Dr Réjean Thomas
The fight against HIV has seen significant progress and breakthroughs in record time, as progress to date can help eradicate HIV. But to achieve this realistically and in a sustainable way, many challenges remain in many areas.
In recent years, HIV prevention has become more complex. Accessibility to post-exposure prophylaxis (PEP – to prevent contracting the virus after exposure) and pre-exposure prophylaxis (PrEP – preventing HIV transmission in high-risk individuals) to diversify the means of prevention. Today, prevention is no longer based solely on behaviors (condom use): we have moved to a biomedical approach that works.
PrEP has proven to be a very innovative and highly effective prevention strategy, as evidenced by the figures: in 2017, the number of HIV cases in Montreal fell by 35% among men who have sex with men. Although this has a major impact on public health, strengthening this strategy among high-risk populations with HIV remains one of the major challenges of prevention.
Deploying PrEP further means making it known to both those who are at risk and who can benefit from it, and the doctors who can prescribe it. It is necessary to disseminate this information more widely. The perception of PrEP has also been able to limit its use because too often PrEP is associated with recrudescence of STIs. On the contrary, PrEP and its follow-up should be considered as assets in that they are an opportunity for people at high risk of STIs to perform screening regularly (every three months). On the other hand, it must be remembered that prevention can not be effective without being integrated into a holistic health perspective.
Social vulnerability remains a fundamental factor in the transmission of HIV through precariousness, discrimination, homophobia and lack of self-esteem, all of which fuel the epidemic.
Barriers to screening and access to treatment are multiple; social vulnerability contributes actively to it.
Each year, globally, 25% of HIV cases are diagnosed at an advanced stage of the disease, which means that people are diagnosed late. Therefore, the accessibility of HIV testing must be increased to reduce the proportion of those who do not know their status (estimated at 20%), put HIV-positive people on treatment as quickly as possible so that their viral load is undetectable and, ultimately, eradicate HIV.
The accessibility of the test is related to the absence of coercive measures vis-à-vis the serological status. In this regard, the Canadian government has received positive feedback from community and scientific communities against the criminalization of HIV status. On December 1, the Federal Minister of Justice announced new, evidence-based guidelines to limit criminal prosecution of people living with HIV who fail to disclose their status to a sexual partner.
It must be remembered that HIV is an STI. As for other STIs, treatment should be free, because although Quebec has a good drug insurance system, some people delay or stop treatment for financial reasons. PrEP, as a preventative treatment, should be free for young people and people with financial difficulties. We have all the scientific means (screening, rapid treatment, PEP, PrEP and condoms) to eradicate HIV in Montreal. Now we need political will.
Réjean Thomas, MD, CM, OQ
Clinique l’Actuel, President-Founder