Groups at higher risk of HIV infection should have access to a course of anti-retroviral medications before and after exposure to the virus, according to new national guidelines aimed at curbing the spread of the disease in Canada.
The guidelines, being published Monday in the CMAJ medical journal, are for health professionals who work with people at risk of acquiring the disease through sexual activity or injection drug use. They recommend doctors prescribe pre-exposure prophylaxis (PrEP), a course of anti-HIV drugs that begins before an exposure to the virus occurs, and nonoccupational postexposure prophylaxis (nPEP), which involves taking anti-retroviral medications after a sexual or drug use-related exposure to HIV.
"There are a lot of people who can benefit from [PrEP and nPEP] across the country, and not nearly enough providers who can provide it to them," said lead author Dr. Darrell Tan, an infectious diseases physician and researcher at St. Michael's Hospital in Toronto. The guidelines were developed by the CIHR Canadian HIV Trials Network with a panel of 24 experts.
"Because PrEP is so effective in treating HIV, the goal is that by increasing uptake, we could actually move Canada towards a reduction in the rate of HIV infections every year and hopefully move towards the ultimate elimination of new infections."
The authors noted that the guidelines bring Canada up to speed with countries including Australia, Britain and the United States, which already have similar national guidelines on HIV treatment and prevention.
Dr. Tan said the hope is that the guidelines can better equip general practitioners to prescribe PrEP, because not all front-line workers are knowledgeable about HIV treatment.
Ryan Lisk, director of community health at the AIDS Committee of Toronto, says that a lack of guidelines previously meant that patients experienced inconsistencies when visiting doctors for treatment.
"It's always been a bit of a lottery if you get a physician who has the confidence to prescribe the medication in the right way," said Mr. Lisk, who was involved in the consultation process for the guidelines.
"These guidelines help to standardize access across the country, so that physicians and general practitioners can prescribe PrEP and nPEP with confidence."
The new guidelines are also more feasible this year, largely because of an expired patent that lowered drug costs. Also, Ontario began covering a portion of the price. Treatment previously cost around $1,000 a month in Ontario, but that cost was lowered to around $250 for people without insurance in September. Some people who are covered by universal or private insurance would pay even less. Dr. Tan said that Quebec also subsidizes the drug, but says that it's troubling that the rest of the country doesn't.
"It's a travesty that [money] should be a barrier to people accessing something that could prevent HIV infection," said Dr. Tan, who pointed out that it is cheaper for governments to fund the prevention of HIV than to treat people who have contracted the disease.
The authors said the guidelines may be of particular importance for health professionals working with populations that are disproportionately affected by the disease. More than half of new infections (54.3 per cent) occur in gay, bisexual and other men who have sex with men, according to the report authors. HIV incidence among people who inject drugs, people from HIV-endemic countries, and Indigenous people is estimated to be 59, 6.4 and 2.7 times higher than other Canadians.
Dr. Tan noted that there is still some stigma associated with the treatment, especially outside of the gay, bisexual and queer community where people aren't as aware of the drug. However, Dr. Tan notes that there used to be stigma around the birth-control pill when it first introduced, and he hopes that PrEP can one day be as routinely accepted as the pill.
"In many senses, birth control represents a form of empowerment to take responsibility and control of one's own health and future, in a way that we now look on as very normal," said Dr. Tan. "We look forward to a day where that can be a reality for PrEP."