At YouthCO, we believe PrEP works, and stigma doesn't.

PrEP stands for Pre-Exposure Prophylaxis, and is one option to prevent HIV for those of us who are HIV-negative. We can take HIV medications on a daily basis before, and continuing after, activities where there is a possibility of getting HIV. Currently, PrEP is available as a single pill. The first approved pill in Canada is called Truvada. Now, generic forms of this pill are available. 

‘Pre-Exposure’ indicates that the medication must be taken before, during, and after potential exposure to HIV. ‘Prophylaxis’ is a word to describe medications that can prevent infection. PrEP works by making it harder for HIV to establish itself once the virus is in our bodies.

PrEP is made up of two medications, tenofovir and emtricitabine, that are also used to treat HIV for those of us living with HIV. Both of these medications are combined in a single pill. In BC, PrEP is available at no cost for those of us with MSP or Interim Federal Health Program.

At YouthCO, we support youth in getting access to the types of health care and medications that are right for us! We believe in providing information to youth so we can make decisions that are right for us.

There are lots of reasons why those of us who are HIV-negative may choose to take PrEP! If we may be coming into contact with HIV through sex or sharing needles, PrEP will help prevent HIV from establishing itself inside our bodies. For those of us who want PrEP, this is a great strategy we can use when it comes to our sexual health. 

We also know that PrEP is not right for everyone, and that PrEP is not the only strategy we can use to prevent HIV. PrEP might not be right for us if we are not able to take a pill every day, and/or attend regular appointments with our doctors. We also may not want to take PrEP if we prefer prevention options that also work to prevent STIs, like condoms and regular testing. Depending on our bodies, other medications we take, and other health conditions we have, PrEP may not be a good fit for our bodies.

When making decisions about our health, it is important for us to use what we know about ourselves to find what works for how we live our lives. If we want to talk to someone about if PrEP is right for us, YouthCO can help! 

The Stigma Project has an online quiz available here to help us determine if we may benefit from taking PrEP based on whether we may be coming into contact with HIV. The only option for gender in this quiz is 'male' or 'female', which we know doesn't represent all the ways we can express our gender. We also know that PrEP is used by folks of all genders, although most of the research that has been done so far has been with men and women who are cisgender, and transwomen. Some research about PrEP and trans men is available too. The Stigma Project quiz are based on the guidelines developed by the Centre for Disease Control in the United States for health care providers who are considering prescribing PrEP. These guidelines are very similar to those developed in British Columbia.

British Columbia is providing free PrEP to those of us who live in BC who are coming into contact with HIV on a regular basis. The BC Centre for Excellence in HIV/AIDS has developed guidelines on the use of HIV PrEP based on existing research about who may benefit from PrEP. We know that the existing research doesn't represent all of our bodies or experiences, and that these guidelines use binary language to talk about gender and who we may have sex with. 

For example, there has not been enough research on how PrEP works for trans men for the guidelines to include specific recommendations. But, we know that some trans men in our community are choosing to use PrEP. There also has not been research about PrEP for those of us under 18 years old, and PrEP is not recommended for folks under 18 at this time.

Here are the recommendations for PrEP use based on the research evidence that we have so far:

• men who have sex with men* who have anal sex without condoms some or all of the time and any of the following:
  • have had a diagnosis of syphilis, rectal gonorrhea, or rectal chlamydia in the past six months
  • have used PEP (post-exposure prophylaxis) more than once
  • have an ongoing sexual relationship with someone living with HIV who is not taking medication and/or does not have a low viral load
  • score at least 10 on a scale called the HIV Incidence Risk Index (HIRI). HIRI takes into account our age, and the types and amount of sex we've had in the past six months. For more information see Table 1 in the guidelines available here.

• transgender women who are having anal sex without condoms some or all of the time and any of the following:

  • have had a diagnosis of syphilis, rectal gonorrhea, or rectal chlamydia 
  • have used PEP (post-exposure prophylaxis) more than once
  • have an ongoing sexual relationship with someone living with HIV who is not taking medication and/or does not have a low viral load
  • score at least 10 on a risk indicator called the HIV Incidence Risk Index (HIRI). HIRI takes into account our age, and the types and amount of sex we've had in the past six months. For more information see Table 1 in the guidelines available here.

• people who share injection equipment with someone living with HIV who is not taking medication and/or does not have a low viral load

• heterosexual men and women who are having condomless anal or vaginal sex with a partner living with HIV who is not taking medication and/or does not have a low viral load

We know that not all of us are included here; for example, the guidelines don't specifically say whether "men who have sex with men" includes transgender and cisgender men, intersex people, nonbinary folks, masc of centre folks, or Two-Spirit people. However, we know that trans men are accessing PrEP, and may be able to help connect trans men to doctors who will prescribe PrEP. We know less about how PrEP works for trans men, but we do know that some trans men are choosing to use PrEP and can do so safely.

*The guidelines don't specifically state whether "men who have sex with men" includes transgender and cisgender men, intersex people, nonbinary folks, masc of centre folks, or Two-Spirit people. What we are hearing from those involved in making this policy and prescribing PrEP is that people who meet the criteria described above (e.g. recent STI diagnosis, previous use of PEP, ongoing sexual relationship with people living with HIV who have viral loads above a certain level, score over 10 on the HIRI) will be offered PrEP. We know that people of all genders are accessing PrEP, and may be able to help connect folks to doctors who will prescribe PrEP.

PrEP is available at no cost in British Columbia for those of us who are HIV-negative and may come into contact with HIV when we're having sex or sharing needles! PrEP is free for those of us who are Indigenous, whether or not we have status, and those of us who are refugees. 

In British Columbia, PrEP is provided by the BC Centre for Excellence in HIV/AIDS, and all the information here about getting PrEP comes from their website here.

Here are the steps to get PrEP!

1. Find a doctor we are comfortable asking for PrEP. In talking about PrEP with a health care provider, we will likely be asked questions about the sex we are having or the drugs we are using. Not all health care providers may be comfortable providing PrEP, either because it is new and they may not feel like they have enough information, or because they may be hesitant about this new HIV prevention option. The BC Centre for Excellence has information we can give to our health care provider here, or we can ask them to call the Centre's pharmacy support line Monday - Friday, 8:00 am - 5:00 pm at 1-888-511-6222.  Doctors in Canada can prescribe PrEP, but not all doctors may have experience doing so. Finding a doctor can be challenging. If you want help in finding someone, let us know and we may be able to help.

2. Complete medical tests required for PrEP. Our doctor will ask us to complete tests before writing us a prescription. These tests include an HIV test, tests to measure kidney function, and tests to detect Hep B  and Hep C, as well as other STIs. Our doctor will also check about other health conditions we may have as it may impact how Truvada impacts our bodies and health. 

If our test results show PrEP is not a good fit for our bodies, we can talk with our health care provider or connect with programs like Mpowerment to learn about other HIV prevention options that may work instead of PrEP.

3. Get a prescription! If our test results show we are a good candidate for PrEP, then our doctor can submit a prescription request form. This form is submitted for approval by the BC Centre for Excellence in HIV/AIDS, who will then tell our health care provider the prescription is approved. Our health care provider will then tell us where to pick up the medications.

4. Pick up our medication. We are responsible for picking up our PrEP medications. For those of us in the Greater Vancouver area, the pick up location is the St. Paul's Hospital Ambulatory Pharmacy at 163-1081 Burrard St. For those of us outside the Greater Vancouver Area, our medications will be sent to the doctor who prescribed them. Once we have our medications, then we are able to start taking them as per the instructions we were given.

5. Stay connected to our doctor. Because PrEP only works for those of us who are HIV-negative, and it may impact our kidneys and bone density, it is important that we make ongoing appointments. These appointments are also required for us to get a refill on our prescription. 

PrEP is one of many strategies we can use to prevent HIV from being passed. Just because we are using PrEP does not mean we can't use other strategies too. Other strategies include things we can do as individuals (get tested and treated for HIV and STIs), with our partners (talk about sexual health, use condoms and/or lube, get tested, support each other in taking PrEP and/or treatment for HIV and/or STIs) and things we can do as a community (providing inclusive sexual health education, and decreasing stigma towards communities most affected by HIV). PrEP works best for those of us who do not always use additional prevention options, whether they are not always available or are not realistic for us.  

PrEP does not prevent other STIs from being passed. This is one reason why as part of getting a PrEP prescription, we need to get STI tests regularly, and why we may choose to use condoms and PrEP some or all of the time. Some STIs (like syphilis, gonorrhea, and chlamydia) are curable, and treatment is available for others STIs like herpes.

Stigma towards sex (especially anal sex), injection drug use, and communities most affected by HIV is a major barrier to all HIV prevention methods. Stigma can make it harder for us to access the information and health care we need whether we are living with HIV or if we are HIV-negative, and stigma continues to drive HIV transmission. YouthCO will continue to work to change stigmatizing attitudes that make it hard for all of us to get the health care and information we need.

Yes, PrEP works! Research consistently shows PrEP, when taken as prescribed, significantly reduces the likelihood of acquiring HIV for cisgender men, and women who are transgender or cisgender. Unfortunately, there hasn't been enough research specifically about how PrEP works for transgender men, non-binary folks, or Two-Spirit people. PrEP research has focused on cisgender gay men and other men who have sex with men, transgender women, and cisgender men and women who are heterosexual and/or use injection drugs.

So far, research has only been done with people over the age of 18, so we do not know how PrEP works for younger youth. How much of a difference PrEP makes on our HIV risk varies greatly based on our exposure to HIV and how closely we are able to follow the prescription. If we are using PrEP, it is important to follow our doctor's instructions about how to use it. 

Studies have shown that PrEP reduces the risk of HIV acquisition between 74% and 92% among individuals who take the medication as prescribed. In these studies, research participants were also given access to safer sex counselling, STI testing and treatment, and condoms. The research participants reported a range of sexual acts and relationships, including having multiple partners, anal sex, and vaginal sex. PrEP does not prevent other STIs such as chlamydia, gonorrhea or syphilis.

PrEP can be used alongside existing HIV prevention methods such as using condoms. We also know that PrEP alone significantly reduces the possibility of becoming HIV-positive, when taken as prescribed. The strongest evidence shows taking PrEP every day works best, especially for those of us with a vagina or front hole. There is also evidence that supports taking PrEP immediately intermittently when we know we are going to be having sex. This is something we can talk about with our doctors.

PrEP does not work immediately when we start taking it: current evidence suggests it can take between 7 and 21 days for there to be enough medication in our bodies to prevent HIV, depending on our bodies and the sex we are having. For anal sex, it takes 7 days for there to be enough medication in our bodies. For vaginal sex, sharing needles, and frontal sex, it takes 21 days for there to be enough medication in our bodies.

More research is underway in Canada and globally to learn more about PrEP.  Current research is looking at the long-term impacts of using PrEP, and if PrEP still works if taken less often or in other forms, such as injections. 

Most of us will not have side effects from PrEP. We know that some people who take PrEP have short-term side effects such as nausea when first starting to take the medication. These side effects usually stop within a few weeks. Our health care provider will likely ask about any side effects we've been having, and may be able to help us manage them!

Decreased kidney function is a possible side effect from PrEP, and is one reason we need to get medical tests as part of accessing PrEP. This side effect is not very common, and can be reversed when we stop taking PrEP.

Decreased bone density is also a possible side effect of Truvada, but more research is needed to understand this side effect for those of us who are HIV-negative. This side effect is not very common, and has also been reversed when people stop taking PrEp. More research is needed to understand this side effect for those of us who are HIV-negative.

These possible side effects are one reason why those of us taking PrEP need to see a health care provider regularly; in most cases, appointments are needed every three months.

At YouthCO, we believe PrEP works, and stigma doesn't. So far, research about PrEP has been for those of us over 18. We support youth in getting health care that works for us, including and beyond PrEP! We continue to advocate for all youth to have consistent access to health care that is inclusive and stigma-free. 

YouthCO knows PrEP will play a role in preventing new HIV diagnoses for some of us! And, we know that PrEP will only work when we have access to it, from making sure its available for free, to being able to see a health provider like a doctor we're comfortable with regularly. We also need a health provider who is knowledgeable about PrEP, and comfortable talking to us about our sexual health.

Now that PrEP is available at no cost, we will keep advocating to reduce the stigma that makes it hard to get PrEP. We want to make sure this new option is available to youth across the province: to those of us in communities without a doctor, to those of us in Indigenous communities, to those of us who are living with people we might not want to know we are taking PrEP. 

PrEP cannot be the only strategy we use to reduce the impact of HIV on British Columbia’s youth. It is crucial that we address the very real ways stigma and social inequities limit access to HIV education, treatment, care, and prevention as part of how we approach PrEP.

Our full position statement on PrEP was written in the spring of 2015 and is available here.

YouthCO has a video about the steps to getting PrEP, whether it is for the first time or refilling our prescription!

Visit https://www.youtube.com/watch?v=m2vEw_8inRc&feature=youtu.be.