An assessment of HIV pre-exposure prophylaxis access in Nova Scotia

Abstract

Background: The HIV pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy, but access in Nova Scotia has not been well characterized. This study evaluated PrEP access in Nova Scotia by examining prescribing and dispensing practices, uptake, and the demographics of individuals using PrEP.

Methods: A descriptive analysis was conducted to track persons who used PrEP from 2019 to 2023. The numbers and geographic locations of prescribers and dispensing pharmacies were determined using their respective licence numbers. The linear distance between patients and providers was calculated to determine the distance travelled to access PrEP services.

Results: The rate of persons who were dispensed PrEP in Nova Scotia doubled from 2019 to 2023, and the male-to-female ratio increased from 7:1 in 2019 to 15:1 in 2023. Most dispensations occurred to those aged 30–34 and to those located in the Central Zone. The number of prescriptions increased by 139.9%. The number of PrEP prescribers increased by 116%. In 2023, 38.5% of clinicians prescribed PrEP only once. The number of pharmacies that dispensed PrEP between 2019 and 2023 was 236. Most users travelled a distance less than 20 kilometres to access the service.

Conclusion: These findings will inform targeted actions to increase PrEP access in Nova Scotia. More work is needed to address the lack of increased uptake by females and to expand PrEP access outside of the Halifax Regional Municipality. Ensuring that more individuals at high risk have access to this effective prevention method can help curb the spread of HIV in the province.

Introduction

According to national estimates, 65,270 Canadians were living with HIV at the end of 2022, resulting in a prevalence rate of 170 cases per 100,000 population ^{Footnote 1}. The Public Health Agency of Canada (PHAC) reports that the national rate of new HIV diagnoses in 2023 was 6.1 cases per 100,000 population, with males experiencing a higher rate (rate: 8.1) than females (rate: 3.9) ^{Footnote 2}. From 2014–2023, the number of first-time diagnoses in Canada was fairly stable until 2020, declined during early COVID-19 years, and then increased in 2021–2023 ^{Footnote 2}. Provincially, in 2023, Nova Scotia (NS) reported 33 HIV cases, with a rate of 3.1 cases per 100,000 population. The rate among males was notably higher at 5.0 cases per 100,000 population, compared to 1.3 cases per 100,000 population among females. The highest age-specific rate was observed in individuals aged 25–39 years, at 7.0 cases per 100,000 population ^{Footnote 3}.

The HIV infection can remain asymptomatic for up to ten years ^{Footnote 4}. National estimates indicate that, at the end of 2022, Approximately 11% of individuals living with HIV remained undiagnosed ^{Footnote 1}. This underscores the importance of preventive measures, especially for high-risk populations. Alongside traditional prevention strategies, PHAC highlights the effectiveness of HIV pre-exposure prophylaxis (PrEP) in reducing transmission ^{Footnote 5}.

Pre-exposure prophylaxis is defined as the use of prescription antiretroviral medication by HIV-negative individuals to prevent infection. Taken prior to potential exposure, it disrupts the virus's ability to replicate and establish infection ^{Footnote 5}. It is recommended for men and transgender women who have condomless anal sex with men, HIV-negative individuals with HIV-positive partners engaging in condomless vaginal or anal sex, and those who share needles ^{Footnote 6}. Pre-exposure prophylaxis is available in oral pill form and as an injectable medication, both prescribed by healthcare professionals ^{Footnote 5}. In NS, oral PrEP is covered through the provincial pharmacare program (with special authorization) and some private insurance plans ^{Footnote 7}.

Several barriers exist to initiating PrEP usage, many of these which may be exacerbated when living in more rural areas, including fear of stigma, lack of access to a primary healthcare provider willing to prescribe PrEP, and residing far away from healthcare services. Research has shown that the further individuals are from healthcare services, the more likely their access to care is diminished. This phenomenon, known as "distance decay," refers to the reduction in healthcare access as travel distance or time increases ^{Footnote 8}. Therefore, it is important to examine the impact of distance on HIV PrEP accessibility. This is the first provincial analysis to assess accessibility of HIV PrEP services by using the linear distance between client, prescriber, and dispenser postal codes as a proxy for travel distance. Additionally, it seeks to describe the demographic characteristics and geographic distribution of individuals currently accessing PrEP in NS to identify potential gaps in service coverage.

Objectives

For the 2019–2023 analysis period, the objectives were to: 1) describe individuals who have been dispensed HIV PrEP; 2) define HIV PrEP prescribers and dispensing pharmacies; 3) understand prescribing patterns of HIV PrEP; and 4) assess the accessibility of HIV PrEP services for clients.

Methods

A secondary data analysis was conducted using a dataset provided by the NS Department of Health and Wellness.

Data sources

Data sources included PrEP dispensing data from the Nova Scotia Drug Information System (DIS) for 2019–2023, population estimates from the 2021 Statistics Canada Census, and physician registry data from the College of Physicians and Surgeons of Nova Scotia (CPSNS) for 2024.

Analysis

The DIS provided all data required for this analysis. The dataset included client demographic characteristics (e.g., age, gender, and postal code), as well as prescriber information, such as professional designation, licence number, and practice location. It also contained dispensing pharmacy identifiers and geographic location, and prescription-level records included the drug name and reason for dispensing. Physician specialties were ascertained using the publicly available CPSNS registry ^{Footnote 9}. Population data for NS were obtained from publicly available datasets provided by Statistics Canada.

A unique person identifier was assigned to each client in the DIS data by the NS Department of Health and Wellness. Clients were characterized by variables such as age, gender, dispensing year, and geographic location of residence. The number of clients per year was calculated by counting the first occurrence of each unique person identifier within each calendar year. Annual rates were determined using the total number of clients as the numerator and the 2021 NS census population as the denominator. A descriptive analysis of clients by zone and by community cluster was conducted. To determine the total number of unique clients over the full study period, duplicate person identifiers were removed. This enabled analysis of unique clients by gender and age group.

Prescribers were identified by their licence numbers. For physicians, their specialty was determined using the CPSNS registry. The first instance of PrEP prescribing or dispensing for each licence number was used to count the unique providers, both annually and overall. The dataset provided information on their zones and postal codes.

The DIS also included data on the number of prescription refills, which were categorized into the following groups: 1, 2, 3, 4, 5, 6 to 10, and 11 or more refills. This classification enabled an assessment of the frequency with which prescribers and clients continue refilling PrEP prescriptions, as well as typical prescribing patterns. To evaluate duration of protection, clients were further grouped based on the total number of prescriptions dispensed annually: those receiving 27 days and less, those completing a one-month trial, and those receiving one, two, or three full cycles of PrEP. The 28–30 days period corresponds to the standard trial phase at PrEP initiation. It was assumed individuals in this group completed the trial but chose not to continue, possibly due to intolerance, behavioural changes, or financial constraints. The subsequent categories represent extended coverage periods: 31–90 days for one full cycle, 91–180 days for two cycles, 181–270 days for three cycles, and 271 days or more indicating coverage beyond three cycles.

Geographic information for client residences, prescribers, and pharmacies was assigned using the Postal Code Conversion File, which allowed locations to be categorized by health zone and community cluster. To calculate the distance between client residences and prescriber/pharmacy locations, and between provider offices and dispensing pharmacies, the linear distance between postal code centroids was used. The geographic centroid, defined as the geometric centre point of a spatial boundary, was calculated for each postal code using its boundary latitude and longitude coordinates. Linear (great-circle) distance between postal code centroids was then calculated using the spherical law of cosines, implemented in spreadsheet form as: distance=ACOS(COS(RADIANS(90-latitude1))*COS(RADIANS(90-latitude2)) + SIN(RADIANS(90-latitude1))*SIN(RADIANS(90-latitude2))*COS(RADIANS(longitude1-longitude2)))*6378, where latitude and longitude are decimal degrees converted to radians, and 6,378 kilometre (km) is the equatorial radius of the Earth ^{Footnote 10Footnote 11}.

To gain a more detailed understanding of clients and the distances they travelled to access PrEP services by course duration, the mean age of clients and the mean distance to both prescribers and dispensing pharmacies was calculated. Additionally, the distribution of prescriber types across course durations was examined. Microsoft Excel ^{Footnote 12}, RStudio Team ^{Footnote 13}, STATA 18 ^{Footnote 14}, Tableau Desktop ^{Footnote 15}, were used to conduct the analysis.

Results

HIV pre-exposure prophylaxis clients

Between January 2019 and December 2023, a total of 955 unique clients residing in NS received PrEP. The majority were in the Central Zone (441 clients, 46.2%), followed by the Eastern (274, 28.7%), Western (131, 13.7%), and Northern (109, 11.4%) zones. Provincially, the rate of PrEP clients doubled from 30.0 per 100,000 population in 2019 to 65.4 per 100,000 population in 2023, a trend observed consistently across all health zones (Figure 1). At the community cluster level, Halifax Needham reported the highest rate at 188.8 per 100,000 population, followed by Halifax Citadel with 156.6 per 100,000 population (Figure 2).

Figure 1 - Text description

The graph shows a substantial increase in provincial HIV pre-exposure prophylaxis uptake in Nova Scotia, with client rates rising from 30.0 per 100,000 population in 2019 to 65.4 per 100,000 population in 2023. This upward trend was consistent across all health zones.

Figure 2 - Text description

The map illustrates variation in PrEP dispensing rates across community clusters in Nova Scotia. The highest rate was observed in Halifax Needham, at 188.8 clients per 100,000 population, followed by Halifax Citadel, at 156.6 per 100,000 population. Overall, the figure demonstrates geographic variation in PrEP uptake across community clusters in the province.

From 2019 to 2023, 95.7% of clients using PrEP in NS were male. The highest number of PrEP prescriptions was among those 30–34 years old, followed by those 35–39 and 25–29 years of age (Figure 3). The mean age of clients increased with longer course durations (Table 1).

Figure 3 - Text description

The chart shows that, from 2019 to 2023, 95.7% of HIV pre-exposure prophylaxis clients in Nova Scotia were male, and that the highest number of prescriptions was among individuals aged 30–34 years, followed by those aged 35–39 and 25–29 years.

HIV pre-exposure prophylaxis prescribers

Three types of healthcare providers have prescribed PrEP in NS: physicians, pharmacists, and registered nurse practitioners (Table 2). The total number of unique PrEP prescribers was 540 (520 with postal codes in NS). The number of prescribers more than doubled over the five-year period of study, rising from 173 in 2019 to 374 in 2023. In that year, physicians made up the largest proportion of prescribers (n=278, 74.3%), followed by pharmacists and registered nurse practitioners (n=48 each) (Figure 4). Among the prescribers, family doctors represented the largest group (n=407, 75.4%). At the zonal level, the Central Zone had the greatest number of unique PrEP prescribers (n=349), followed by the Western (n=66), Eastern (n=64), and Northern (n=41) zones (Figure 5). In 2019, a little over half of prescribers (54.9%) prescribed PrEP one time only, while in 2023, this proportion had reduced to 38.5%. In 2023, 41.4% prescribed two to five times, and 12.0% prescribed six to 10 times (Table 3).

Figure 4 - Text description

The chart shows that the number of HIV pre-exposure prophylaxis prescribers increased substantially, from 173 in 2019 to 374 in 2023, with physicians consistently representing the majority of prescribers. In 2023, physicians accounted for 74.3% of prescribers (n=278), followed by pharmacists and registered nurse practitioners (n=48 each).

Figure 5 - Text description

The graph illustrates the number of physicians who prescribed HIV pre-exposure prophylaxis by health zone and year, with the highest number in the Central Zone (n=349), followed by Western (n=66), Eastern (n=64), and Northern (n=41) Zones.

HIV pre-exposure prophylaxis dispensers

The number of pharmacies dispensing PrEP showed a steady increase, rising from 113 in 2019 to 165 in 2023. From 2019 to 2023, a total of 236 pharmacies in NS dispensed PrEP, representing 75.2% of all pharmacies in the province (314 total) ^{Footnote 16}. Most of these pharmacies (47.5%) were in the Central Zone. Among community clusters, Sydney and area had the highest number of pharmacies dispensing PrEP (n=15) (Figure 6).

Figure 6 - Text description

The map shows that from 2019 to 2023, a total of 236 pharmacies in Nova Scotia dispensed HIV pre-exposure prophylaxis, representing 75.2% of all pharmacies in the province (n=314). Nearly half of these pharmacies (47.5%) were located in the Central Zone.

HIV pre-exposure prophylaxis prescribing patterns

The number of unique PrEP prescriptions rose from 561 in 2019 to 1,346 in 2023 (Figure 7). During the same period, the total number of dispensed prescriptions increased by 101.5%. Out of 935 total dispenses in 2019, 264 prescriptions (28.2%) were dispensed once, a proportion that grew to 42.6% (802) by 2023 (Table 4). Additionally, the duration of coverage per dispensed prescription varied, with the most common coverage range falling between 31–90 days (Table 5).

Figure 7 - Text description

The graph illustrates a marked increase in the number of unique HIV pre-exposure prophylaxis prescriptions dispensed in Nova Scotia, rising from 561 in 2019 to 1,346 in 2023. This represents more than a two-fold increase over the study period, demonstrating a substantial growth in PrEP use across the province.

HIV pre-exposure prophylaxis accessibility

The linear distance between clients, their PrEP prescribers and dispensers, was 20 km or less for most clients. However, 18.9% of clients lived more than 40.01 km from their prescriber, and 7.3% lived more than 40.01 km from their dispensing location. For 15.6% of clients, the linear distance between the PrEP prescriber and dispenser was more than 40.01 km (Figure 8). The median distance was 7.8 km between client residence and prescribing healthcare provider, and 2.7 km between client residence and dispensing pharmacy. The maximum distance between a client's residence and their healthcare provider or pharmacy was 370 km and 407 km, respectively.

Figure 8 - Text description

The figure shows that, for most clients, the linear distance between clients, their HIV pre-exposure prophylaxis (PrEP) prescribers, and dispensing pharmacies was 20 km or less. However, 18.9% of clients lived more than 40.01 km from their prescriber, and 7.3% lived more than 40.01 km from their dispensing location. For 15.6% of clients, the distance between the HIV PrEP prescriber and dispenser exceeded 40.01 km.

At the zonal level, most clients travelled less than 20 km to access PrEP services. However, 36.1% of clients in the Western Zone and 35.5% in the Northern Zone travelled 40.01 km–100 km to access the service (Table 6). Travel distance varied among various age groups in accessing a prescriber or a dispensing pharmacy (Figure 9 and Figure 10). Distance travelled also differed by course duration and by direction of travel. Overall, clients travelled farther to access prescribers than to access pharmacies (Table 1).

Figure 9 - Text description

The figure illustrates the association between age group and distance travelled to access HIV pre-exposure prophylaxis prescribers. Individuals aged 50–54 years and older travelled longer distances to access PrEP prescribers compared with younger age groups.

Figure 10 - Text description

The figure illustrates differences in the distance travelled to access pharmacies dispensing HIV pre-exposure prophylaxis across age groups. Overall, older individuals travelled longer distances to access PrEP dispensing pharmacies, with distance increasing with age.

Discussion

In this analysis, PrEP use in NS increased markedly over time, with substantial growth in clients, prescriptions and prescribers. Uptake was concentrated among middle-aged, male-identifying individuals and in the Central Zone. Despite expanded provider and pharmacy participation, gender- and region-based disparities persisted, and some individuals travelled considerable distances to access services, indicating ongoing inequities in access.

Nationally, new HIV diagnoses rose substantially in 2023, with a 35.2% increase reported in 2023 compared to 2022 ^{Footnote 17}. According to the World Health Organization (WHO), this surge is partly attributable to enhanced testing efforts, new testing policies, and a rebound in HIV testing and case detection following the COVID-19 pandemic ^{Footnote 18}.

Although antiviral treatments have proven highly effective ^{Footnote 19}, HIV remains a public health concern because the infection can remain asymptomatic for years, increasing the likelihood of unrecognized transmission to partners. This highlights the importance of regular testing and PrEP use.

Between 2019 and 2023, the rate of PrEP use in NS doubled, likely reflecting improved access and affordability through provincial pharmacare programs ^{Footnote 20}. This trend is consistent with national data, where PrEP use prevalence increased from 61 per 100,000 population in 2019 to 89 per 100,000 population in 2022 ^{Footnote 21}. Notably, British Columbia reported the highest prevalence of PrEP use, at 132 per 100,000 population in 2022 ^{Footnote 21}. However, to obtain PrEP, individuals must enroll in the NS Family Pharmacare Program and receive special authorization from a healthcare provider ^{Footnote 7}. Recently, prescribing authority was expanded to include pharmacists, enhancing accessibility ^{Footnote 22}.

Client demographics in NS align with national trends, with most PrEP users being male ^{Footnote 21}, reflecting the higher burden of HIV risk among men, particularly men who have sex with men ^{Footnote 3}. Across age groups, individuals aged 25–39 demonstrate the highest PrEP utilization, which may be associated with higher levels of sexual activity and a greater number of lifetime partners in this cohort, contributing to increased exposure risk. In Canada, younger adults are more likely than older adults to report two or more sexual partners in the past year, with 25.1% of those aged 20–29 and 9.3% of those aged 30–39 reporting multiple partners ^{Footnote 23}. Additionally, PrEP is more actively promoted and accessible within this age group, driving increased uptake.

Geographically, the Central Zone had the highest number of PrEP clients, consistent with the Halifax Census Metropolitan Area's status as the province's most populous region ^{Footnote 24}. Notably, 22.4% of Halifax's population falls within the 25–39 age group ^{Footnote 25}, further explaining elevated PrEP use in this area. The Central Zone also has the greatest concentration of healthcare providers, influenced by population growth, increased healthcare demand, and the availability of advanced medical services.

Primary care physicians constitute most PrEP prescribers, likely due to easier access through walk-in clinics or established family physician relationships, unlike specialists who require referrals and often involve long wait times. However, only 45.4% of registered Nova Scotian family physicians (including those with dual specialties) have prescribed PrEP, highlighting a need for greater education and promotion of PrEP prescribing among family doctors. According to NS policies, pharmacists and nurse practitioners can prescribe PrEP, but more efforts are needed to expand their prescribing role, especially in medically underserved areas.

Between 2019 and 2023, the average duration of PrEP prescriptions doubled, with most clients receiving a 31- to 90-days supply, necessitating provider visits at least every three months. These regular visits provide opportunities for healthcare providers to conduct HIV testing, aligning with guidelines recommending at least annual testing for high-risk populations ^{Footnote 26}. The increasing number of refills reflects growing acceptance of PrEP as a preventive tool by both clients and providers.

This study also highlighted geographic accessibility challenges to PrEP services. Most clients travelled 20 km or less for PrEP prescribing or dispensing, but some travelled over 40 km, potentially creating barriers to care and negatively affecting health outcomes. For example, the Eastern Zone had the highest percentage of clients travelling more than 300 km for PrEP access. While there is no universally accepted cut-off distance for distance decay in healthcare utilization, Siegler et al. identified substantial geographic barriers to PrEP access among MSM in the United States, with access becoming more limited as travel time to PrEP providers increased ^{Footnote 27}. Notably, increased challenges in obtaining PrEP, including financial and time-related burdens, tend to occur as travel distances grow longer. Additionally, the distribution of travel distances differs significantly across age groups, indicating a potential relationship with age, while acknowledging that other factors may also influence how far individuals travel for healthcare. Further research is needed to determine whether these travel distances are influenced by the use of virtual care, difficulties accessing local PrEP services, client preferences, such as concerns about privacy or choice of healthcare provider, or if the availability of long-acting injectable PrEP could improve access.

The primary strength of this analysis lies in its comprehensive consideration of clients' demographics, prescriber characteristics, prescribing patterns, pharmacies dispensing PrEP, and linear distance to services. This multifaceted approach deepens our understanding of barriers to PrEP accessibility and generates actionable evidence to guide targeted public health interventions. However, the analysis has a few limitations. First, client postal codes may not reflect current addresses, as individuals may move without updating their information, which limits the accuracy of location data. Additionally, distances were calculated between postal code centroids, which may introduce error, especially in rural areas where postal codes can cover large geographic regions. Linear distance is also an approximation that does not capture actual travel routes and may underestimate travel burden, particularly in areas with complex geography or limited transportation options. However, it remains a practical and consistent measure of accessibility. Moreover, the order of a client travel, use of virtual healthcare services, and prescriptions delivery status were unknown. For readers, these findings highlight areas where interventions could improve PrEP uptake, inform resource allocation, and guide future research to address remaining gaps in accessibility.

Limitations

The low rates of PrEP dispensing among females warrant further investigation to determine whether specific populations, such as individuals who share injection equipment or engage in sex work, face barriers to access. Expanding the capacity of diverse healthcare providers to prescribe PrEP is essential to improving accessibility across NS. In particular, increasing the involvement of pharmacists and nurse practitioners, especially in rural and remote areas, could significantly benefit underserved communities. Exploring online and virtual platforms for PrEP access may also enhance reach across the province.

Additionally, estimating the size of the population at highest risk for HIV in NS would allow for a calculation of PrEP coverage rates and help identify access gaps. To more effectively curb the spread of HIV, it is critical to identify areas in need of expanded PrEP access. This can be achieved by analyzing community-level HIV testing data and positivity rates to pinpoint regions with elevated risk and inform targeted prevention strategies. Ongoing monitoring of prescribing and dispensing patterns is necessary to track progress and emerging trends.

Future research should explore potential barriers to PrEP access, such as gaps in insurance coverage, lack of access to primary care providers, non-adherence or infrequent medication refills, or the use of on-demand dosing strategies to manage costs.

Conclusion

This analysis described patterns of PrEP utilization, prescribing practices, and service accessibility in NS. The number of clients receiving PrEP in the province doubled between 2019 and 2023, with the largest increase observed among male-identifying individuals aged 30–34. During this period, the total number of healthcare providers prescribing PrEP grew by 116%. Of all prescribers, 70% were based in the Central Zone, and the majority were family physicians. Additionally, 75.6% of pharmacies in NS dispensed PrEP from 2019 to 2023. The total number of PrEP prescriptions filled increased by 101.5% over these years. Most clients travelled 20 km or less to access PrEP services; however, 18.9% and 7.3% of clients travelled more than 40.01 km to reach prescribers and dispensers, respectively. This analysis identifies strategic priorities to strengthen PrEP accessibility, providing a foundation for evidence-informed public health action to expand equitable HIV prevention and accelerate progress toward reducing HIV transmission in NS.

Authors' statement

TW — Conceptualization, methodology, writing–original draft, writing–review & editing
JK — Conceptualization, methodology, writing–review & editing
MN-W — Conceptualization, methodology, writing–review & editing
AR — Methodology, writing–review & editing
DG — Writing–review & editing
KO — Writing–review & editing

Competing interests

None.

ORCID numbers

Tamer Wahba — 0009-0009-4874-263X
Jesse Kancir — 0009-0008-7009-4731
Maria N Wilson — 0000-0003-0187-0713
Alysia Robinson — 0000-0003-4915-8944
Diana Gibson — 0009-0000-6960-7482

Acknowledgements

We would like to thank James Broesch (Director of Science and System Performance, Nova Scotia Health), Mary-Anne Finlayson (Manager Foundations Science and System Performance, Nova Scotia Health), and Jocelyne Galloway (Manager, Canadian Public Health Service, Public Health Agency of Canada), for their valuable support and encouragement throughout the development of this study. We would also like to thank Brittany Peterson (Decision Support Analyst, Nova Scotia Health) for her assistance with data collection. Their help and support contributed significantly to the success of this work.

Funding

This work was supported by the Public Health Agency of Canada via the corresponding author's (TW) salaried appointment. No separate external grant supported this study.

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