Can we end the North American HIV epidemic?

We have the pills, the prevention plan and the strategy to prevent infections — so what’s stopping us?

I was on PrEP (pre-exposure prophylaxis), the daily anti-HIV pill, for about a year and a half before I had to stop because I lost my private health insurance. My lack of access made me feel much less protected.

In 2014, there were an estimated 2,570 new HIV diagnoses in Canada and 44,073 in the United States — and it’s still a very real problem. But between PrEP and using HIV treatment as prevention (TasP) we have the tools to end this epidemic, along with all HIV-related stigmas. So what’s stopping us?

The Centers for Disease Control and Prevention (CDC) claims that expanding the use of PrEP for those who are uninfected but at high risk could prevent 17,000 new HIV infections in the US by 2020. Achieving such an increase, though, has proven to be tricky in the past.

Approximately 1.2 million people in the US are at substantial risk of HIV and would benefit from PrEP, yet many healthcare providers are unaware of this option. And there’s only an estimated 100,000 worldwide on PrEP.

There’s also a lack of access in the US, particularly in the rural South, because of poor public transportation infrastructure, as well as poverty, income inequality and stigma. In Canada, too, it’s more difficult to access without private health insurance.

Morality, of course, is another big obstacle inhibiting access. At the HIV Research for Prevention (HIVR4P) conference last month, Sarah Calabrese, associate research scientist in epidemiology (chronic diseases) at Yale University, reported on some hypothetical scenarios that medical students were given in relation to gay men seeking PrEP.

She found that 45 percent of these students were less willing to provide PrEP to men who were non-monogamous and already not using condoms — one of the groups who needs PrEP the most, according to the CDC. So is this punishment?

“It is critical that PrEP access be governed by science and not by personal values,” Calabrese rightfully claims. This is particularly true when the goal should be to end the epidemic.

Although PrEP could prevent 17,000 new HIV infections by 2020, which is impressive in itself, what’s more surprising is that by reaching the National HIV/AIDS Strategy’s goal of getting 80 percent of those diagnosed with HIV on antiretroviral therapy (ART), and achieving an undetectable viral load (TasP), it would prevent 168,000 new HIV infections.


As a strategy to end the epidemic, the impact would be 10 times greater than PrEP alone, yet we hear much less about this — and that’s a problem in itself.

Only 37 percent of the 1.2 million people with living with HIV in the US are on an ART, which is less than half of what is required to reach such goals.

To be clear, somebody living with HIV who has achieved an undetectable viral load through ART for at least six months has a negligible to no risk of transmitting the virus to others, even without a condom. This crucial fact has been endorsed by many organizations, including the British Columbia Centre for Excellence in HIV/AIDS, the Human Rights Campaign, and the New York City Department of Health and Mental Hygiene.

Yet less than 10 percent of the 1.2 million people living with HIV are aware of this.

The Prevention Access Campaign (PAC), a multi-agency health equity initiative to end HIV and HIV-related stigma, has been working overtime to push this information. While it seems that few other agencies are doing this, it may just be a similar case as with PrEP — medical providers aren’t up to date with the current science. But that’s not all.

“There are people from public health departments that, although they agree with the science they’re concerned about two things,” Bruce Richman, the executive director of PAC, tells me. “One is about a decrease in condom use among people with HIV, and the resulting increase in STIs. And two, the sophisticated consumer issue, which means that the person with HIV, might not understand that in order to stay undetectable, they have to adhere to treatment.”

“Those are issues that can be address by education.”

Richman explained that some medical providers feel it’s okay to share this information, on a case-by-case basis, with patients who they feel are “responsible.” And by responsible, they mean monogamous or have stable linkage to treatment and care.

“So you can guess who’ll get left out,” Richman said. “Marginalized groups.”

Worrying about the STI epidemic is a valid concern that requires a serious conversation, but to me, it seems separate from the challenge of ending the North American HIV epidemic. Whether people use condoms or not, PrEP and TasP may still reduce an estimated 185,000 new HIV infections by 2020 — that’s more to the point.

Until PrEP becomes more easily accessible in Canada without a private health plan, all I can do is continue to use condoms and hope that I don’t slip up or have a condom break (which has already happened to me four times). I’ll continue to get tested for HIV every six months and if necessary, I’ll get treated.

I’ll continue to debate people at dinner parties about PrEP and TasP, especially with those who try to peddle misconceptions and fear. And let’s hope we’ve made some progress, both on the scientific and moral front, in the next four years.

PrEP School runs every other Monday on Daily Xtra. Columnist Mike Miksche explores and navigates the world of sex and PrEP.

>Read more PrEP School columns here.

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