of the medications will be covered for this pilot by PharmaCare.”

NPEP will soon be available at St Paul’s Hospital’s emergency department, the John Ruedy Immunodeficiency Clinic at the BC Centre for Disease Control, the Bute St Clinic, Spectrum Health Clinic and the Vancouver Coastal Health Downtown Community Health Centre.

“We are in the process of carefully reviewing the necessary information for the pharmacy, the pilot sites and the individuals who may access nPEP,” Montessori says. “We anticipate that the pilot will be ready to roll out in May.”

NPEP is not the “morning-after pill” for unsafe sex, but it can be an effective tool to prevent infection, says Jody Jollimore, project manager for the Health Initiative for Men (HIM).

“PEP is not a silver bullet,” he notes. “It’s not going to prevent HIV infections in our community completely, but certainly in certain instances it can be an effective tool. Our key will be to promote it not as the end of condom use but something that can be used in addition to a condom.”

PEP can have mild to severe side effects for many people, he adds.

“This is not a walk in the park,” he says. “In fact, the research says that over 80 percent of guys who access PEP once never return for a second course. So guys aren’t using this as a morning-after pill. And they won’t.”

HIM has been pushing for PEP to be more accessible to gay men for years. In 2010, the organization released a position paper titled “Post-Exposure Prophylaxis for Consensual Sexual Activity in British Columbia” which argues that gay men are becoming HIV-positive because they can’t access PEP.

The paper describes three Vancouver-area men who attempted to access PEP after having unprotected receptive anal sex with other men. One of them was “able and eager” to pay for the PEP himself; the other two were not given the option of paying. All three were denied the treatment and subsequently seroconverted.

Bill Coleman, a Vancouver therapist who has worked with the HIV community for more than 25 years, says inaction from provincial HIV policymakers led to many needless HIV infections.

“They are slow and backward in their policy,” Coleman says “That is just really unforgivable. I still see people who, if they would have known about PEP, might not be infected and may not have infected other people. I just think it’s quite unforgivable that they didn’t take any action for years.”

Jollimore notes that some gay men are able to access PEP with the right health insurance, a doctor who will prescribe it and knowledge of the treatment itself. “Without that it’s a bit of a patchwork as to who can get it and who can not,” he says. “Certain third party health insurance companies already cover these medications. For instance, we had a flight attendant contact us about a year ago and we directed him to the appropriate health care providers, he got a prescription, submitted the prescription to his insurance company and they covered the medications for him.”

Coleman says some gay men in the community, unable to access PEP, have taken matters into their own hands by taking their HIV-positive friends’ medication. “But most people wouldn’t know enough about PEP to do it.”

Jollimore believes the nPEP pilot project was implemented in response to growing pressure from the gay community, as well as studies that show PEP is an integral component of HIV prevention, especially among people at higher risk of HIV infection such as gay men and intravenous drugs users.

“There are a number of factors I think that are influencing why it’s happening now,” Jollimore says. “One of them is the Stop HIV/AIDS pilot project which of course is touting a treatment-as-prevention model, which is saying that having people on medication can prevent transmission of HIV. So PEP fits within that model, of course, but also there’s been a growing pressure that comes from the community onto the various health authorities to make this prevention available.”

Montessori agrees that nPEP “dovetails nicely with the efforts currently underway in BC to expand HIV treatment as prevention, which is aimed to curb AIDS-related morbidity and mortality, as well as new HIV infections. BC is currently leading the country regarding the rate of decline of AIDS-related morbidity and mortality, as well as new infections, and this trend has remained apparent over the last decade.”

Coleman wonders why the project is limited to just Vancouver. He believes the action being taken is halfhearted and still leaves much of the population at risk.

“Why would it be a pilot project and why isn’t it available everywhere in the province?” he asks. “What if you live in Victoria or Prince George and need PEP? Many provinces provide it so why is this place so backwards?”

Access to nPEP varies by province and territory. It is covered only in Quebec, Prince Edward Island, Newfoundland and Labrador and on a case-by-case basis in Alberta, according to Jim Pollock, communications director at the Canadian AIDS Treatment Information Exchange.

NPEP has been available to Quebec residents since 1999 and is funded there by the provincial drug plan regardless of how the patient was exposed to HIV.

It’s also available at every hospital and health centre in Newfoundland and Labrador.

“It’s all covered here,” says Gerard Yetman, executive director of the AIDS Committee of Newfoundland and Labrador. “We’re also in discussion to have PEP available with our needle exchange van that actually operates in two centres in the province. PEP is available basically for anybody who requires it.”

Montessori says the BC-CfE will share the results of the pilot project with the BC government, which will ultimately decide how readily available nPEP will be in the future.