Authors: Tyrone Curtis, Lucas Gergyek, Ben Klassen, and Daniel Grace
On May 13th 2024, Health Canada approved the first long-acting form of HIV-PrEP (LA-PrEP) in the form of long-acting injectable cabotegravir (CAB-LA). While details about how CAB-LA will be delivered in Canada are still to be determined, the Future of PrEP is Now study is aiming to inform the rollout of LA-PrEP in Canada in a way that reduces current inequities in PrEP access and increases uptake among Two-Spirit, gay, bisexual, queer and other men who have sex with men (2SGBQM). With that in mind, the Future of PrEP is Now team led a panel discussion and workshop centred around reimagining HIV prevention in Canada at the Community-Based Research Centre’s (CBRC) annual Summit in Vancouver in November 2023. This conference brought together a diverse group of 2SGBQM, 2SGBQM-serving organizations, healthcare providers, and public health actors from across Canada for conversations about our health and wellbeing. Taking advantage of this dynamic setting, the Future of PrEP is Now session particularly focused on reducing inequities in PrEP access experienced by marginalized 2SGBQM and brainstorming ways that we can optimize this promising new form of HIV prevention.
The session started with a short primer on CAB-LA delivered by Dr. Darrell Tan of St. Michael’s Hospital, Toronto. Dr. Wale Ajiboye of Unity Health Toronto then presented on current inequities in PrEP access, and the importance of reducing these inequities. Finally, Dr. Tyrone Curtis from University of Victoria presented preliminary results from focus groups and interviews conducted with members of marginalized communities of 2SGBQM.
After these presentations, attendees broke up into 4 discussion groups, each focusing on a different topic related to the delivery of CAB-LA. The discussions in each group were energetic and engaging, reflecting the enthusiasm among attendees for new approaches to HIV prevention in Canada. Included here are summaries of these discussions.
Group 1: Knowledge Dissemination
Uptake of LA-PrEP will require 2SGBQM to have information about this new prevention approach. In group one, attendees discussed strategies for knowledge dissemination about LA-PrEP, including approaches for reaching marginalized populations of 2SGBQM through tailored messaging. Attendees brainstormed a variety of methods for raising awareness about LA-PrEP, including social media advertising and connecting with community-based organizations and harm reduction services to share information with the populations they support. The group also discussed the potential for raising awareness about LA-PrEP through magazines and newspaper articles and by advertising in-person on public transport, in sexual health and harm reduction services, and in 2S/LGBTQ+ spaces, such as bars, bathhouses, and Pride events. When considering what information resources should look and sound like, participants emphasized the importance of developing multilingual resources, tailoring language and approach according to the intended audience, and recruiting community leaders or ambassadors to relay our messaging. Folks also highlighted that first person testimonies from people already using LA-PrEP may be useful for building comfort, increasing knowledge about risks and benefits, and furthering awareness of LA-PrEP.
When considering what community members need to know about LA-PrEP, the group discussed the importance of building baseline knowledge about PrEP, and in turn, outlining the “why” of LA-PrEP. In general, ‘need to knows’ fell under five broad categories:
- administration — how it’s administered and by who, how much it hurts;
- access — cost, coverage, and eligibility across provinces, and how to access and who to ask;
- side effects and interactions — possible interactions with other medications and/or substances, cosmetic concerns, and long-term impacts and tolerability;
- frequency of injections and testing — different testing schedule and how this relates to timing of injections, potential for an oral bridge when travelling, and potential for on-demand use; and
- sub-communities — why this tool is relevant/important to young folks and newcomers and refugees.
The group also discussed how to build knowledge among healthcare providers, including through the development of fact sheets and flow charts comparing and contrasting the different options for PrEP, and casual knowledge-building events such as webinars, where community-based organizations can play a key role in bolstering information. Other opportunities suggested for healthcare provider-specific promotion included online training modules and the inclusion of information and training regarding LA-PrEP in medical school curriculums including why it represents an effective alternative to daily oral PrEP.
Group 2 – Accessing and implementing CAB-LA
The rollout of CAB-LA will require rethinking access and implementation models for PrEP (e.g., due to administration via injection vs. an oral pill). In group 2, attendees first discussed potential service-related access barriers to uptake of CAB-LA, with a major topic of discussion being the need for standardisation of HIV-related care across Canada. Currently, the care received and HIV prevention and treatment options available vary across provinces. For example, access to long-acting injectable treatment for people living with HIV remains extremely limited in BC compared to many other provinces, and so there were concerns that CAB-LA would also not be approved in BC. Attendees also discussed the question of how eligibility for LA-PrEP will be assessed, and how this might be improved over current models of assessing PrEP eligibility which can paradoxically result in some individuals with higher HIV risk being unable to access PrEP.
The group also discussed the need to expand which services are able to provide PrEP, noting that CAB-LA administration will require visits to a care provider every two months at a time when finding a healthcare provider is extremely challenging. In contrast to oral PrEP, which can be prescribed to an individual without requiring an in-person visit to a clinician, CAB-LA would need to be administered in-person by a healthcare worker. Administration at local pharmacies was suggested as one possible way to expand access, as they already administer other injections (e.g. vaccinations). However, attendees noted that many pharmacies may not have suitably private facilities for administering CAB-LA injections (which are injected into the buttocks). Outreach nurses were also highlighted as a way to expand access to CAB-LA, as they are already able to refer patients for PrEP in BC’s Interior Health, and also deliver other injections. Finally, community-based organizations are already involved in HIV and STI testing as well as mpox vaccinations, and are frequently able to set up these services (with the necessary privacy) anywhere, so would also be suitable. The group also acknowledged the importance of involving community-based organizations from the very start of policy development.
Finally, the group discussed ways to facilitate adherence to repeat injections of CAB-LA. Existing infrastructure and models were highlighted that could be used to support adherence, including text reminder services similar to those used by provincial governments for vaccination reminders and partner notification systems. Regardless of what systems are implemented, the group acknowledged the importance of asking the individual themselves what would work best for them. There was also concern that the tail period of CAB-LA (during which an individual who has ceased CAB-LA must continue to take oral PrEP to avoid resistance in the event of a new HIV infection) would result in those who would most benefit from CAB-LA (i.e., those who have trouble with oral PrEP adherence) being considered ineligible. Finally, the group discussed the importance of leveraging the relationships that outreach healthcare providers (e.g. street nurses) have in the community to facilitate adherence among members of the community who typically struggle with this.
Group 3 – What should PrEP look like in future?
With other PrEP technologies on the horizon, attendees in group 3 discussed what PrEP modalities and access could look like without any barriers and in an ideal world. This was an animated and wide-ranging discussion. Participants focused a lot on access. PrEP—in all forms—must be free. People echoed calls for the need to have PrEP paid fully by the government, and that cost and insurance coverage remained pernicious barriers to access. The inequity of global access to PrEP was also discussed.
Attendees also discussed administration methods for injectable PrEP. For many people, long-acting injectable PrEP was exciting, but they wondered if an easier injection (possibly even self-injection) might be possible. Some people discussed that rather than injections, an ‘all-in-one’ pill that does more than HIV prevention would be exciting (e.g., combination doxy-PrEP + HIV-PrEP to prevent HIV and other STIs). Or perhaps an option with no side effects. Many people reflected on the future of PrEP being one where multiple options exist in the tool box that are the ‘least invasive’ (including on-demand PrEP and implantables in addition to injectable PrEP and daily oral PrEP). A recurring theme in discussions was also the importance of centering the needs of people living with HIV, and ensuring that all individuals living with HIV can access new forms of HIV treatment as they become available.
The centrality of bodily autonomy is key in PrEP futures, including patient-centred care as a cornerstone of how PrEP is delivered. The group also discussed that we need to also think about access to primary healthcare for all. PrEP discussions must become more normalized and broader education campaigns for healthcare providers and the general public are needed. PrEP is ‘not just for gay men,’ and this is important for the rollout of CAB-LA. We also need to address stigmas around sexuality and pleasure and think about PrEP as part of larger movements of sexual health and sexual liberation. A future world we imagined was one free of all stigma, as we discussed the impact on our communities of multiple forms of intersectional stigma, including HIV-stigma.
Group 4 – The healthcare providers’ perspective
Group 4 consisted of healthcare providers involved in PrEP delivery, including clinicians, nurse practitioners, social workers, and pharmacists, and was facilitated by Dr. Darrell Tan of St. Michael’s Hospital. James Morrison, a pharmacist and pharmacy owner from Toronto who attended the session, has summarized this group’s discussion in a related blog post, which will be released in September.
Summary
The Future of PrEP is Now team is incredibly grateful for the energy and enthusiasm that attendees brought to the session and the discussions. Their excitement for the potential offered by CAB-LA (as well as future LA-PrEP products still in development) was matched by their energetic advocacy for achieving more equitable access to PrEP among those who would benefit from it. The Future of PrEP is Now team left the session feeling inspired to continue work on the project. They’ve so far wrapped up focus groups and interviews with community members and stakeholders to determine the factors needed in providing more equitable access to PrEP, and will soon be conducting a quantitative study to determine the preferences of 2SGBQM in Canada for accessing LA-PrEP. The results of these studies will inform the design of a proposal for a CAB-LA implementation project, to coincide with the rollout of CAB-LA in Canada in the near future.
