While HIV cases surge, PrEP implementation is far from being a fact. How do we put us on the fast track? – An open letter.
IT’S 2020, BABY …
… and it’s time to check the current situation of PrEP, a medical method to prevent HIV, in Colombia. Our flyer READY FOR PrEP IN COLOMBIA was released in May 2018. At that time everyone was asking: How do we get PrEP? How much does it cost? When will it be available? – People were excited, hopeful and surprised to see someone speaking about it. They also had the natural expectation that this would soon be available to all who needed it.
Sadly, the situation today is that PrEP is still not accessible. People are getting infected by HIV every day in Colombia, and at high rates. So it’s time to ask: How much longer do we have to wait for PrEP in Colombia and why? And what has to be done for this effective method to protect everyone who needs it?
In times of the coronavirus pandemic we all have a higher awareness of societal efforts to protect the population (or certain groups of it) from infections and efforts in prevention, vaccine development and treatment (and their social costs). That’s why we think: this is the right moment for this text!
LET’S HAVE A REALISTIC VIEW OF THE SITUATION IN COLOMBIA
If you want to start using PrEP, you can do so only if you’re able and willing to pay for it yourself. Your doctor can prescribe it only off-label, when he/she considers it appropriate. As it stands now, by the time we write this letter, PrEP is not approved for preventive use, which is precisely how it works!
Lack of clarity and safety is one of the main issues surrounding PrEP, PEP and HIV prevention. For example:
- You’ve had a situation with risk of HIV transmission and have to go to a hospital emergency room to get PEP. You might face doctors who have never heard about it! Maybe you are denied PEP despite a relevant transmission risk and therefore are possibly infected with HIV.
- Maybe you think about taking PEP as PrEP, because you see no other way to obtain PrEP. (and maybe without the needed medical surveillance)
- There is also a good chance that you are offered overpriced PrEP from your drug dealer.
- You, as a seropositive person, may actually sell your medication to some PrEP users, because you need money.
- Or you try to obtain PrEP for personal use from abroad and don’t receive serious information from customs about how much, if any, you can bring to Colombia.
These situations reveal that confusion around PrEP is about much more than finances.
Although a high percentage of HIV-positive people benefit from antiretroviral therapy (ART, which is paid by health insurances) and therefore are not infectious, a considerable number of people are untested and unaware of their HIV status. This might be a reason for you to protect yourself with PrEP or other methods.
COLOMBIAN HIV INFECTION RATES BREAK THROUGH THE CEILING
The annual report of new HIV cases has increased every year, going from 7,793 in 2012 to 15,908 in 2019, with a 10-15% increase every year. Even though this means that more people are tested and have access to ART (which is great!), we must ask ourselves whether this is the only reason behind this increase…
Between the 1st of January of 2017 and the 31st of January 2018, the Colombian Fund for High-cost Diseases reported 1152 deaths among people diagnosed with HIV. This represents an increase of 307 cases for the same period between 2016-2017. Additionally, of these 1152 deaths related to HIV for 2017-2018, 30.6% (Approx. 353) correspond to causes directly connected to AIDS.
Particularly affected are the groups of men who have sex with men, trans women and sex workers. The number of HIV transmissions among heterosexuals also increases significantly from year to year. Furthermore, migrants are vulnerable and particularly affected by HIV and its implications.
Colombia has committed to the Sustainable Development Goals and the implementation of the 2030 AGENDA, which aims to end the AIDS epidemic by 2030. The increase of new HIV infections every year indicates that the country is currently on the wrong track to achieve this target!
COLOMBIA: PrEP IS NOT APPROVED AND NOT ACCESSIBLE FOR MOST OF THOSE WHO NEED IT
The statistics show that policies so far implemented do not prevent HIV transmissions. Policies have to be evaluated and strengthened with a structural prevention approach, with a particular emphasis on primary prevention (before there is evidence of infection). If Colombia wants to implement the 2030 Agenda, this must happen now, not in 10 years! Negligence to act causes more and more cases and deaths.
PrEP is one of the most important strategies of public health to prevent HIV transmissions and it is time to implement it in Colombia. Studies have repeatedly shown that PrEP is an effective strategy for the prevention of HIV in risk populations. Furthermore, it has been shown to save money for health systems.
On the one hand, in Colombia there is an important legal aspect that needs to be fixed in order to use PrEP. Truvada® is registered by the Colombian regulatory entity (INVIMA) as a treatment, not a preventive medication. That means that it is important to develop clinical guidelines and an administrative process. Both can be adopted from other countries easily.
On the other hand, right now PrEP has to be prescribed by doctors off-label, Physicians must justify how each patient can benefit by an “off-label” use and prescribes the medication on her/his own risk. Also, stocks in pharmacies are low since it is only distributed to cover ART. All these are reasons for obstruction besides the cost factor. Under these conditions, PrEP will be difficult to obtain and will not have relevant preventive effects.
Even though there is positive evidence of PrEP, there is not much public information in Colombia and it is not part of the national HIV strategy (at least not in the official and public documents). People who want to use PrEP can only obtain it by buying privately (and only prescribed off-label), so it is the privilege of a few. How much time do we have to wait to have access to a modern public policy that guarantees our sexual rights?
IS A STUDY ENOUGH TO MEET THE URGENT NEED OF PrEP IN COLOMBIA?
A PrEP pilot study is held by two UN agencies from December 2019 to December 2020. It includes 450 people (50% trans women, 50% men who have sex with men) in the capital and currently does not enroll new candidates. Whoever is still interested to participate is offered only a self-payment program, including medical consultations, regular tests, and PrEP generics for $1,780,000 COP per year. Although this offer is unaffordable for most, it is worth noting that this extended access is being offered.
Bertha Gómez, Sub-Regional Advisor on HIV for the Pan American Health Organisation-PAHO, recognised the urgency of PrEP in our country: “The implementation of PrEP in Colombia is important (…). It is a key strategy for the elimination of AIDS as a public health problem and to reach populations that traditionally do not seek health services and where the diagnostic gap could be located.” She also points out that it is critical to recognise the capacity of the system to implement PrEP: “It is important to be clear on what is the cost of the intervention and its financial impact for the national health system. (…) Besides, it is required to recognise what the programmatic capacity is if PrEP is implemented and what is the population size that would be susceptible to the intervention.”
There is only insufficient information about PrEP and the study on their website (www.prep-colombia.org). The pilot is not held in the usual structures of the Colombian national health system (general practitioners, health insurance). Participants were offered daily PrEP only. Regular STI testing is part of the program. Moreover, there is no public mention of any financial studies or guidelines development.
How does the study address the social dimension of PrEP? People who use PrEP rely on their communities to obtain it. In these spaces they are more open about their anxieties and questions regarding HIV. For example, many people decide to take PrEP out of fear, even though they are not in risky situations. These are problematic issues that, if not discussed socially, cannot be resolved.
Naturally, it is justified to evaluate the financial and practical feasibility of a new method. And, of course, we need to discuss the particularities in Colombia. But, given the overwhelming evidence in favor of adopting PrEP, another study may just as well be: playing time.
For instance, in Peru since May 2019 PrEP has been implemented as part of the ImPrEP Study in cooperation with Mexico and Brazil. As in Colombia, the access was initially limited to 1,800 people, but the goal was clearly formulated: rapid implementation in the health system and access for all who need PrEP as soon as possible. See www.preparate.pe 
The delay in the implementation of PrEP has consequences. In the UK, a study that included 10,000 participants assigned people that came “too late” on a waiting list. Later some of them tested HIV-positive, reported this to the BBC and a public discussion started about the ethical aspects of limited access caused by holding one pilot study after the other. Following a British court order, from April 2020 PrEP is accessible for every person in the UK as NHS health insurance benefits! 
There’s no time to lose. More people are being infected with HIV every day, and it’s urgent to accept the facts and act:
- PrEP is efficient at lowering the infection rate of HIV.
- Individuals want to use it and benefit from its destigmatising effects.
- Many countries have successfully implemented it into their health plans.
- It is effective at reducing costs for health systems when being part of a comprehensive HIV policy strategy.
Apart from a study with negligible numbers of participants – the country’s policy does not exhibit a clear strategy regarding HIV. We do not want to discredit any efforts to gain further knowledge, but we want to point out that further efforts are necessary to make PrEP a reality in our country. A study is not a sedative pill!
WHY IS PrEP NOT A REVOLUTION HERE?
During the 90s, someone who would have thought about a HIV prevention pill would have been called a dreamer: people were dying and struggling with the epidemic, there were no treatments, no healing perspective, no vaccination.
In 2020 this pill exists (it has for almost 10 years) and we’re not using it widely. Why?
Is lack of money really a reason? PrEP is affordable as generics and is cheaper than ART long-term!. Who argues against PrEP referencing costs, does not argue based on data and in long term perspectives.
Is the condom ideology holding us back? The statistics show that public health strategies that basically promote condom use fail to reduce infection rates. It’s time to break the dominance of this condom talk. As important as the rubber is, it is not a magic bullet that can solve all our problems.
The internet is such a good tool to campaign for safer sex. Why don’t we use it more? We don’t find enough (reliable) information online about PrEP, PEP, UNDETECTABLE or read about the destigmatising potential of these new forms of safer sex for Colombia. This leads to a gap in communication and new approaches cannot be discussed.
As the access to information is difficult or non-existent, it would be interesting to know who is holding it back and what is their interest? If substantial PrEP information (for which there is a huge demand) is not provided, someone else decides what and when I am allowed to know about a topic that concerns me. Self-determination of people is thus restricted. To hold back information is not only a sign of inefficiency but also “playing time”.
How serious are we about our fight against HIV? If PrEP is not on top of our to-do list, we miss the potential of normalisation that it offers. Is there a passive acceptance of constant new infections in order to support jobs in the health care and prevention sectors, business incomes and moralistic reasonings? – How okay are we with the fact that so many new infections occur every year?
Is our community organised enough to speak out for our rights? – If we do not claim PrEP as our right it is because of our fear of rejection and opposition of conservative movements, institutions and politicians. We are less powerful if we don’t speak with one voice.
Are the institutional prevention efforts inefficient? – A limited approach of the Colombian policy strategy regarding HIV does not consider access to information, treatment flexibility or particular social contexts. Are public campaigns addressing all of us?
To what extent the lack of action or urgency on PrEP is an expression of homo/transphobic structures in Colombia? Could we possibly have had PrEP by now, if it particularly affected heterosexual men?
WHAT HAS TO BE DONE?
It is time for Colombia to incorporate PrEP into a national HIV strategy. We demand:
- That the social dimension of PrEP be acknowledged. We need more than a study. We call on the responsible actors (like SOMOS, LIGA Contra el Sida and new organizations and social groups) to participate in this discussion! We need wholehearted action together and constructive pressure on the government.
- INVIMA to reclassify medical products containing emtricitabine and tenofovir (Truvada® and generics) both as preventive and treatment medicine. To this end, the authority and the responsible health policymakers must act on their own initiative.
- The Ministry of Health to initiate a process of updating the Obligatory Health Plan to include PrEP in the health insurance benefits. Campaigns that focus on the condom are no longer an excuse for not communicating PrEP widely. A public commitment to PrEP including a specific timeline is necessary!
- That communities of transgender women, sex workers and men who have sex with men take part in decision making. PrEP implementation is more than a clinical issue. A clinical-only strategy can only focus on people that are linked to medical services.
- That both daily and on-demand PrEP be promoted as valid prevention options. It needs to be discussed how on-demand PrEP can lower infection rates and costs effectively. People who face HIV transmission risks only from time to time could benefit from this approach.
- Not to misuse the measures regarding the Covid-19 pandemic as an argument for slowing down efforts to fight the spread of HIV. It is time for joint learning and to act in solidarity, not in competition. – There are no “better” risk groups!
- That you take action! Do you want to take PrEP? Talk about it and claim your right! Tell everyone how you want to protect yourself from HIV infections and discuss this openly. This includes taking a stand against any unobjective criticism of PrEP and against “slut shaming”. You don’t wanna take PrEP? You still can support anyone who needs it. Talk about it with all your lovers, family and friends!
We call on the government to take responsibility and make PrEP in Colombia accessible to everyone who needs it! We demand a specific timeline to implement it. We are open to discuss it with everyone interested in this topic.
Now during the corona pandemic we have learnt that failure to act by the authorities produces more sickness and death. We cannot allow us as a society to keep ignoring the benefits of preventing HIV with an effective method like PrEP. We shall not use Covid as an excuse to not do anything!
In the future, we will use all means to advance this process, be it open meetings, community networking or the “derecho de petición” (right to petition). Everyone is invited to fight together with us for this important right of ours.
ACT UP! IT’S TIME FOR PrEP!
 Off-label use is the use of pharmaceutical drugs for an unapproved indication or in an unapproved age/dosage/route of administration.
 Absolute numbers of new HIV infections in COL/year (and relative number of infected persons per 100.000 inhabitants):
2012: 7,793 (17.1)
2014: 9,497 (19.9)
2016: 11,992 (no data)
2018: 14,474 (28.2)
2019: 15,908 (30.0)
 Same source
 Out of 795 documented HIV cases of non-Colombians in the country, 93.4 % concern persons from Venezuela.
 17 Sustainable Development Goals (SDGs) of all UN member states: one of the targets of “SDG 3. Good Health and Well-being” is to end epidemics like AIDS by 2030.
 For example, the National Health Service of the UK could save £1 billion over a 80-year period.
 UNFPA (United Nations Population Fund) and PAHO (Panamerican Health Organization)
 conducted by Pro familia and SIES Salud IPS in Bogotá
 What daily PrEP / on-demand PrEP means explain the chapters HOW SAFE IS PrEP? and HOW IS PrEP TAKEN? in our PrEP information.
 www.theguardian.com/society/2020/feb/16/prep-hiv-infection-nhs-available-drug?fbclid=IwAR24ujKOy-TmZtQjzTArPmAA6W9vnOZl2byuTLom-58lFKOmQzPRX3RKlFQ and
© Love Lazers 2020. All rights are reserved by Love Lazers. Artwork by Anna Ehrenstein “The Future/PREP”, 2020. Translations: Andrés, Eduardo, Jonathan, Dr. Nihil, Fabian, Falk, Juan. Thanks to Diego for comments. Contact us at firstname.lastname@example.org.