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Views From the Front Lines: Pre-Exposure Prophylaxis in Canada

Spring 2011

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Views From the Front Lines: Pre-Exposure Prophylaxis

We spoke to four people with very different perspectives on PrEP.

  • Dr. Mark Tyndall -- Professor of Medicine, University of Ottawa
  • Dr. Peter A. Newman -- Associate Professor, Faculty of Social Work, University of Toronto Canada Research Chair in Health and Social Justice
  • Jody Jollimore -- Program Manager, Health Initiative for Men, Vancouver, British Columbia
  • Shari Margolese -- Community Consultant, Women and HIV Research Program, Toronto, Ontario


Dr. Mark Tyndall

Do you think PrEP has a role to play in Canada?

I would say "no." I think we need to be open to all new prevention strategies, whether its technologies or behaviours, but in terms of what should be a priority in Canada, I don't think PrEP will play much of a role.

The number of new infections just aren't that high in Canada. You would have to treat a lot of people to prevent an infection. I couldn't imagine putting people who are at a relatively low risk of infection on continuous antiretroviral medications. It's just not necessary and the risks of the medications would outweigh the benefits.

With the prevention strategies we have now, we can actually keep HIV transmission to relatively low levels. I deal with the highest risk people in Vancouver and despite this I see very few new infections using the interventions that we now have. Give injecting drug users enough clean needles and they don't get infected, give sex workers and gay men condoms and they don't get infected.

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Its true that some people aren't doing what they could do to prevent HIV infection, but offering them another technology opens the door to a lot of problems and unintended consequences. Once one person starts taking a pill and having unprotected sex, others who are using condoms are going to want to take a pill so they can have unprotected sex too. If people are going from a form of prevention that is highly effective to prevention that is 60 or 70% effective, that is potentially going to put even more people at risk of infection.

If a gay man tells me that he will never use a condom and he will continue to have unprotected sex with anonymous partners, it seems counter-intuitive to me to give him a pill. He already has highly effective tools at hand to prevent exposure and we need to focus on removing the barriers that prevent him from using these tools. I don't think we want to create a situation where taking a pill is how we prevent HIV infection because I think it will fail. We have not even discussed the problems with adherence, side-effects, drug resistance and the cost of PrEP.

Don't get me wrong. I don't think that we have figured out the optimal ways to deliver HIV prevention, or that specific groups are not in need of renewed prevention efforts, or that innovative strategies should not be developed, it's just that I don't see PrEP being a major addition to HIV prevention initiatives in Canada.

What can Canada do to prepare for the implementation of PrEP?

The epidemic among gay men in some Canadian cities is continuing because we are not doing a good enough job of reaching those at highest risk of infection. I think we need to keep working with the tools that we have and find more innovative ways to reach people at risk of infection and understand what drives their risk behaviour. I think we have let that slip.

We aren't even prepared to give people post-exposure prophylaxis (PEP) and I think that's an even more important debate. In British Columbia this has been an ongoing battle. If the exposure is the result of consensual sex, no matter how big the risk of infection is, the government won't pay for PEP.

What will the role of ASOs be during the implementation of PrEP?

Staff at ASOs will be the ones who are asked many of the questions. They are going to have a big role in educating people about the potential downside of PrEP and helping to prevent the unintended consequences. My general feeling from those working in ASOs is that this is not some great new prevention tool and has the real potential to undermine other prevention efforts if not explained properly.


Dr. Peter A. Newman

Do you think PrEP has a role to play in Canada?

PrEP is going to play a role in Canada regardless of what you, me or people at the policy-level think. It exists and people may already be using it. Some gay men in the United States have engaged in self-administering PrEP for years and it's likely to be a similar situation in Canada.

I would feel much more comfortable if different stakeholders in Canada recognize that PrEP is going to play a role, whether we like it or not, and become engaged in discussing the possible ramifications. PrEP is going to be much safer and more effective if it is delivered with as much education and strategizing as possible -- by the people who represent the populations who will use it, people who have experience working with those populations, and hopefully social scientists as well.

What can Canada do to prepare for the implementation of PrEP?

Barriers in accessing culturally competent and appropriate care exist for many health conditions in Canada and will likely impact the use of any new HIV prevention technologies that become available. It will be important to use the possible introduction of PrEP as an opportunity to bring attention to the barriers that prevent disenfranchised populations from accessing medical care. We need to develop strategies to overcome these challenges and improve access to healthcare where inequalities exist.

A lot of individuals from marginalized populations have not had good experiences with the healthcare system and this may discourage them from accessing PrEP and using it correctly. We need more specialized health clinics that serve marginalized populations that may be at risk for HIV infection and could benefit from new HIV prevention options.

What will the role of social science be in the implementation of PrEP?

There is no HIV prevention technology that can reasonably ignore human behaviour, human decision-making, relationships, and other messy things like emotions. It doesn't exist. We know people make mistakes and human behaviour isn't perfect. There are going to be particular challenges with the uptake and use of a technology that is partially protective. We have to look at any new prevention technology in the light of real-world human behaviour and human decision-making.

Social and behavioral science needs to be involved from the get-go, from the clinical trial stage through to the roll-out and beyond. We can potentially learn a lot about possible behavioural challenges from clinical trials but it's very difficult to predict exactly what's going to happen when the technology is rolled out. Social and behavioural monitoring during the rollout of PrEP will be important to guide implementation changes and change the course of action if needed. Unfortunately, social and behavioural science tends to be given a lower priority than biomedical science until things start to go wrong.

Front-line service providers will need to be included in social science research. They have intimate knowledge of what's happening on the ground and have a good idea of what might happen and how it might happen. All this information needs to be to be factored into the development of implementation policy and strategy.

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This article was provided by Canadian AIDS Treatment Information Exchange. It is a part of the publication Prevention in Focus: Spotlight on Programming and Research. Visit CATIE's Web site to find out more about their activities, publications and services.
 
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