I attended the most recent BC Centre for Excellence in HIVAIDS (BCCfE) Antiretroviral update yesterday and left with good information. Presentations covered cancer and HIV; cardiovascular disease risk and management; harm reduction and opioids; PEP guidelines and best practices. Dr. Julio Montaner gave a BCCfE update, including here we stand on publicly funded PrEP, an advocacy issue that’s a high priority for many in the PAN community.
Part 1 of my write up summarizes the morning’s information and community takeaways on cancer and cardiovascular disease. This post will capture thoughts on harm reduction and opioids; PEP guidelines and best practices; and the BCCfE update.
Harm Reduction and HIV in Correctional Settings
Dr. M.J. Milloy and Wayne Campbell of Positive Living BC co-presented information on the populations with HIV in prison and the issues they face. The criminal justice system has higher rates of HIV than in community and correctional systems complicate HIV care. Prison doors can revolve; people who are released may end up back inside sooner than later. Among DTES residents who use drugs, more than 75% have been incarcerated at some point.
Wayne Campbell works for the Prison Outreach Program of Positive Living BC. He said that harm reduction efforts in corrections difficult and inconsistent across facilities. Harm reduction supplies can be difficult to obtain and HIV prevention still hindered by personal biases of staff. Stigma and discrimination play their parts- imagine being the man who requests condoms from a homophobic staff person.
A pilot program for safer tattooing was cancelled under the former Harper government, and the prison ombudsman says it should be restored. The call for needle exchanges in prisons need not cause panic; a needle exchange in prison started in Switzerland d in 1992 saw no incidents of needles being used as weapons (a common concern). When expanded to 8 countries and 60 prisons, there were no new cases of HIV or hepatitis C (HCV) due to drug use. Wayne concluded, “All harm reduction tools in community should be available in prisons”, a good goal to aim for, but along a road that we can see is long.
Treating Pain with Chronic Opioid Therapy
PLHIV can experience neuropathic pain that requires medication, and Dr. Jeffrey Samet talked about the balance of chronic pain management against the concerns about opioid use. He acknowledged that opioids can be safe and effective but are imperfect.
Pain experiences can differ from person to person and when treating someone with chronic pain, judge the treatment, not the person, he advised. Prescription opioid use disorder appears to be more common in people with HIV, an obvious concern, but if there’s benefit in the absence of harm, continue therapy. The opposite is true too: if harm of opioid use outweighs the benefit, discontinue use.
He shared treatment approaches that doctors may use to treat pain, and recommended a couple of sites where all could learn more:
Safe and Competent Opioid Prescribing Education: Scopeofpain.com
Safe and Effective Opioid Prescribing for Chronic Pain: Opioidprescribing.com
Mytopcare.org: Although this site is “dedicated to practicing Physicians, Pharmacists and other Clinical Professionals who care for patients with chronic pain using opioid medications” jump in.
Post Exposure Prophylaxis (PEP): New Guidelines and Patient Education
Dr. Marianne Harris talked about the new (May 2017) BCCfE Guidelines for the use of PEP. They include recommendations for use in instances of occupational (“accidental exposure”), events, which include workplace injuries and sexual assault, as well as non-occupational exposure, which includes consensual sexual activities and needle-sharing.
Harris walked through the assessment for PEP and drug treatment options once treatment decisions are made. She stressed that PEP is most effective within 2 hours of exposure and not more than 72 hours post exposure. Drugs are available to anyone in BC, although a couple of people pointed out that policy and practice can differ, and some work needs to be done on that count.
Turning to clinical practice, Dr. Liz Kirkpatrick presented about the importance of doctor-patient communication when prescribing PEP. Language matters on several counts: not all men who have sex with men (MSM) identify as gay or bi, and this can impact HIV prevention itself. If people are trans, ask them what pronouns they prefer, and use them. Make sure they are used consistently in your office/organization.
The stress of seeking PEP can’t be ignored. Having consensual sex does not mean that people consented to HIV risk. Ensure people understand the PEP plan; health literacy is an essential part of success. They must understand the potential but also the ramifications if they don’t take medication as prescribed. This is a good reminder for all, medical service providers, or community if you are supporting someone through PEP.
BCCfE Update
Dr. Julio Montaner gave BCCfE updates, including 90-90-90 targets, a new partnership with Saskatchewan, and where BC stands on publicly funded PrEP, an advocacy issue that’s a high priority for many in the PAN community.
The BCCfE recommends PrEP, and has issued clinical guidelines for its use. (published October 2017). The Ministry of Health has thus far decided not to cover the costs of PrEP for all people who may benefit from it, citing costs. It’s important to note that PrEP is available free-of-charge for people who receive health benefits through the First Nations Health Authority. With the new availability in Canada of generic TDF/FTC, the BCCfE has secured access to the generic. It continues to advocate with the Ministry of Health and has submitted a cost-neutral proposal for PrEP coverage. As PAN has recently been advised, the Ministry of Health will make a decision on this by the end of the year. It wasn’t announced yesterday, so I’m looking hopefully to World AIDS for the reveal.
NOTE: Slides from the ARV Update are available on the BCCfE website. Any errors in information are mine, and this post and its partner Part 1 can’t be taken as medical advice.
BCCfE Update Part 1: Cancer and Cardiovascular Disease
Questions? Feedback? Get in touch!
Janet Madsen, Capacity Building and Knowledge Translation Coordinator,
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