A year ago CMAJ, the journal of the Canadian Medical Association, published guidelines for health-care providers trying to determine who might be an appropriate candidate for pre-exposure prophylaxis (PrEP), the daily use of antiretroviral medications by people who are at high risk of HIV infection, before and after potential exposure. The guidelines recommend PrEP for men who have sex with men, transgender women and heterosexual couples when one partner is HIV positive.
As a result, doctors may hesitate to prescribe the regimen to other patients, even if there are behavioral, clinical and social factors that are known contributors to HIV risk, such as having condomless sex with multiple partners or intravenous drug use, according to an editorial published Thursday in the Canadian Journal of Human Sexuality. This is especially true for women and people of colour, whose lives are not fully understood by the guidelines’ experts, says LaRon Nelson, a public health nurse, research chair at the Ontario HIV Treatment Network and lead author of the report.
“We should create guidelines that are consistent with the way people live their lives – however complex that may be – and not how doctors think people should act,” he said. “People know they should share their sexual history and HIV status with their doctors and sexual partners, but the reality is that they do not. That’s why the guidelines should be based on behaviour and the patients’ clinical history and not their sexual orientation or the HIV status of their partner.”
Darrell Tan, an infectious diseases physician at St. Michael’s Hospital in Toronto and the author of the CMA guidelines, says his team took a strictly evidence-based approach when drafting the recommendations, but they are not meant to exclude any patient if they are a good candidate for PrEP.
“The guidelines are intended as just guidelines. They’re not a strict set of criteria against which every single person needs to be strictly evaluated. They’re intended to give broad, overarching guidance to clinicians,” Dr. Tan said.
However, some HIV specialists say too many family doctors are still reluctant to prescribe the daily regimen of life-saving drugs.
“Often what we hear from clients is that their doctors outright refuse to prescribe PrEP to them because of a lack of knowledge or they try to pass them off to an HIV specialist,” said Alex Urquhart, a program co-ordinator and PrEP expert for the AIDS Committee of Toronto. “Unfortunately, the process of getting prescribed PrEP can often feel like trying to win a court case.”
Timothy Matheson, a doctor in Nova Scotia who has cared for hundreds of HIV patients, explains that health-care providers are more inclined to turn to the guidelines for advice because PrEP, which Health Canada only approved for use in 2016, is still relatively foreign to them.
“Not many physicians have as much experience with PrEP or have a large population of patients with HIV,” he said.
Dr. Matheson says PrEP should be an option for anybody who may be at risk for an HIV infection. “The fact that someone is gay should not push that person in the direction of having PrEP more than a straight person. It really should come down to the behaviour and the risk factors,” he said.
In the United States, a federal task force released a statement this week calling for PrEP to be recommended for all women who recently had a sexually transmitted infection.
However, even with more inclusive guidelines, there are still barriers preventing people from accessing PrEP.
Dawn K. Smith, a medical officer for the U.S. Centers for Disease Control and Prevention who created the American PrEP guidelines, said “special efforts are needed to increase PrEP access [in the United States] among people of colour, who disproportionately face limited access to health care, low financial resources to pay for health care, and discrimination, which can all hinder people from obtaining PrEP as an HIV prevention service.
“With no vaccine or cure, prevention of HIV is paramount,” she said.