Preventable and treatable in 2022, why is HIV still rising in Canada?
By Dr. Caley Shukalek
Brought to you by Freddie
Every year, more and more people in Canada are living with HIV – a result of continued transmission of this preventable virus. While HIV itself does not discriminate, certain populations like LGBTQ2S+ communities have higher rates of infection than do their cisgender, heterosexual counterparts. It is estimated that in 2018, more than 62,000 people in Canada were living with HIV, but only 87 per cent of them were aware of their HIV status. In the same year, 2,516 new infections were diagnosed, an 8.2 per cent increase from 2017. This is in spite of the Canadian government’s commitment to end transmission and achieve the World Health Organization (WHO)’s “90-90-90” goal:
90 per cent of all people living with HIV know their status, 90 per cent of those diagnosed receive antiretroviral treatment, and 90 per cent of those receiving treatment achieve viral suppression.
Two years after the deadline, Canada has not yet met these goals!
To achieve these targets, the Canadian government needs to focus on three key principles: testing, treatment and prevention.
Testing
Knowing your HIV status is empowering and offers the opportunity to either treat it or prevent future infection. To learn your HIV status, you need to be tested at a clinic or lab after speaking with a healthcare professional. The introduction of commercially available self-testing in late 2019 puts more power in the hands of patients, but with the exception of some community agency access, it is not yet easily acccessible, and cost is also a barrier.
Treatment
For those living with HIV, modern HIV treatment is generally well tolerated and limits the effects of the virus. It also completely eliminates sexual transmission (Undetectable=Untransmittable; U=U). All provinces offer some cost coverage for these medications, but the amount covered varies province to province, as does access to experienced, patient-centred care.
Prevention
For those who test negative for HIV, avoiding sexual transmission can include many strategies, such as behaviour modification, condoms, and HIV pre-exposure prophylaxis (PrEP). Counselling about HIV risk and condom use is strongly recommended for sexually active people, but evidence and my own clinical practice have not demonstrated success through these methods alone, because they do not meet people where they are (i.e., not harm reduction). This is why PrEP is so important!
PrEP prevents HIV through the use of medications that were originally developed to treat HIV. Two drug combinations are currently approved in Canada for PrEP:
- Tenofovir disoproxil fumarate and emtricitabine (commonly referred to as Truvada; available as a brand-name medication as of 2016 and later in generic form)
- Tenofovir alafenamide and emtricitabine (marketed as Descovy; available as a brand-name medication as of 2020; generic form not available)
Both medications are equally effective at preventing HIV infection (up to 99 per cent when taken daily), and are extremely well tolerated and safe, with evidence suggesting that Descovy has a lower risk of side effects to both bones and kidneys.
Of course, PrEP requires a prescription and access to health services – in particular, affirming health care. For those lucky enough to live close to an inclusive prescriber, in-person health services can facilitate access to PrEP. Fortunately, online prescription of PrEP – already common in Australia, the United States and the United Kingdom – has been available in some Canadian provinces since 2020 and this offers convenient access to PrEP.
PrEP access can also be quite costly. Some Canadian provinces – Alberta, British Columbia and Saskatchewan – offer PrEP free to eligible persons. All other provinces have variable coverage based on age, income, and private insurance requirements that limit or restrict access to this important HIV prevention strategy.
Despite advances in medicine and initiatives of some governments and providers, HIV transmission continues as a result of inaction in ensuring accessible testing, treatment and prevention strategies. As a provider and expert in this field, I intend to continue to advocate for and work towards improved access to affirming sexual health services, and will continue to hope that funding bodies, like the government, can end HIV transmission.
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CALEY SHUKALEK is the medical director of Freddie, a virtual service that is making HIV PrEP accessible and inclusive through virtual care, as well as a clinical assistant professor at the University of Calgary and Alberta Health Services with clinical and research focused on the treatment and prevention of HIV and sexually transmitted infections and on the healthcare experiences of sexual and gender minority persons.
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