Julian Hopwood-Raja argues that universal, barrier-free access to HIV medicines is not just a matter of beneficence for patients and the health system but important for public health and ethical resource allocation.

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Since the early 1980s, the treatment of people living with HIV has been rife with controversy. Numerous organizations, including ACT UP, have supported those living with HIV across North America and advocated for LGBTQ+ rights, against HIV-related stigma, and against price gouging by the pharmaceutical industry. HIV is now considered a chronic medical condition and medication can help people living with HIV to have a similar quality of life to those living without HIV. However, not all patients living with HIV can afford treatments.

In a previous healthcare clinic where I worked, there was a patient who was admitted for an AIDS-related illness that involved being treated for multiple invasive infections. Her six-month hospital stay was a burden on her family, and impacted her quality of life. Her extended hospital stay likely cost the province of Quebec around $6000 per day as an inpatient and $19000 per day in ICU. Two years prior to her hospital admission, she had stopped coming to the clinic for follow-up appointments and had stopped taking her antiretroviral (ARV) therapy. I learned that this was due to an issue with copayment at her pharmacy. I wondered, would she have experienced severe infections, and an extended hospital stay, if the system for accessing medications was simpler?

Photo Credit: NIAID/flickr. Image Description: Scanning electron micrograph of a human H9 T cell (blue/green) infected with HIV virus particles (yellow).

HIV diagnoses, particularly in the prairies, have been increasing at an alarming rate (Canada-wide increase of 24.9% from 2021 to 2022). To help combat this increase, Manitoba recently began providing free ARVs to those living with HIV as well as pre/post-exposure prophylaxis (PrEP/PEP) for HIV prevention. This joins other provinces across Canada including Alberta, British Columbia, and Saskatchewan who offer free access to provincially monitored HIV medications. However more populated provinces, such as Quebec and Ontario, still require a copayment and deductible depending on a person’s annual household income. This copayment can be a burden for some people, including those who may be recent immigrants to Canada. With a high influx of immigrants living with HIV who already have challenges navigating the health system, this only adds to the risk of them falling through the cracks, especially when juggling other aspects of Canadian life.

In terms of ethical resource allocation, one might think that providing free ARVs may result in taking resources from other communities (possibly marginalized) to fund this endeavour. This allocation would then place a higher priority on care for people living with HIV than on those living with other chronic conditions. While it would be virtually impossible to properly compare HIV to other chronic conditions considering the stigma and public health implications associated with HIV, the fairness of resource allocation is still a relevant consideration.

Much of the costs of ARVs are already paid for by public insurance, including several programs in Ontario (i.e. Trillium) and RAMQ in Quebec. It is then the responsibility of the patient to either pay the copay (at a maximum of $100 per month in Quebec or income-dependent in Ontario) or sign up for a patient support program if available (usually with pharmacy, nursing, or social work assistance). Therefore, since most of the costs of ARVs are already covered, the only additional resources needed would be the copay.

Allied healthcare providers often have to balance clinical work while also taking time to help patients with drug access. By making ARVs universally accessible, it would open up time and resources to allow allied healthcare providers to focus clinically on preventing HIV, caring for those living with HIV, and even addressing other patients’ medical care. Combined, free universal access to ARVs would promote public health while also utilizing clinical health resources more appropriately.

Looking at this from a public health lens: while there is an individual patient risk of poor outcomes when not taking ARVs, there is also a risk to others as HIV spreads via bodily fluids (in the presence of a detectable viral load). Looking at population health and vulnerable communities, HIV also disproportionally affects those who use drugs; a patient group that already has established barriers to accessing care. Therefore, the more people living with HIV accessing ARVs or people accessing PrEP for HIV prevention, the less likely people are to have poor HIV-related outcomes or be diagnosed with HIV in the first place, respectively.

While the treatment and prevention of HIV have progressed well, there are still areas where improvements can be made in the Canadian health system. Removing additional steps to accessing HIV medicines will not only allow our most vulnerable communities easier access to medications but will also support better outcomes from a public health standpoint. Additionally, since resources are allocated to support drug access, these could be optimized to keep patients connected to care and hopefully prevent more people from having an AIDS-related hospitalization in the future.

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Julian Hopwood-Raja is a clinical pharmacist for Alberta Health Services in the Northern Alberta Program providing care to those living with HIV in Alberta and Northwest Territories, and is pursuing a MHSc in Bioethics from the University of Toronto – Dalla Lana School of Public Health.