Reflections from the frontline on barriers to access PrEP
I’m a registered nurse and until recently, I worked at Toronto Public Health. Instead of talking to people about COVID-19 – which is how my old colleagues now spend their days – I would talk to them about sexual health. Similar to COVID-19, no one wanted to get a call from me, as it meant that they had a sexually transmitted infection (STI) or one of their partners had a STI. I’m a gay cis-male and many of the people that I spoke with were gay, bisexual, trans or queer men. I have heard every question about sex that you can imagine. I have also heard the embarrassment and shame in people’s voices.
...we want to prevent new HIV infections as much as possible. One of the most effective ways is through medication, also known as pre-exposure prophylaxis (PrEP)
There is no shame in testing positive for a STI or contracting HIV and nowadays. And living with HIV is living with a chronic illness. But people living with HIV still experience stigma and are at higher risk of health complications, so we want to prevent new HIV infections as much as possible. One of the most effective ways is through medication, also known as pre-exposure prophylaxis (PrEP). If taken on a daily basis, it has almost a 100 per cent success rate at stopping HIV transmission.
I have heard every question about sex that you can imagine
When I would talk to someone who tested positive for a STI, it was an opportunity to find ways to prevent an HIV infection. Infections like chlamydia, gonorrhea and syphilis are early warning flags that the person is at increased risk of contracting HIV. I would call people to help them manage their current STI, to make sure they received treatment and their sexual partners were notified. An arguably more important conversation would be about PrEP. Imagine receiving a call from a stranger who works for the government and wants to get deep into your sex life. I had about five seconds to make the person feel comfortable to keep them from hanging up on me, then within a minute pivot to convince them they were at risk for acquiring HIV and should go on a medication to prevent it.
Increasing PrEP awareness is key to HIV prevention
Some people truly did not believe they were at risk of contracting HIV. I may as well have been calling them and telling them that they were at risk of contracting Ebola and needed to act now. I was delivering an uncomfortable message to people. Whether or not they believed they were at risk of acquiring HIV, the reality is that gay, bisexual, trans or queer men in Canada are 131 times more likely to be infected with HIV than straight cis-men.
What’s more, not even all health care providers are on board with the idea of PrEP. Rarely these reservations are about the side effects, but often are a moral argument about how much sex a person should or shouldn’t have. Public health messages to tell people to have less partners or use condoms 100 per cent of the time have not stopped the HIV epidemic.
Overcoming barriers to access PrEP
I’ve learned a lot from the people that I talked to. Some were so excited to hear about PrEP – a way to control their sexual health was a revolutionary concept for some people. The biggest challenge would be overcoming barriers to access PrEP, and a lot of it boiled down to cost or not knowing how to access the medication.
...gay, bisexual, trans or queer men in Canada are 131 times more likely to be infected with HIV than straight cis-men
When people weren’t convinced about the benefit of PrEP or worried about side effects, it was even harder. I would be told they didn’t have sex often enough to justify using a daily medication. Despite all of these concerns, I also knew that they were still at risk of acquiring HIV.
For those still on the fence, I would offer to make PrEP appointments for them (and in some cases tagalong to offer support) or suggest ‘on-demand PrEP’, which is less effective (and not effective at all for receptive front hole sex), as a better-than-nothing option. For some people, ‘on demand’ is a way to make it more affordable, for others it's a way to alleviate fears about side effects or not take medication when not having sex.
PrEP for everyone
I wish I could say I had a lot of success stories, but with too many people there were barriers that we couldn’t get over or find a way around. As I reflect on what we need to stop the HIV epidemic, there’s an obvious answer (well, at least part of it). We need to get PrEP into the hands (and mouths!) of the people at greatest risk of acquiring HIV. It needs to be easy to access and it needs to be covered through pharmacare for everyone.