PrEP requires a prescription from a doctor or nurse practitioner, and also requires some minor (but really important) regular follow up. Because PrEP is so new, sometimes doctors may not have heard of it, and might not feel comfortable prescribing it. Also, like we discussed above, sometimes doctors will only prescribe PrEP if you disclose sexual activity that fits one or more of the ‘high risk’ categories we talk about elsewhere on this site. Below are all the steps you need to take to get a prescription for PrEP, and a link to a printable fact sheet that can help with some pointers, and contains a list of required tests.
Talk to your doctor or nurse practitioner about why you are interested in PrEP. This might require sharing some pretty personal information, and we know that can be a barrier to guys when talking to their primary healthcare provider not just about PrEP, but sexual health in general. If you’re not comfortable sharing details about your sex life with your primary care provider, contact HIM and we can try to help connect you with a gay-friendly provider, or with providers here in Vancouver who might be more familiar with PrEP, and more willing to work with you to consider it as an HIV prevention strategy for you. Remember that the most important thing here is that you have to have a prescription for PrEP, and it does require some follow up, so having a regular provider is essential.
Once you and your healthcare provider decide PrEP is a good choice for you, they’re going to need to have you complete some really important tests. These tests are listed below, and you should make sure you know about them, just in case your doctor isn’t familiar with all the steps to prescribing PrEP. If your doctor doesn’t ask for one of these tests, it’s essential that you let them know, because not getting one of them could cause big complications later on. Here is the printable fact sheet that has some helpful hints on talking to your provider about PrEP, and a brief list of all the required tests you need before and after starting PrEP- just in case they aren't familiar with PrEP, and aren't sure what tests you need.
Before Starting PrEP: The Tests
- HIV: It’s essential you get an HIV test before you start PrEP. If you start PrEP and are positive but don’t know it, it can be a big issue. Even though Truvada is used as an HIV treatment drug, on its own it isn’t powerful enough to control the virus. This means if you’re taking PrEP but are HIV positive and don’t know it, the virus could mutate and become resistant to Truvada. Because Truvada is considered a ‘frontline’ medication for HIV treatment (because it’s so safe and well-tolerated), it’s important that it is only reserved for proper use in combination with other drugs for HIV treatment and prevention. After you take your HIV test, your provider will likely recommend that you avoid any sexual activity that can pass HIV for about seven days after you start Truvada for PrEP. This is just to make sure you have enough medication in your bloodstream to protect against HIV before you have sex.
- Hepatitis B: Truvada can also cause complications for guys who have Hepatitis B, even if they don’t know it. It can also cause complications for guys who contract Hep B after they start PrEP. So, another essential test is a Hep B test if you haven’t been vaccinated, or what’s called a ‘titer reading’ if you have been vaccinated. A titer reading tells your provider how active your vaccination is, and will help them determine if you should be re-vaccinated. If you haven’t been vaccinated against Hep B., you will need to be before you can start PrEP.
- Kidney function test: because a very small number of guys will have decreased kidney function as a side effect of PrEP, your provider should test your kidney function before you start PrEP, and also one month after. This will let you and your provider know if it’s safe to start, and will also let you both know very quickly if any kidney issues arise. The specific test your doctor should ask for will measure (or estimate) how efficiently your kidney’s clear a kind of protein called ‘creatinine.’
- STI tests: STI screening is also part of initiating PrEP, both when you start and for however long you take the medication. REMEMBER: PrEP DOES NOT PROTECT AGAINST ANY OTHER STIs! Vancouver is currently experiencing a significant syphilis outbreak, and rates of other STIs here remain high. For many reasons, you should get tested every three months. One great thing about PrEP is STI testing becomes a more regular part of your overall healthcare regimen!
While You’re on PrEP: The Tests
- HIV: even though you’re taking PrEP to prevent HIV transmission, you’ll still need to get tested for HIV every three months. Because PrEP is still pretty new, researchers are following users closely to make sure it’s as effective as the studies indicate. We also know that all HIV prevention methods, including condoms and PrEP, will not work 100% of the time. Getting tested for HIV every three months ensures that in cases where PrEP didn’t work to prevent HIV transmission, guys can get the treatment they need immediately.
- STI tests: Because researchers have established that some (though not most) guys might change how they use condoms after they start PrEP, you’ll need to get tested for all STIs every three months, even if you’re still using condoms. These are part of the guidelines established by Health Canada, so remember that if your doctor or nurse practitioner isn’t asking for these tests, they’re not following the guidelines, and you might want to find a provider who knows more about PrEP. As we have noted before, STI rates in Vancouver are high, and some, like syphilis, are now considered outbreaks. It’s important to get your STI tests for your PrEP regimen, but all guys should be getting tested a lot more frequently, and taking more steps to protect themselves and others from STI transmission through safer sex methods.
- Kidney function test: just like we talked about above, PrEP can impact kidney function for a small number of guys. Usually this happens pretty soon after you start the medication, but it can also develop later on, so your provider should be making sure you have your kidney function / creatinine clearance tested every three months as well.
Some, but by no means all, insurance companies in BC cover PrEP. Because PrEP is such a new medication in Canada, even if you have insurance that covers it, you might need to take a few extra steps first before you can get the prescription covered. Your insurance provider might ask you for some additional information from your doctor or nurse practitioner, or for what’s called a ‘drug exception request,’ or even documentation from the BC Centre for Excellence in HIV & AIDS stating that you aren’t a poz guy. When insurance companies ask for these things, it’s usually because HIV medications in BC aren’t ever covered by private insurance- they’re paid for by a special program set up by the province. Sometimes an insurance company will see a prescription for Truvada, and refuse it because they think you might be eligible to get the prescription through the province. When this happens, you usually just need to take a few more steps before you can get your prescription filled. It can take a while (even up to a month) to work through the steps with your insurance, so it might be helpful to start working with your insurance as your first step after you get your prescription, and do all of your tests last. If you do your tests first, and then have to spend a few weeks waiting for coverage, you might have to do some or all of the tests all over again. If you have questions or need assistance in working with your insurance provider to access PrEP, call HIM at 604-488-1001, and we can help connect you with a Health Promotion Case Manager who can help you navigate the process.
Other Ways to Get PrEP
There may be research studies in Vancouver (or other major cities across Canada) that will provide PrEP for participants. In these studies, sometimes all the participants will receive the drug, and sometimes only half will (like when they’re comparing guys not taking PrEP to those who are). Right now there aren’t any active PrEP studies in Vancouver, but this could change- make sure and sign up for our email list and check our NEWS page regularly for updates, including active recruitment for local or national PrEP studies.
If you live in Vancouver, you might have heard guys talking about ‘generic PrEP’ or ‘generic importation.’ In a nutshell, some countries have received permission from the World Health Organization (WHO) to manufacture generic HIV and HIV prevention medications even though these medications are still under patent in Canada (this means we can’t manufacture a generic here yet, though that may change in 2017). These manufacturers supply a lot of different kinds of generic medications, and their manufacturing sites and practices have been reviewed and recognized by the United States Food and Drug Administration (FDA) and WHO as reputable suppliers of medications, including emtricitabine / tenofivir (the combination of meds used in Truvada, and also generic PrEP). Because Truvada is still under patent in North America, it’s still a very expensive medication in Canada- so expensive that most guys without insurance simply can’t afford it. Because Truvada for PrEP isn’t listed through Pharmacare (and might never be), and because a lot of guys don’t have private insurance or have insurance plans that won’t cover PrEP, generic importation is one way that PrEP can be made more affordable for guys without any other access.
In Canada, both Health Canada and Canada Border Services Agency (CBSA) allow Canadians to import up to three months of a prescription medication in order to continue a course of treatment, so long as it’s brought into the country on your person (this means it can’t be mailed in), and you have a copy of your prescription, and don’t bring more than a three-month supply in at a time. IF YOU ARE IN CANADA ON A TEMPORARY PERMIT (not a permanent resident or citizen; for example, if you're here studying),YOU MAY IMPORT A 90-DAY SUPPLY OF GENERIC PrEP BY MAIL. Please note, however, that all other rules and regulations that apply to importation by permanent residents and citizens still apply. For some guys without access to insurance, or who can’t afford to pay out of pocket, importation is the only way for them to access PrEP (for more specifics on generic importation, you can go HERE). HIM neither endorses nor discourages importation of generic emtricitabine / tenofivir (aka generic PrEP), because we recognize that for most guys in Vancouver, importation is their only option, and we recognize that some guys who are at high-risk for HIV with no other access to PrEP may decide that importation of generic PrEP is right for them. For a link to CBSA regulations on importing generic drugs, please visit their site and scroll to the section titled "Personal Importation of Generic Drugs" HERE.
For guys who are importing PrEP, we remind you that just like any PrEP prescription, you need to take this medication under the supervision of a licensed medical provider, and need to make sure that you are following the once-daily PrEP dosing, and quarterly testing for HIV, STIs, and kidney function as recommended by Health Canada. We know that some guys might have concerns about the quality of generic drugs. In the United Kingdom, 56 Dean Street (one of the world’s largest gay men’s health clinics) has been conducting free blood drug level monitoring for generic PrEP users. This means that they take a blood sample once a month to ensure that the level of PrEP in the blood is sufficient to prevent HIV transmission, and that the generic they are taking has the same concentrations of medicine as Truvada for PrEP. To date, they have found no discrepancies between generic PrEP and Truvada for PrEP. We also know that some private clinics here in Vancouver are also offering blood drug level monitoring for their patients, but this service isn’t widely available in Vancouver yet.
HIM supports the use of imported PrEP for HIV prevention when other methods aren't feasible, accessible, or effective for guys, AND if the person decides for themselves to take the risk of using products that aren't regulated by Health Canada, even though they are legal for you to bring into Canada.
We don't see the supply chain guys are using to get generic PrEP, so we can't say anything about the PrEP guys are getting through generic importation. Because of the work of 56 Dean Street in the UK, and some private clinics here in Vancouver, we do know these medications are being monitored for safety and effectiveness, and that no issues have arisen yet. We just want to be clear that HIM is just not in a position to confirm that what guys are getting through generic PrEP importation is the same stuff as Truvada- that's up to the guys who take it to decide. We do know some clinics are doing blood drug level monitoring here in Vancouver, so if you’re taking generic PrEP, you may want to talk to your health care provider to see if that’s an option for you.
We recognize that the importation of generic medications is approved by Health Canada and the CBSA, and want to remind ANY PrEP user that these medications must be taken under a doctor’s care regardless of where they are sourced. Whether you get your prescription at a Canadian pharmacy or via generic importation, after you start PrEP, always remember that you’ll still need to get the mandatory up-front HIV, kidney function, and Hep B tests, and will still need to be tested every three months for HIV, STIs, and kidney function. These are all quick and easy tests, and only require your provider to take some blood samples and send into a laboratory for analysis.