PrEP Guidebook for 2021

12.5.2021
7 min read
Thomas Trombetta
Dr. Caley Shukalek

Considering and getting PrEP can be daunting. Here's everything you need to know about what PrEP is, how it works, side effects, cost, and whether it's right for you.

1. What is PrEP?

PrEP (short for Pre-Exposure Prophylaxis) is a once-a-day pill that prevents HIV. The medication works to prevent HIV from establishing infection inside the body.

HIV PrEP has two main components: emtricitabine and tenofovir-disoproxil-fumarate. These components are also used as treatment by people who have HIV. Although PrEP prevents HIV, it does not prevent other STIs, like syphilis, gonorrhea, chlamydia, etc.

It’s important to understand PrEP is part of what’s called ‘combination prevention’, which is the best method to prevent HIV and STIs. Combination prevention involves the use of multiple strategies that have each been proven to work:

  • Pre-Exposure Prophylaxis (PrEP)
  • Post-Exposure Prophylaxis (PEP)
  • HIV Treatment
  • Sexual health education
  • Needle distribution programs and safe consumption sites
  • Anti-poverty work, housing efforts
  • Sex Work decriminalization and protections
  • Condom use

2. How does it work?

Rather than a physical barrier such as condoms, PrEP is a chemical barrier. It prevents the HIV virus from replicating in the body, leading it to die out and not get a hold of a person’s immune system. Essentially, PrEP works by preventing the HIV virus from reproducing, thereby preventing HIV transmission. 

Like any barrier, PrEP needs to be strong enough before it can prevent HIV, usually that means being on PrEP for 7 days for anal sex and 21 days for vaginal sex. These timelines allow the PrEP components to be absorbed by different tissues in the body.

3. How effective is PrEP?

PrEP is around 99% effective when taken as prescribed. Usually, PrEP is prescribed as a daily pill, to be taken everyday, once a day. Some choose to take PrEP differently, opting for ‘on-demand’, or ‘event-based’ PrEP. This regimen involves taking 2 pills 2-24 hours before HIV-transmissible contact and then 1 pill daily, for two days after (nicknamed the 2-1-1 method). This method is also effective, although less so than everyday PrEP since PrEP’s effectiveness is directly correlated to adherence (taking medication as prescribed). Freddie advocates taking PrEP every day. As they say, safe is better than sorry!

4. Is PrEP right for me?

It very well could be! PrEP is recommended for people with the highest risk of acquiring HIV, including (but not limited to):

  • Men who have sex with men and transgender women
  • Heterosexual women and men who have high-risk exposure, such as having a partner with HIV, sex workers, or having sex with a person at high risk for HIV
  • People who inject drugs
  • People whose condom use is inconsistent

So all in all, PrEP should be considered by those who are HIV negative and at higher risk for HIV. The decision to be on PrEP is made between patient and healthcare provider. A clinician will assess your HIV risk, and ask questions about your sexual and drug-use behaviour to determine if you’re a suitable PrEP candidate. All kinds of people can be on PrEP, for all kinds of reasons!

Some exams (bloodwork and urine) are required prior to initiating PrEP. These tests are necessary to ensure you remain HIV negative, that your body is tolerating PrEP well, and that you’re being tested and treated for STIs. If you decide to get PrEP through Freddie, your clinician and Care Coordinator will support you through all of the steps of your PrEP experience through check-ins and reminders

Learn more about whether PrEP is right for you in our article “Is PrEP right for me?”.

5. Truvada vs. Generic Truvada

A lot of people know PrEP as Truvada, while many are only familiar with PrEP. So, what’s the difference between Truvada and non-Truvada PrEP? 

HIV PrEP and Truvada and generic truvada are all (mostly!) interchangeable! Here is a nifty little breakdown:

  • Truvada: a drug (combination of Tenofovir disproxil fumarate 300 mg/Emtricitabine 200mg) invented by the US pharma company Gilead Sciences back in 2001. It costs about $2000/month in the US!
  • Generic truvada: After the research, development, and marketing of a new drug like Truvada, companies such as Gilead Sciences are given a patent to exclusively sell the drug for a certain period of time. The company can also determine the prices charged for the medication. After that period of time, other manufacturers have the right to create and sell a generic version of the same drug, which include the exact same components. With generics, you get the exact same drug, but at lower costs! Gilead Sciences made a deal with pharmaceutical manufacturer Teva to begin manufacturing generic truvada for Canadians. This is the exact same drug as Gilead’s Truvada, just a fraction of the cost. It was approved for use in Canada in 2016 by Health Canada. There are now four different generic pharmaceutical companies that offer PrEP in Canada. The price is around $250/month, but it is covered (i.e. free!) for many Canadians through provincial insurance, and is covered by most private insurance drug plans. You can read more about the cost below.
  • HIV PrEP: Technically PrEP is not a drug. It is a treatment modality - the idea of taking a drug before getting a disease to reduce your risk of acquiring it. Right now, Truvada and generic truvada are the most commonly used drugs for PrEP and so the terms are used interchangeably. That being said, there are a few other drugs used for HIV PrEP (the main one being Descovy), and more being researched. Generic truvada is the only drug covered by provincial plans and most private insurance plans given it is 99% effective and (relatively) affordable. 

6. Side Effects 

PrEP may present some short term side effects like nausea, headaches, and stomach aches. In general, less than 10% of PrEP patients experience any side effects, and if they do, they tend to cease after a week. With regards to long term side effects, PrEP has been shown in some patients to lead to a decrease in bone mineral density, as well as kidney function - however they don’t cause complications unless patients have a pre-existing condition (which would be screened through lab work before PrEP initiation). The levels of bone and kidney health also return to normal levels after somebody stops PrEP.

That’s why PrEP requires lab testing every three months - just to make sure your body is tolerating PrEP well. If there are any issues, your clinician will help you manage them to keep you safe.

7. Cost

Thankfully, PrEP is free or low cost for most Canadians! Whether or not you pay for PrEP, and how much you would pay, depends on a couple of factors: the province where you reside, and your clinical eligibility. Here is a summary by province for the provinces Freddie serves:



Alberta

PrEP is fully covered provincially (i.e. free!) for all Albertans who clinically qualify! That means that if you meet certain criteria (about sexual behaviour, for example), you can access free PrEP with your healthcare card. 

Nova Scotia

The lowest cost option to get PrEP in Nova Scotia is through private insurance. Most insurance plans cover 80% of the cost of PrEP! And with Freddie’s financial assistance programs, we can help lower the cost of your co-pay!

PrEP is also covered by Nova Scotia’s provincial Pharmacare program for those who do not have private insurance, however there are unfortunately very high deductibles and co-pays involved for anyone who earns more than $25,000 per year. You can calculate how much you would pay through this online calculator.  Freddie is working on developing financial assistance programs for our Nova Scotia patients using Pharmacare. 

Ontario

The situation is a bit more complicated here. 

Ontario residents under 24 years of age can access free PrEP through the Ontario Health Insurance Plan! 

If you’re 25 or older, there’s two main scenarios in the province:

  1. You have private insurance. This means that you’ll either get your PrEP fully or partly covered by your insurance. Sometimes, there are co-pays, meaning you’d be required to contribute towards the price of the medication. With Freddie’s financial assistance program, most patients pay a $0 co-pay!
  2. You don’t have private insurance. If you are over 25 and don’t have insurance, usually that means you would have to pay around $250/month for PrEP. Luckily, Ontario offers the Trillium Drug Program to support PrEP costs. Freddie will support you with your Trillium application, and with our financial assistance programs, you can access PrEP for free or at lower cost through Trillium.

Quebec

The lowest cost option to get PrEP in Quebec is through private insurance. Most insurance plans cover 80% of the cost of PrEP! And with Freddie’s financial assistance programs, we can help lower the cost of co-pays associated with labs!

PrEP is also covered by RAMQ for those who do not have private insurance, however there are unfortunately co-pays involved. You would pay up to $93 a month for PrEP through RAMQ, although if you are already paying co-pays for other prescription drugs, the amount you’d pay for PrEP is less. 

Unfortunately, financial assistance programs to help with the cost of PrEP are not allowed under Quebec law, so Freddie is not able to offer them. 

Saskatchewan

PrEP is covered provincially (i.e. free!) for all Saskatchewanians who clinically qualify! That means that if you meet certain criteria (about sexual behaviour, for example), you can access free PrEP with your healthcare card. 

You can see if you qualify for free or low cost PrEP through our one-minute eligibility questionnaire.

8. How do I get PrEP?

Like with any prescribed medication, there are some steps one needs to take before starting on PrEP:

  1. Speak to a clinician. A clinician visit will assist you in determining if PrEP is right for you. They will ask about your sexual activity, drug use, and any other behaviour that may put you at higher risk for HIV. Clinicians will also instruct you on the necessary tests before you get your prescription and answer any questions you may have
  2. Get your lab work done. Initial lab work tests your HIV status, STIs, and kidney function to ensure you’re suitable for PrEP. Given the results come back as expected, you can receive your 30-day PrEP prescription
  3. Repeat lab work after 1 month and then every 3 months. This is done to ensure you’re tolerating PrEP well, remain HIV negative, and any STIs are detected and treated

Should you get PrEP in person or online? You can learn more in our article “3 benefits of Accessing PrEP online.” As the title implies, we might be a bit biased :)

If you are thinking about PrEP, why not schedule a free phone call with one of our affirming clinicians? Don’t worry, having a consultation doesn’t mean you automatically have to go on PrEP! We’re here to help you understand if PrEP is for you, because it isn't for everyone. And if you’re on the fence, that’s okay – the best place to get your questions answered is one-on-one with an experienced healthcare professional who knows the ins and outs of life on PrEP. With Freddie, you’ll have your very own dedicated Care Coordinator assigned to you; if you hate calling customer service lines and waiting on hold, this is especially fantastic news for you because you can quite literally just text your Care Coordinator directly with your questions and concerns, and they will figure out exactly what you need behind-the-scenes and get back to you in a timely manner.


Written by:
Thomas Trombetta

Thomas is passionate about gender and sexuality liberation social movements. Before beginning his work with Freddie, Thomas studied Sociology and Global & Development Studies at the University of Alberta, after which he began working with marginalized communities. In previous roles, Thomas was involved in queer and trans health education, PrEP health promotion, community-based research, HIV education, and LGBTQ2S+ advocacy.

Dr. Caley Shukalek

Caley is passionate about evidence-based, patient-centred care, including telemedicine that can provide high quality care from wherever a patient may choose.

He helped create Alberta's PrEP guidelines and works as a specialist in General Internal Medicine with additional training in sexual health, including HIV and sexually transmitted infections.

He holds an Masters of Public Health from Johns Hopkins University, an MD from the University of Calgary and an MSc from the University of Alberta.

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