HIV Pre-Exposure Prophylaxis and Sex Work in Canada 2016

Disease Control in the States where they’ve taken huge cohorts of gay men and looked
at predictors of HIV infection in those cohorts. They came up with a risk score, and if you
score greater than 10 on this scale that goes from zero to 48—you can go as high as 48
on that scale—then they would say that is significant enough risk that the person should
be at least thinking about considering PrEP. That’s what we used for column B. And with
column C, we asked the guys: “What do you think the risk is for getting HIV? Is it zero? Is
it low? Is it moderate? Or high?” Just however people interpret those words. And that’s
the “moderate” or “high.”
Q I’m also interested in how would you define risk in terms of sex workers? Earlier
we heard that, in Canada, anyone exchanging sex for money—doing sex work—is
considered at risk. That’s clearly not anything grounded in research, because sex workers
in Canada have not been at high risk for getting or transmitting HIV, since the whole thing
began. So what is the high risk? And does it ever involve a vagina?
A Honestly, I don’t know the answer to that question. And I think that’s why I’m
actually really happy to be in this room with you, because I’m very interested in what
your perspective is. In terms of how do we define high risk? How we define high risk in
this particular one study doesn’t really matter. With respect to your question, the bigger
question is: how are we going to use that concept of “risk” on a case-by-case, individual
basis—and in some cases a collective basis—to decide where should we use PrEP? I
don’t know the answer to that question. There’s lots more data for gay men, just because
this is the population that has always had the highest incidence and prevalence of HIV
infection in Canada since the beginning of the epidemic. And, if there are data gaps that
we need to fill in terms of understanding how risk is perceived; how it’s acted on; what it
actually is—even logically—with sex workers in Canada, then I think that’s an actionable
fact to find out what the data gaps are that we need to fill in order to figure out what we
need to be doing next.
Q What do you think needs to happen to address this? What can we do?
A I think one piece of it is advocacy,
right? The reason that this bus ad
exists, to me, it’s symbolic of a lot. To
walk down the street and see a big ad
celebrating something like this, and to
have the name on it that’s doing it be
the city—the public health authority
of the city—that says a lot. That’s a
big commitment. That’s a public show
of leadership, and unfortunately that’s
been relatively absent in Canada for a
bunch of reasons.
Q When it comes to risks—both in
the study and risk in general—does
ethnicity factor into it? Because I
do know within the cis queer black
community, HIV status is not something
we talk about. And that does relate to
Caribbean culture. You don’t go to the doctor unless you’re really hurting. You don’t talk
about things like that you’re ill, because it’s viewed as shameful, and it’s something that
you’re supposed to take on yourself. So in certain communities, PrEP is an elusive idea
because we don’t disclose—about partners, about status… I talk to a lot of youth of
colour and it’s hard to even get them to go for testing. So, is that factored in at all? And,
if not, how can it be? Because that is a big determining factor.
Transit shelter ad by City of San Francisco Deptartment of Public Health
A I think you’re absolutely right about that. It’s not unique to PrEP, as you are pointing
out. It applies to testing as well, engagement, all kinds of care as well. It’s a related issue,
absolutely. The way I see my own small role in all of this is, which hat do I wear? On
this one I’m a researcher so I’m wearing that hat. One project that we’ve initiated in the
last year—and we just got a small seed grant to do—is to work in partnership with
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