PrEP-ing to End HIV
Written by Jill Greenlaw, MSc Candidate and TMED 801 Student
On February 16th, the Department of Medicine had the pleasure of hearing from Dr. Martinez-Cajas, a Division of Infectious Diseases physician, and Dr. Guan, the Associate Medical Director of Health at KFL&A Public Health. Their presentation titled “PrEPing to End HIV” discussed the role of HIV PrEP adoption in HIV elimination and STI prevention, reviewed challenges for PrEP in Southeastern Ontario, and presented a collaborative project to understand the role of HIV PrEP in primary care.
Human Immunodeficiency Virus (HIV) is a virus that attacks immune cells that are vital in pathogen defence1. Extensive research on HIV has led to the development of antiretroviral therapy, which prevents the virus from replicating and suppresses the amount of virus in the body, preventing disease progression to Acquired Immunodeficiency Syndrome (AIDS) and transmission of the virus to others1. Pre-exposure prophylaxis (PrEP) for HIV is antiretroviral medication for individuals who have not been infected with HIV but are at risk of being exposed to HIV through sexual contact, or injection drug use, and is highly effective at preventing the acquisition of HIV2.
In 2014 the WHO proposed 90-90-90 targets to end the AIDS epidemic with the goal of having 90% of infected individuals diagnosed, 90% of diagnosed individuals on antiretroviral treatment, and 90% of those on treatment having achieved viral suppression3. These targets were revised to 95-95-95 in 2020 however, it was recognized that certain high-risk populations were nowhere near the proposed targets and without the interventions targeting HIV-negative populations, these goals could not be achieved4. It was therefore proposed that 95% of individuals at risk of HIV acquisition needed to be offered effective HIV prevention options5.
Dr. Cajas-Martinez explained that in Canada, there are only two HIV PrEP medications available, both of which are orally delivered, however, there are newer technologies that use injected antiretrovirals6,7. He described the process to obtain HIV PrEP which first involves an HIV risk assessment, then eligible individuals would receive PrEP education and adherence counselling. Individuals receiving HIV PrEP will be regularly monitored for medication toxicity, breakthrough HIV infections, and other STIs every 3 months. Individuals who take PrEP daily can expect a protection level of over 90%8. Dr. Guan explained that PrEP can be accessed through certain primary care providers, although very few offer this service. It can also be accessed through infectious disease services at KHSC, through online services, as well as through the PrEP clinic at KFL&A Public Health.
Dr. Guan discussed local HIV rates in KFL&A which have remained relatively stable over the last decade. He noted, however, that local rates of other STIs have skyrocketed in recent years including syphilis and gonorrhea, which in fact is not gone. Similar trends have been observed in surrounding public health units including Hastings and Prince Edward Counties, and Leeds, Grenville and Lanark regions.
In Ontario, a 2018 policy change made prep free of cost for individuals younger than 25 and older than 659. Additionally, anyone can access PrEP medication free of charge for the first 3 months. These changes have increased PrEP utilization by more than 700% between 2015 and 20189. However, it is estimated that of approximately 30,000-40,000 individuals in the eligible MSM population in Ontario, only 11,000 individuals are currently accessing PrEP services9. Additionally, out of 10 sexual health clinics in Southeastern Ontario, only one offers PrEP services highlighting the need for increased promotion and accessibility of PrEP in Southeastern Ontario.
Finally, Dr Martinez-Cajas talked about his own research which aims to gather information from primary care providers on their willingness to become consistent PrEP providers, learn about their perceptions about barriers to adopting PrEP services into their practice, and develop strategies to facilitate this implementation.
Following their lecture, Dr. Martinez-Cajas and Dr. Guan met with the TMED students to discuss how the accessibility and adoption of HIV PrEP services benefits patients, how it is represented in the lay press and considers Equity, Diversity, Inclusivity and Indigeneity initiatives, and their journey to their careers. They shared with us how HIV PrEP services support can mitigate the spread of other STIs and the challenges of implementing HIV PrEP into primary care. They also discussed the stigma around HIV services, and the disproportionately high rates of HIV in Indigenous populations, and the need for Indigenous-led initiatives to combat this. Finally, they shared their career paths, and what drew them to their respective disciplines.
On behalf of the TMED class, I would like to sincerely thank Drs. Martinez-Cajas, and Guan for their informative lecture and thought-provoking discussion.
1. Volberding PA, Deeks SG. Antiretroviral therapy and management of HIV infection. Lancet. Jul 3 2010;376(9734):49-62. doi:10.1016/S0140-6736(10)60676-9
2. Spinner CD, Boesecke C, Zink A, et al. HIV pre-exposure prophylaxis (PrEP): a review of current knowledge of oral systemic HIV PrEP in humans. Infection. Apr 2016;44(2):151-8. doi:10.1007/s15010-015-0850-2
3. Levi J, Raymond A, Pozniak A, Vernazza P, Kohler P, Hill A. Can the UNAIDS 90-90-90 target be achieved? A systematic analysis of national HIV treatment cascades. BMJ Glob Health. 2016;1(2):e000010. doi:10.1136/bmjgh-2015-000010
4. Frescura L, Godfrey-Faussett P, Feizzadeh AA, et al. Achieving the 95 95 95 targets for all: A pathway to ending AIDS. PLoS One. 2022;17(8):e0272405. doi:10.1371/journal.pone.0272405
5. New global pledge to end all inequalities faced by communities and people affected by HIV towards ending AIDS. UNAIDS; 2021.
6. Tan DHS, Hull MW, Yoong D, et al. Canadian guideline on HIV pre-exposure prophylaxis and nonoccupational postexposure prophylaxis. CMAJ. Nov 27 2017;189(47):E1448-E1458. doi:10.1503/cmaj.170494
7. Durham SH, Milam A, Waer D, Chahine EB. Cabotegravir: The First Long-Acting Injectable for HIV Preexposure Prophylaxis. Ann Pharmacother. Mar 2023;57(3):306-316. doi:10.1177/10600280221102532
8. Underhill K, Morrow KM, Colleran C, et al. Explaining the Efficacy of Pre-exposure Prophylaxis (PrEP) for HIV Prevention: A Qualitative Study of Message Framing and Messaging Preferences Among US Men Who have Sex with Men. AIDS Behav. Jul 2016;20(7):1514-26. doi:10.1007/s10461-015-1088-9
9. Tan DHS, Dashwood TM, Wilton J, Kroch A, Gomes T, Martins D. Trends in HIV pre-exposure prophylaxis uptake in Ontario, Canada, and impact of policy changes: a population-based analysis of projected pharmacy data (2015-2018). Can J Public Health. Feb 2021;112(1):89-96. doi:10.17269/s41997-020-00332-3