Paying for HIV prevention

Imagine moving from one province to another and finding that the costs of your prescription medications aren’t covered in your new home. While the Canada Health Act provides for comparable levels of medical care from province to province, the same is not true when it comes to paying for life-saving medicines, including HIV meds.

Various provinces and territories have catastrophic drug plans, and each has a different mechanism for determining which diseases and drugs are covered for which people at which income levels. Residents of Nunavut are completely covered, for example. Alberta covers specific HIV medications completely but once lagged far behind. New Brunswick has no catastrophic drug plan at all, leaving patients to rely on private insurers or to pay out of their own pockets

Jim Kane, the prairie regional HIV/AIDS director at the Canadian AIDS Society, learned about the pitfalls firsthand when he moved from Alberta to Manitoba.

“In Alberta, all your HIV meds are covered under the catastrophic drug plan,” says Kane. “In Manitoba, they have a pharmacare plan, which assesses a deductable, depending on your income. If I were still working and not retired, the first $6,000 would come out of my pocket unless I had some kind of co-insurance. For other people, the variety of those who do not have co-insurance, they’re falling between the cracks of our social safety net.”

Early detection and treatment of HIV plays a crucial role in controlling the spread of infection. Starting a drug regimen early after becoming HIV-positive can reduce viral load to undetectable levels, thereby making transmission highly unlikely. But some drugs work more quickly than others, different patients have different tolerances, some drugs are more costly than others, and – depending on where you live – some are covered by catastrophic drug plans and some are not. In many cases those who become HIV-positive don’t get appropriate treatment or delay treatment simply because they can’t afford the medications.

“What happens if you are found to be HIV-positive, and you are given this drug, and within the first dose the viral load drops?” asks Liberal health critic Hedy Fry. “By the second dose, the virus is no longer detectible and you cannot transmit HIV. This is prevention and treatment in one. If we had a national pharmaceutical or pharmacare strategy, we would stop the spread of HIV.”

The issue of catastrophic drug coverage – coverage that protects patients from undue financial hardship – came up repeatedly during the last federal election and is a frequent topic of debate in the House of Commons. And the Harper government has so far fended off calls for a national pharmacare strategy. Its reasons tend to boil down to two main points. The first is that healthcare provision falls to provincial jurisdiction.

Leah Stephenson, a policy analyst with the Canadian Treatment Action Council (CTAC), says the provinces and territories are not solely responsible for prescription medications, given that the federal government has a role in national healthcare and has six different drug plans in place for specific groups: federal government employees, First Nations and Inuit Health, refugees, the armed forces, veterans and federal inmates. Further, adds Stephenson, much of the reason there is no national pharmacare program has to do with the Health Canada Act.

“There’s nothing in the Canada Health Act about covering medications and treatments, and a lot of that comes from the fact that it was written at a time when acute healthcare, meaning going to ER and seeing your doctor was kind of the modality, and the whole development of chronic disease and self-management of disease through medication wasn’t really in play like it is today,” Stephenson says.

The second reason cited by the Harper government for not moving on a national catastrophic drug program is that the Health Care Accord, signed by Paul Martin’s Liberal government in 2004, won’t be up for renegotiation until 2014.

That’s not good enough for opposition health critics, who say the lack of a national pharmacare strategy is due to a lack of leadership on the part of the Harper government.

“The Health Accord identified a pharmacare strategy and a homecare strategy as two objectives to be achieved by 2014, so that when they meet in 2014 they can build on it,” says Fry. “The money is there; it was set to have a six percent increase every year.”

NDP health critic Libby Davies says that if the Martin government had attached funding conditions for a pharmacare strategy back in 2004, the Harper government wouldn’t be dragging its feet now. Still, she says, the Conservative government should move forward on the matter now.

“I think it’s very unfair, and in fact one could argue that it’s very discriminatory and completely contrary to the Canada Health Act, that depending on where you live or on your income, that you may or may not get the drugs that you need for HIV/AIDS,” says Davies. “To me, that’s structural discrimination. It’s more evidence of why we’ve got to fix this, and we shouldn’t be waiting until 2014.”

So how should a national pharmacare strategy work? One proposal is for the federal government to buy medications in bulk, something the NDP is advocating.

“We could be saving possibly $10 billion a year for Canadians overall and for our healthcare system by bulk purchasing,” says Davies.

But, Davies adds, there is an ongoing battle with the pharmaceutical companies over the idea of bulk buying.

“They have a huge vested interest, a lot of influence, and a lot of lobbying power with this government, so there’s huge interests in not allowing this sort of national plan with a generic application going ahead.”

While there is a profit motive, there is also the cost in time and money of developing new drugs; for every drug that does make it to market, there are a number that fail. As well, many of the most expensive drugs are newer and using breakthrough technology, such as biologics, which are seen as miracle drugs by many patient groups.

“People say, ‘Look, you’ve already got stuff that’s cheap and old and on the market. Why don’t you just use those?’ Well, because it doesn’t work as well,” Stephenson says. “I have a rheumatoid arthritis colleague who went from hospital-bound to a productive citizen and healthy mother in months because of a biologic.

“I would say that what they really need is a more sophisticated, adult dialogue that doesn’t involve any blaming of any one stakeholder, and that everybody needs to be at the table and everybody needs to have a really frank discussion,” says Stephenson.

Stephenson says that there are things the government could do to save billions every year on drug costs by expanding the comparator countries used by the Patented Medicine Pricing Review Board without negotiating with the pharmaceutical industry.

But is there any one system that we should be adopting right away? Stephenson says there are still issues that some of the suggestions, like a national drug list, won’t solve.

“I would say that none of them quite get there,” Stephenson says. “For example, if you have a national [drug list], some people will still fall through the cracks and not be able to access the treatments they need, and that’s part of the work that CTAC is trying to do: come up with a model safety net that truly catches everybody.”

But until the provinces and federal government can come to an agreement on making drug coverage a national system that guarantees equal access, the patchwork between jurisdictions will continue forcing people to choose between getting medications they need and financial devastation.