Davie Buyers Club

Disclosures: the author is not affiliated with the websites, organizations, pharmacies or medication described in this tutorial. The author has no financial interest in people obtaining PrEP by these or any other means. The author is a concerned citizen who feels that people who could safely benefit from PrEP, under supervision of their doctor or nurse practitioner, should be able to access it at a reasonable cost.

Disclaimer: the author is not providing medical advice and is not responsible for any undesirable outcomes such as financial, legal, or health problems. PrEP is known to have side effects and it is not 100% effective at preventing HIV infection.

News:

HIV Pre-Exposure Prophylaxis is now covered in the following provinces:

• British Columbia (no cost)
• Alberta (no cost)
• Saskatchewan (no cost)
• Ontario (deductible for some, free for others)
• Quebec (deductible for some, free for others)
• Nova Scotia (deductible for some, free for others)
• New Brunswick
• Newfoundland & Labrador 
• Prince Edward Island
• First Nations and Inuit peoples in any province or territory via NHIB

Visitors to Canada (those who are not Canadian citizens or permanent residents, and are visiting Canada under a work, student, or travel visa) who are not covered by provincial health plans are permitted to import PrEP by mail directly to their address in Canada. See here for more info. 

Because of the great progress in accessibility of PrEP in Canada, the Davie Buyers Club website will no longer be updated. Thanks to all who advocated for access to this important addition to the toolbox of HIV prevention. It was an honor and a privilege to assist in this effort.

Sincerely,

Alex Smith
Creator, Davie Buyers Club

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Introduction: 

Pre-exposure prophylaxis (PrEP) is the use of daily anti-HIV medication by people who are HIV-negative but are at risk for HIV infection. Research studies have shown that people who took PrEP were 86% (and may be up to 99%) less likely to become HIV-positive than those who did not take PrEP.

Currently, the only oral medication approved to prevent HIV is emtricitabine/tenofovir 200/300mg, also known as Truvada. Currently, in many Canadian provinces, the cost of this medication is covered when used to treat HIV, but is not covered at all for use as prevention. This is problematic because PrEP costs up to $250-$1000 per month to purchase out-of-pocket. Many people at-risk of contacting HIV do not have third-party health insurance, and fewer have insurance that will agree to cover emtricitabine/tenofovir for prevention. As of January 1st, 2018, PrEP is provided at no-cost in British Columbia; it is partially covered in Ontario and Quebec.

For more information about what PrEP is, how it works, who should consider taking it and what are its side-effects, please see the following resources:

• GetPrEPed.ca by Health Initiative for Men (HIM)
• PrEP Fact Sheet by Canadian AIDS Treatment Information Exchange  (CATIE) 
• PrEP by US Centers for Disease Control (CDC)
• Is PrEP right for me? (The Stigma Project)

To learn more about other strategies for HIV prevention such as condoms, Treatment as Prevention (i.e. undetectable HIV viral load), routine testing, post-exposure prophylaxis (PEP), and sero-sorting/positioning, check out TheSexYouWant.ca by the Gay Men’s Sexual Health Alliance of Ontario.

The rest of this site assumes the reader has basic knowledge about PrEP and provides a step-by-step guide for people in Canada who do not have coverage for PrEP to import a generic version from a foreign pharmacy for approximately $45 CAD per month.

The site uses the template/examples for those living in Vancouver, but people elsewhere in the country can also follow this guide by substituting information relating to their area, found on the page called Other Canadian Cities

A quick overview of the process:
       (start with See MD/NP)

To complete this process as described, you will need: 

• a family doctor or nurse practitioner
• provincial medical coverage (e.g. BC MSP) in order to see and MD/NP and for lab tests to monitor safety and effectiveness
• a Canadian credit card or Bitcoin (depending on supplier chosen)
• at least $115-280 CAD available funds (depending on supplier chosen)
• a valid passport
• transportation to a USA-border parcel service, such as a car and driver’s license or a friend with a license/passport/car. (public transit instructions for Point Roberts, WA, added here!)
• no criminal record that would prevent entry to the USA

Step One: Getting a Prescription

Even though you are buying the medication from abroad, you still need a valid prescription to order it online and to import it to Canada. More importantly, PrEP still needs to be diligently monitored for safety and effectiveness, regardless of where the prescription is filled. You must be monitored with blood/urine tests every three months for rare but known adverse events including kidney problems, bone density loss, HIV seroconversion and drug resistance.

If you do not have a family physician or nurse practitioner
You can find one at the BC College of Physicians website. Here are the settings to select to find a GP in Vancouver.

If your primary care provider (PCP) is not experienced in prescribing/monitoring PrEP
You can print out and bring the Canadian guideline on HIV pre-exposure prophylaxis and nonoccupational postexposure prophylaxis (CMAJ, 2017). You can also ask him/her to refer you to a specialist or another care provider who has experience in this area.

Still having problems finding a care provider?
If you need assistance finding a PCP, or if you need a referral to a specialist because your doctor is still not comfortable with PrEP due to lack of experience with it, or doesn’t know a specialist to refer you to, the nurses at the HIM Clinics will be able to assist you.
UPDATE 30-Mar-2017 for Vancouverites: There are now three physicians seeing patients for PrEP at HIM on Davie at varying times during the week. To see one of these doctors for PrEP, please see a nurse at HIM on Davie Street or Commercial Drive for a referral.
UPDATE 01-Dec-2017 for Vancouverites: There are now two physicians seeing patients for PrEP at Bute Street clinic at varying times during the week. To see one of these doctors for PrEP, walk-in to see a nurse at Bute for a referral.

Your visit with your care provider
Your PCP will ask you questions about your general health history, sexual health, partners, and practices in order to assess whether PrEP would be necessary, safe and effective for you. They will also require blood and urine tests checking for HIV, syphilis, hepatitis B & C, gonorrhea & chlamydia, and the health of your liver and kidneys. Some PCPs will not write the prescription until after they have received all these results, while others may write the prescription at the first visit and ask that you not start the medication until they direct you to, after the results are in. Be open and honest with your PCP about your plan to import generic medication.

Your prescription
Ask your PCP to not write the prescription for the brand name “Truvada”. Instead, ask him/her to write it for the generic “emtricitabine/ tenofovir 200/300mg” because the medication won’t have the brand name on the bottle. This reduces chance of hassle at the border, as your prescription will match the bottles exactly.

Some guidelines recommend a first prescription of 30 days, however, due to logistical issues of importing medications, ask your PCP to write the prescription for 90 days/ tablets. This is the maximum legal quantity of medication to import to Canada for personal use. Also, the prescription must show your PCP’s name, address, and registration number.

Step Two: Getting a Mailbox in Point Roberts, WA, USA

Register for a Point Roberts mailbox at InOut Parcel.
Go to https://inoutparcel.com/register/ and enter your username, email and name. Registration is free, but the cost of receiving is $3.75 USD per package. When you register, you will be assigned a Customer ID number that you will include as a part of your shipping address when ordering the medication.

Step Three: Order Medication Online 

There are three reputable online suppliers of PrEP for which this website provides comprehensive guides. Suppliers vary in terms of cost, payment method, shipping method, etc. Please examine the summary table below and the accompanying guides to determine which supplier is right for you.

Click here for the guide to ordering via Dynamix International

Click here for the guide to ordering via Green Cross Pharmacy

Click here for the guide to ordering via Freedom Health

Click here for the guide to ordering via All Day Chemist

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2017-Feb-08 Update: click here if you are a visitor to Canada (NOT a citizen or a permanent resident). You may be able to ship PrEP directly to your Canadian home address using Dynamix.

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Step Four: Pick Up Your Order and Return to Canada

InOut Parcel will email you when your package has arrived and is ready to be picked up.

Make sure you bring with you:
-your valid passport
-your prescription for tenofovir/emtricitabine 200/300mg x 90 days/tablets
-a print-out of your invoice from the online pharmacy, showing its price in US or Canadian dollars (the is the value of the goods you are importing, which is sometimes requested by the CBSA border agent)
-recommended: a printed or saved copy of any info you require: directions, customer ID number for InOut Parcel, or any other instructions. Once you are in the USA, your phone will switch to roaming mode which will make cellular data either unavailable or extremely expensive to look these things up.

Drive to 145 Tyee Drive, Point Roberts 
It takes about 45 minutes to drive there from downtown Vancouver, without traffic. The border wait can be anywhere between 5 and 45 minutes; weekends are typically worse than weekdays. You can check the current border wait-times here.

What if I don’t have a car, a license, or someone who can drive me?
You can take public transit! From downtown Vancouver, it takes roughly 1hr15min each way, which includes the 7min walk from the bus stop, across the border, to InOut Parcel. It is a 2-zone fare (weekdays) so the cost for a round trip is $8 cash or $6.30 on Compass stored value. Click here for the transit itinerary.

At the border

Present your passport to the USA border agent. They will ask you the reason for your visit; you can tell them you’re visiting to pick up a package.

Click here for instructions on how to actually receive your package from InOut Parcel
On your first visit, you will have to see a customer service person, fill out a form and provide credit card payment. On subsequent visits, you can just pick up from your locker 24 hours per day, 7 days per week. For your first visit though, make sure you attend during their staffed hours: Mon – Fri 9am – 5:30pm, Sat – Sun 9am – 3pm.

Returning to Canada

IF YOU ARE A NEXUS CARDHOLDER, DO NOT USE NEXUS TO RE-ENTER CANADA
As one user pointed out, medication (whether you have a prescription or not) is consider a restricted or controlled product and cannot be brought in to Canada using Nexus and may result in a loss of your Nexus privileges. Use the ‘regular’ line to return to Canada. 

The Canada Border Services agent will ask the reason for your trip and if you have anything to declare. Declare that you have a 90-day supply of medication for personal use, as prescribed by your doctor/nurse practitioner. If requested by the agent, present the paper prescription and medication. If the agent asks you questions about the medication or why it was sent to the USA, answer truthfully that it is a preventative medication that is not covered and not accessible to you in Canada. As per the Government of Canada website, you are not breaking any laws and you will not likely be further scrutinized.

You’re home!
Now that you have the medication, check in with your doctor or nurse practitioner, if they requested that you wait for their ‘okay’ before initiating PrEP. Again, it is of critical importance to ensure that you have an up-to-date negative HIV test as close as possible to initiation of PrEP — it is sometimes even necessary to delay PrEP initiation to wait-out the ‘window period’ if there was a  recent possible high-risk exposure and/or flu-like symptoms to rule out acute HIV infection.

Next steps

• Remember that PrEP is most effective when taken exactly as prescribed. Do not miss doses — setting an alarm/reminder on your phone is helpful for many people. TheSexYouWant has a text message reminder service for PrEP, ART, or testing 
• The amount of time it takes to reach maximum protection is unknown, but research shows that drug concentration in the rectal mucous membrane reaches its steady state 7 days after initiating the medication. For for women and trans guys, it takes about 21 days to reach maximum drug concentration in the vagina/ front hole
• See your doctor or nurse practitioner at least every three months to do tests for HIV, syphilis, chlamydia & gonorrhea, and to check the health of your kidneys
• Because of the time it takes to import generic medication from abroad, get a new prescription and refill it online using the steps above when you have one month remaining (to ensure you do not run out!)
• If you take other medication, inform your pharmacist that you are taking generic Truvada so that he/she can check for drug interactions and other considerations

Please use the comments section below to describe your experience: success stories, hiccups, tips, questions or other feedback. These can also be emailed to daviebuyersclub@gmail.com