Who is getting PrEP in Canada? Who is getting left behind?
Who is getting PrEP in Canada? Who is getting left behind?
PrEP (pre-exposure prophylaxis) is a powerful HIV prevention tool. With one pill a day or an injection every two months, people who are HIV-negative can reduce their chances of getting HIV by up to 99%.
It has become widely known and used today, especially among gay, bisexual, and other men who have sex with men (GBM).
But there’s a big question we still need to ask: who’s being left behind?
A new study using data from the Engage survey — a large, multi-city research study based in Toronto, Montreal, and Vancouver — digs into this very problem.
Analyzing responses from over 2,000 HIV-negative or unknown-status GBM, the findings are clear: while access to PrEP is growing, it’s still out of reach for many.
The Doctor Divide: Not Everyone Has Access
Almost 1 in 3 men in the study didn’t have a regular healthcare provider. That alone makes it tough to get PrEP.
But it’s not just about having any doctor — it’s about having the right doctor. Bisexual men, Indigenous men, refugees, and permanent residents were far less likely to have a regular healthcare provider than gay-identified and Canadian-born men.
And even when they did, they often didn’t feel comfortable talking about their sexual health. This underlines how critical it is for healthcare settings to feel safe and affirming.
Why Affirming Care Matters
It’s not just about access — it’s about acceptance. The study found that having a gay-friendly or affirming doctor was essential to navigating access to PrEP.
Unfortunately, not everyone experiences this. Bisexual men, as well as those identifying as questioning, asexual, pansexual, or two-spirit, were less likely to find a provider they trusted.
Many weren’t comfortable disclosing their sexual identity. Racial inequities showed up too.
East and South Asian, West Asian, Arab, North African, and African, Black, Caribbean men were more likely to report challenges in finding an affirming provider and being open with their doctors about their sexual identity — these are key barriers to accessing PrEP.
Financial Barriers Remain High
Even if someone knows about PrEP and has a supportive doctor, cost can still get in the way. Almost half of the men in the study said the expense of PrEP discouraged them from getting a prescription.
In many parts of Canada, insurance coverage for PrEP still often depends on having full-time work with health benefits, though some provinces now offer broader public coverage.
Unsurprisingly, new comers, refugees, and people in precarious work situations were among the least likely to have insurance, and most likely to experience financial barriers to PrEP.
Anxiety Plays a Role
The study also examined how overlapping health challenges impact PrEP access. While several mental health and social factors were assessed, anxiety stood out as a significant barrier.
Men who struggled with anxiety were less likely to find a supportive doctor or access sexual health services, though it’s also possible that difficulties finding affirming care contribute to feelings of anxiety.
Interestingly, other factors like depression, substance use, and childhood trauma, while highly relevant to overall well-being, were not strongly associated with PrEP access in this analysis.
Mapping the Barriers
When researchers looked at how all these issues connect two key barriers stood out:
- Not having a supportive and affirming doctor
- Not having insurance to cover the cost of PrEP
These two challenges were closely tied to economic insecurity: lower education, unstable employment, and newcomer status. On the other hand, men who had a regular doctor and being out to that doctor was strongly connected with knowing how to get PrEP and actually taking it.
So, who isn’t getting PrEP? The answer is clear: GBM who are marginalized across lines of identity, income, and immigration status. The study paints a vivid picture of a system where structural and social inequalities deeply shape who can benefit from this powerful HIV prevention tool.
This has to change.
For PrEP to reach its full potential, we need more than awareness campaigns. We need policies that expand healthcare access, provide universal drug coverage, and ensure that every GBM — regardless of identity, race, or background — can get the supportive and affirming care they deserve. Until then, too many will be left on the outside looking in.
Research for Real is part of The Positive Effect’s ongoing effort to bring important academic research to the communities it’s meant to serve. We partner with researchers to turn peer-reviewed papers into accessible, plain-language blogs that reflect the realities and priorities of people living with and affected by HIV. If you're an academic interested in sharing your work this way, let’s talk.
