A recipe for increasing racial and gender disparities in HIV infection: A critical analysis of the Canadian guideline on pre-exposure prophylaxis and non-occupational post-exposure prophylaxis' responsiveness to the HIV epidemics among women and Black communities

Abstract

Clinical guidelines have emerged as an important tool for improving healthcare quality and controlling healthcare costs. However, they also have the potential to limit access to treatment and services for those who could greatly benefit. In November 2017, a clinical guideline for prescribing HIV pre-exposure prophylaxis (PrEP) was published in the Canadian Medical Association Journal. After careful review, we determined the current Canadian PrEP guideline is not wholly inclusive and lacks sufficient sensitivity for detecting HIV seroconversion risk in African, Caribbean, and Canadian Black (Black) communities, as well as women. In this article, we present several scenarios to illustrate how the Canadian guideline for HIV PrEP compromises patient-centered HIV prevention for Black communities and women and may imperil efforts to reduce HIV incidence in these communities. As it stands, the current PrEP Canadian guideline omits the behavioural, clinical, and social factors known to contribute to HIV risk, which also disproportionately affect Black communities. We recommend that healthcare providers, who opt to consult the guideline, exercise clinical discretion, and consider relevant contextual information about the patient presenting for care. However, for a greater impact, the existing guideline should be revised or supplemented with additional recommendations to ensure equitable access for all individuals who would benefit from PrEP.