The Need For Equal Access to Post-Exposure Prophylaxis (PEP) in Ontario

      January 2014

      Post-exposure prophylaxis (PEP) is a four-week daily dose of anti-HIV medications in pill form that can possibly stop HIV infection if taken within 72 hours of potential exposure. ii iii iv v vi

      In Ontario, access to PEP is subject to a healthcare provider’s discretion. It can be argued that people who are exposed in the workplace to body fluids that may contain HIV (e.g. a healthcare worker who accidentally suffers a needle-stick injury) or in emergency circumstances, such as a sexual assault, elicits one response, while those people whose exposure to HIV is through unprotected sex, a condom break during sex or shared needles elicits another. ACT believes that PEP be prescribed to individuals regardless of method of exposure.

      Barriers to accessing PEP include incorrect assessments, the cost of PEP medication and a lack of information regarding prioritization or awareness of PEP among health care providers. These barriers can reduce the timeliness in which people receive treatment or the prescription of anti-HIV medications with difficult side effects.

      It is estimated that 646 people were infected with HIV in Toronto in 2012. Each HIV infection prevented in Canada is estimated to save our health care system between $242,686 and $376,785.vii While PEP is offered free of charge in a sexual assault situation and in many occupational exposure situations, the cost of a month’s supply of PEP for an individual in Ontario can cost between $900 - $1300 depending on the medications prescribed and requires private health insurance to cover it.viii ACT believes money should not be a barrier for an individual’s access to PEP and that a provincial standard of care for non-occupational PEP is long overdue.

      This disparity between Ontario and other provinces and jurisdictions’ standards leaves Ontarians at a greater risk of a potentially preventable disease.

      It is imperative that the government of Ontario extend treatment coverage of PEP to all Ontarians and establish provincial standards of care for all types of HIV exposures; and to ensure that all health care providers are informed and equipped to provide service to people who have been potentially exposed to HIV in a timely and respectful manner.

      Background

      After potential exposure to HIV in the workplace and in sexual assault circumstances the cost of PEP is covered through Ontario’s health care system. ACT believes that other circumstances of exposure such as consensual sex or drug use also merits the same, consistent coverage.

      Affordability, stigma and a lack of access should not be a detriment to an individual accessing medication. ACT believes that prevention is a more sustainable and considerate allocation of resources than a lifetime of treatment.

      ACT believes that all Ontarians deserve access to PEP if they have been exposed to HIV, regardless of method of exposure. People who are at risk in community settings (i.e. human bites, accidental contact through discarded needles, or those that result from consensual sex or sharing of injection equipment) should be eligible for coverage. The current two-tier approach adopted by the Ministry of Health and Long-Term Care discriminates against those who have had sexual exposure. Moral judgements about people who engage in sex have no place dictating public health policy.

      There is currently no standard of care for non-occupational exposure in Ontario. The decision to provide PEP lies with the healthcare provider and is made on a case-by-case basis. Many healthcare providers in Ontario are unaware of non-occupational PEP, are not trained to provide PEP, or may be unwilling to prescribe it. This means that people may be assessed differently, kept waiting longer, or prescribed older anti-HIV drugs with more severe side effects that impact people’s ability to adhere to the treatment.

      PEP for non-occupational exposures is an accepted clinical practice in many jurisdictions. In Canada, Alberta, Quebec, Manitoba, Saskatchewan, Prince Edward Island and British Columbia have standard of care protocols in place. Internationally, the US, UK, Australia, Netherlands, France, Switzerland, Spain and Denmark, among others have protocols.

      The present funding position of the Ministry of Health and Long-Term Care represents a contradiction. The science and efficacy of PEP treatment is not in question. We know that it works and the government recognises this by providing access and coverage for occupational and sexual assault exposure. ACT believes coverage of PEP should be provided as part of a comprehensive HIV prevention strategy.


      References:

      i. CDC. 2005. Antiretroviral Post-Exposure Prophylaxis After Sexual, Injection-Drug Use, or Other Non-occupational Exposure to HIV in the United States: Recommendations from the U.S. Department of Health and Human Services. MMWR. 54(RR-2): 1-20
      ii. Tsai CC, Emau P, Follis KE, Beck TW, Benveniste RE, Bischofeberger N, Lifson JD, Morton WR. 1998. Effectiveness of postinoculation (R)-9-(2-phosphonylmethoxypropyl) adenine treatment for prevention of persistent simian immunodeficiency virus SIVmne infection depends critically on timing of initiation and duration of treatment. Journal of Virology. 72: 4265–73.
      iii. Otten RA, Smith DK, Adams DR, Pullium JK, Jackson E, Kim CN, Jaffe H, Janssen R, Butera S, Folks TM. 2000. Efficacy of postexposure prophylaxis after intravaginal exposure of pig-tailed macaques to a human-derived retrovirus (human immunodeficiency virus type 2). Journal of Virology. 74: 9771–5.
      iv. Cardo DM, Culver DH, Ciesielski CA, Srivastava PU, Marcus R, Abiteboul D, Heptonstall J, Ippolito G, Lot F, McKibben PS, Bell DM. 1997. A casecontrol study of HIV seroconversion in health care workers after percutaneous exposure. New England Journal of Medicine. 337(21): 1485-90.
      v. Tsai CC, Emau P, Follis KE, Beck TW, Benveniste RE, Bischofeberger N, Lifson JD, Morton WR. 1998. Effectiveness of postinoculation (R)-9-(2-phosphonylmethoxypropyl) adenine treatment for prevention of persistent simian immunodeficiency virus SIVmne infection depends critically on timing of initiation and duration of treatment. Journal of Virology. 72: 4265–73.
      vi. Otten RA, Smith DK, Adams DR, Pullium JK, Jackson E, Kim CN, Jaffe H, Janssen R, Butera S, Folks TM. 2000. Efficacy of post-exposure prophylaxis after intravaginal exposure of pig-tailed macaques to a human-derived retrovirus (human immunodeficiency virus type 2). Journal of Virology. 74: 9771–5.
      vii. Toronto Public Health. 2012. Sexually Transmitted and Bloodborne Infections: Communicable Diseases in Toronto 2012.
      viii. Shoppers Drug Mart via Toronto Public Health, September 16, 2013.