Will we get access to PrEP in Colombia this year for those of us who cannot afford self payment?
PrEP is still not established or extended as a basic service by Colombian EPS health insurances. Without full cost coverage, however, most people simply cannot afford PrEP. But there is news: The Ministry of Health has published new guidelines stating that PrEP is part of the standard medical treatment. The document is meant to be a frame of best practices for the EPS services. How the health insurance companies will now implement it is not clear yet.
It is urgent that PrEP becomes easily accessible for all those EPS users who need PrEP to be able to protect themselves effectively against HIV. The mentioned guidelines recognize PrEP as a possibility and not as an extended right. It states that it will be prescribed only to people at considerable risk, which is defined by medical criteria. It establishes a gap between PrEP as a medical service and the sexual autonomy of the people.
We encourage you to get PrEP by the EPS, even though it might be bloody bureaucratic. In case that you get rejected, you will find recommendations on how to complain and to start to fight for your right to protect yourself. We know of individuals who are already getting PrEP completely paid through their EPS. But some had to present their complaint first through a petition (derecho de petición) and then a tutela process.
We will update this article as soon as we have news. You can help us by sharing your experiences with PrEP and EPS.
- WHAT’S THE SITUATION OF PrEP ACCESS IN COL?
- WHAT ARE THE NEW CLINICAL PRACTICE GUIDELINES AND THE RESOLUTION 2292 de 2021 SAYING ABOUT PrEP ACCESS IN THE EPS SYSTEM?
- MANUAL: THE STEPS TO GET PrEP
- WHAT IS IMPORTANT TO TELL THE DOC TO GET PrEP?
- WHAT CAN I DO IF THE DOC DOESN’T PRESCRIBE ME PrEP? – FIRST STEP: SUBMIT A ‘PETITION’ TO THE EPS
- NEXT STEP: SEND A TUTELA TO CLAIM MY RIGHT TO STAY HEALTHY
- I DON’T HAVE AN EPS – WHAT CAN I DO?
- WHY ARE SO MANY QUESTIONS OPEN?
1. WHAT’S THE SITUATION OF PrEP ACCESS IN COL?
Even if access to PrEP in Colombia has changed in the last months, it is currently unclear how to get PrEP in Columbia, and its access is very unequal.
Many people in our communities ask us how they can access PrEP. They heard about it and want to use it to protect themselves efficiently against an HIV infection (read in our leaflet READY FOR PrEP! to learn more about it).
Indeed, people are looking for it with good reason: the HIV infection rate in Colombia is high and increasing every year. PrEP is a modern and effective prevention method. Access for everybody who needs it is long overdue, not only in our eyes. This delay forces people to buy it at international online pharmacies or on the black market.
The massive interest led private providers, such as IPS, private laboratories and also so-called NGOs, to the idea of offering paid PrEP to those who can afford it. These providers are trying to make money with PrEP (e.g. for a payment of COP 1,000,000 per year). The problem is that almost everyone who is eligible for PrEP cannot afford these market prices at all.
A PrEP study was carried out in Bogotá in 2019/2020. It ended in the first months of the Covid19 pandemic and the results never got published. Nevertheless, there already exists a global mountain of evidence that PrEP implementation is effective and lowers infection rates impressively.
Finally, in Dec 2021 Minsalud, the National Ministry of Health of Colombia, published a guideline and the resolution 2292 to set up PrEP in the health system. Even if the procedure is still unclear, it is good news for everyone interested to obtain PrEP as soon as possible: it means that for the first time, the government officially stated that a person of substantial risk for HIV infection has the chance to get PrEP fully covered by their EPS!
And this entitlement is ready to be claimed.
2. WHAT ARE THE NEW CLINICAL PRACTICE GUIDELINES AND THE RESOLUTION 2292 de 2021 SAYING ABOUT PrEP ACCESS IN THE EPS SYSTEM?
For the first time, the recently updated and published guidelines mention1“For this process, new elements were specifically incorporated, such as pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP), comorbidity prophylaxis,… all of this so that the guide is in accordance with comprehensive care policies. of health in Colombia, favoring primary care.” (2021, p. 23) PrEP (in addition to PEP) as a meaningful prevention to be offered by the healthcare system, which will result in the EPS including it in their catalogue of services.
The 1500 pages document defines evidence-based prevention, diagnosis and treatment of HIV based on data and studies. With this paper, physicians and medical staff working in the Colombian health system have a technically formulated catalogue at their disposal. They can now provide professional medical treatment and care for people with HIV as well as those with special risks of becoming infected with HIV. In parallel the government published the “Resolution 2292 of 2021”2Medications that can be prescribed as PrEP for this target audience are also mentioned, such as Tenofovir, Emtricitabine, among others (p. 38), these first two are included among the lists of health services financed with government resources. the Capitation Payment Unit (UPC) as mentioned in resolution 2292 of 2021 (p. 156) establishing that EPS can afford PrEP costs.
People on the EPS health insurance who have a substantial risk of HIV infection are entitled to PrEP from now on. This statutory entitlement to PrEP includes counselling, supply of the medication, and required testing.
For people at high risk of contracting HIV, PrEP thus becomes prescribable. Who exactly is eligible is listed in the guidelines3“ … history of an acute sexually transmitted infection, history of transactional sex , having sex without a condom with someone whose HIV status is unknown or positive, having received PEP”. p. 103. in detail: persons who:
- have an acute sexually transmitted infection
- do sex work (so called “transactional sex”)
- have sex without a condom with someone who’s HIV status is unknown or positive
- have received PEP
It will be critical to meet at least one of these characteristics (in each case referring to the previous six months) in order to be prescribed PrEP medication.
The guidelines also discuss the costs for the healthcare system: PrEP is cost-effective because avoiding HIV infections means that health insurances save the costs of lifelong (and more expensive) HIV therapy. In addition, they classify various prevention and treatment methods according to their effectiveness for the population, rating PrEP as “moderate”. This means that the prophylaxis prevents infections effectively at the individual level, and its efficacy for certain target groups is “high.”
Even “on-demand PrEP”4p. 101 is mentioned as a treatment option, which gives users more choice and PrEP a higher acceptance in the communities.
3. MANUAL: THE STEPS TO GET PrEP
As long as there is no clear regulation on how exactly PrEP should be handled by the EPS, you can only try it on your own: you will receive access to it only if you have a substantial risk of getting infected with HIV. You may have to claim and enforce it by convincing the doctor about something they possibly have never heard about.
We recommend that you proceed as follows:
- Make an appointment at your EPS with your general practitioner and ask for a transfer to an expert of infectious diseases/HIV treatment or internal medicine. Only these experts are allowed to prescribe PrEP. You may also have to talk to a social worker, if evaluation is needed about risks associated with your “social and access conditions,” as the guideline calls them.
- If you want to talk to a doctor you know or one who has been recommended, ask for an appointment with this doctor. This could be worth waiting some weeks longer.
- Be prepared for the first appointment: read about PrEP, to assess what you know about PrEP and its function. Know your risks and why you are the right person to get it prescribed.
- Use the full term “HIV Pre-Exposure Prophylaxis”, instead of “PrEP”. Doctors may not be familiar with the abbreviation PrEP. Make sure not to mix it up with PEP, which is better known and sounds very similar.
- If the doctors don’t know what PrEP is for:
- Refer to the flyer “Ready for PrEP” and the handout that we have prepared. Print it out and give it to the doctor just in case. Especially mention the guia clinica!
We have recently heard from individuals that they have been prescribed PrEP this way. So this can work, otherwise, tell the doctor that you demand to be treated in the same way as other EPS-insured people who got PrEP prescribed as well.
Some EPS are trying to charge extra for PrEP, or have patients pay for it entirely. However, PrEP is a basic service that health insurers now have to pay for out of their budgets. Insist that all costs for appointments, blood tests, prescriptions and medications are covered.
4. WHAT IS IMPORTANT TO TELL THE DOC TO GET PrEP?
Before you go to the doctor’s office, ask yourself about your substantial HIV transmission risk: did you have unsafe sex in the last half a year, and why could it happen again? How motivated are you to take PrEP medications regularly?
Be clear with the arguments that you will give the doctor when you ask for PrEP. Be prepared if they never heard about PrEP. Maybe they think that condoms are enough for you to have safe sex. You might have to explain then why condom use does not (always) work for you. It helps to clearly articulate why you want to do PrEP.
Here are some reasons which pose a substantial risk for HIV infection. Critical to the doctor’s decision is what happened in the last 6 month. Reasons can include:
- you are a person with (often) changing sexual partners.
- you sometimes have/had sex without a condom, or you had “safer sex accidents” (unprotected sex) or (sometimes) you don’t remember about it.
- sometimes you have been drunk or high on other psychoactive substances; you loose control while having sex sometimes.
- you got PEP (HIV Post-Exposure Prophylaxis) prescribed already.
- condoms are not allowing you to enjoy sex; you have erectile dysfunction or lose the desire to have sex in connection with condom use
- you have sex with HIV-positive people who are not undetectable or their status is unknown
- you have HIV-positive partners who are not undetectable, or are not in treatment at all
- you engage in sex work
- you use recreational drugs to increase the fun of sex (chemsex)
- you are an intravenous drug user
- you live in a community with a high number of HIV-positive people
- you have or had multiple STIs
- you have rough sex that can cause bleeding (e.g. fisting)
- your sexual partners put social, physical or moral pressure on you to not use condoms during sex
- you enjoy sex with strangers in cruising places like sauna, dark rooms, parks and so on where you cannot easily communicate about safer sex.
It can be uncomfortable to talk about sex with a doctor/social worker. You may be allowed to take a companion with you to this conversation, which we would recommend doing if possible. Furthermore, it can be helpful to rehearse the conversation with friends beforehand.
In case of conflict or moral judgement, better not to enter into discussions with the doctor. Just mention the guideline again, which outlines a clear frame how PrEP should be used. Also, you can ask for another doctor (HIV specialist / infectologist) to speak to. If nothing works out, you have the right to register a complaint about the process/decision (see next chapters).
There are two different application schemes for PrEP (daily/on demand). Even if both are mentioned in the guidelines, we recommend you to ask for a prescription of a daily application, to have enough later in any case.
5. WHAT CAN I DO IF THE DOC DOESN’T PRESCRIBE ME PrEP? – FIRST STEP: SUBMIT A ‘PETITION’ TO THE EPS
If you have been denied PrEP by your doctor, you may want to consider starting a complaint process where you demand your case to be evaluated. The process can only be successful if you have clear evidence of denial of PrEP. We recommend that if you do not have it, you first talk to a lawyer, acquaintances or associations. If, despite not having this evidence, you still want to go ahead with the process and try, it is completely legitimate.
Before you start, you should know that complaints are a time-consuming bureaucratic process, with sometimes very long waiting times, and that your information will go through a number of different stages. It is likely that you will have to tell your case with its personal details to different people several times. However, filing a complaint is a process that can not only help you get PrEP, but also make access for others easier.
The first step is to file a right of petition to the EPS. If this is unsuccessful, you can file a tutela action.
We recommend that you write down a memory protocol5Que es memory protocol (memory log) right after the appointment: what happened, who said what and what reasons were given. Use this information later to fill the attached form (see pdf below). Write all immediately (even handwritten) down, so you won’t forget any detail.
Describe exactly what your HIV transmission risks are and why you cannot reduce them in any other way (e.g. with condoms)! If you haven’t seen a social worker – as proposed in the guidelines – record this in writing in the complaint’s procedure.
Petition rights are one established way to request access to health services. Once you have filled your request you have several options where to send it: you can take it to the EPS user service office, send it by email, or register it by a phone call. Do not forget to note your case number. We strongly recommend doing it with a printed letter so you have an official receipt of your complaint (bring two copies: one to give away and one for you). Remember that the response time for a right of petition is about 15 days.
In case that you are not ready to talk openly about all those details or if you feel that this will put you at risk, we cannot recommend that you go down this route.
SAMPLE FORM PETITION (PDF download, in spanish)
Download it, fill in the blanks, and follow the instructions in parentheses (replace it with your text). Don’t forget the signature at the end. Add your memory protocol. Send it to the EPS. And save a copy.
6. NEXT STEP: SEND A TUTELA TO CLAIM MY RIGHT TO STAY HEALTHY
If more than 15 days have passed since you sent your “right to petition” and you have not received a response, or the response denies you access to PrEP, you can take a tutela action. It allows people to ask a judge to intercede so that their rights are immediately protected. It can be presented without the need for a lawyer and has to be sent to a court. A list of the courts in the country, with their addresses, can be found here.
The court must answer the Tutela within 10 days.
Below we present a model that can help you prepare the document to present to the judge. However, you can also consider obtaining advice from other institutions (such as the “Ombudsman”) to legally support your case.
SAMPLE FORM TUTELA (PDF download, in spanish)
The document may look complicated, but it is easy to fill in the blanks. Follow the instructions in brackets and don’t forget your signature at the end. Attach your answer to your right of petition and the memory protocol. Finally, bring it to the court (link above).
It can help you not to be alone in the grievance process, and seek support from your friends or political groups. Of course, legal support is also great, but it costs money.
It will help us if we know about ongoing petition and tutela procedures. Please inform us about progress and results of your tutela, so we can incorporate the information into our texts. Please send it to obvio/at/loverazers.org or via social media. Unfortunately, we as Love Lazers do not have the capacity to coach individual cases.
You can also consider making your decision to complain publicly (e.g. on social media), so that as many people as possible learn where PrEP in Colombia is working and where it is not.
7. I DON’T HAVE AN EPS – WHAT CAN I DO?
The integrity of health is a fundamental human right of every citizen, also without EPS. Demanding this right by legal means would certainly be successful, but can be very bureaucratic and time-consuming on an individual level. If you think you need PrEP right now to protect yourself from HIV it might be better for you to try to find an EPS first.
If you have an income that allows you to pay approximately 280,000 pesos per month, you can affiliate as an independent to a contributory EPS. To do this, identify an EPS where you know someone got PrEP already. Normally you must download the form from the EPS website, fill it out and file it. You can do it through the transactional affiliation system of the Ministry of Health.
If you do not have enough money to be part of the contributory system, you can join the subsidised system. For this you need to have a Sisben (with scores 1 or 2). If you do not have the Sisben6a governemantal survey to categorize the socio-economic conditions (means the poverty) of households by levels survey you can request it with a public bills receipt and your identity document. This process can be complex if your score is higher than 2 and you do not have enough money to pay a monthly affiliation. If you have a score greater than 2 but less than 5, you can still show that your situation is precarious. Let’s say you live at a friend’s place and pay with domestic services, for example.
Another possibility to access health insurance is to do it through a member of your family. If a member of your family is a contributor to the EPS, he or she can add you as a financial dependent. In this case, this person will have to pay an additional amount (UPC) of between $60,000 and $150,000 per month depending on your age. This can be a convenient option if for some reason you cannot enter the contributory scheme and have problems joining the subsidised scheme (link in spanish only).
In Colombia, access to PrEP is conditional on insurance, limiting access for those who are on the margins of, or outside, the system:
- people who work for short-term service provision
- freelance workers who in several cases only pay their health insurance in the month in which they receive their payment (because their incomes are not high enough) etc.
Unfortunately, we don’t have any tips on how to get PrEP if you don’t have health insurance. To finance medications privately is just too expensive. Profamilia, for example, offers a plan of PrEP for 300.000 Colombian pesos every three months! Having to get the medications on the black market is also a completely untenable situation: the pills are expensive and the medical check-ups are not guaranteed. Furthermore, we are not currently aware of any regional PrEP program for the uninsured that is funded by the municipalities or the national government.
This chapter opens up another topic for discussion that goes beyond the objective of this article. Access to PrEP, as the right to health care should be universal and not conditioned to socioeconomic income of the population. And we have to fight for it.
8. WHY ARE SO MANY QUESTIONS OPEN?
We have written this article following the dynamics and structure of a system whose rules we have not actively and democratically decided upon. The fact that this article follows these rules does not mean that we agree with them. However, given the current situation of increasing HIV cases in Colombia, we understand that we are in an emergency situation. The fact that we do not have alternatives to act outside the system is an invitation to rethink the structures we are living in and the decisions that are made about them.
In the perspective of a further implementation of PrEP into the Colombian health system the following questions need to be answered first:
When will we see EPSs raising awareness of the importance of PrEP amongst medical staff? Why is it the case when we come to the EPS to ask for PrEP, nobody knows what it is? And why do we have to explain to the doctors what PrEP is, what it means, and how it works?
After the guidelines were published in December 2021: What are the reasons why the EPSs continue to block some of us from access to PrEP? How many more of us have to become HIV positive to finally change this unfair practice?
Is the access to PrEP a right, or is it just risk-based? Having different sexual partners and enjoing certain sexual practices is our freedom, our own decision. Should a doctor decide about our ways of having sex? And will the involvement of social workers in this process make everything more complicated and bureaucratic for us? Is dealing with the kafkaesque Colombian EPS system not enough struggle for an individual?
Why do the government and EPSs not understand that, when we ask for PrEP, we are asking for a method we decided to use to protect ourselves – as we would do when we decide to use condoms?
That our sex partners are using PrEP might help to reduce the number of HIV transmissions in our communities. Also the ones of us who are non-PrEP-users will benefit from it. Even if the general risk will be lower, this will of course remain for those who don’t have access to PrEP: For some of us protection is granted and for others it is just a lottery to get HIV at some point. Why do some of us have to pay the risk of protecting specific groups and not all as individuals?
The government actually has the necessary apparatus with PrEP to guarantee the fundamental right of health even for those who are not EPS insured. How successful is a legal case against the state (e.g. through a tutela)? And who will lobby for the people without health insurance? Who will run such a case against the government?
Why do checkpoints in Colombia not exist, and why aren’t they planned? When those community based health clinics become a reality, where can we come regardless of bureaucratic issues and health insurance status? Checkpoints: places where PrEP is provided successfully in other countries.
When will the government launch a national HIV campaign to provide a proper strategy on how to end the pandemic?
Is PrEP a right, ready to be claimed? – Seeing the guidelines in this critical context we wonder: why is PrEP promoted as a breakthrough on social media by some representatives of our communities, although the guidelines do not explicitly state it as a right?
And why is today’s HIV Prevention understood as biomedical practices which excludes the voices of the users and their communities? Because where we are with PrEP in Colombia at this point, it is actually the contribution and success of all us! How can the impact of the social movements of getting PrEP implemented be a fair process discussed at eye level?
What does it need to get us dancing on the street (maybe in front of EPS or MinSalud)? Let’s come together. Let’s make things happen! And let’s ask: How do we enjoy all our bodies in a better tomorrow?
© Love Lazers 2022. All rights are reserved by Love Lazers. Photos by Faber Franco y Camilo Galvis. Contributions: Andrés, Jonathan, Carlos, Fabian, Martin, Alejandro, Falk, Juan, Oshnur. Thanks to all who commented on our article in the process. Contact us at obvio/at/lovelazers.org or on social media.
- 1“For this process, new elements were specifically incorporated, such as pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP), comorbidity prophylaxis,… all of this so that the guide is in accordance with comprehensive care policies. of health in Colombia, favoring primary care.” (2021, p. 23)
- 2Medications that can be prescribed as PrEP for this target audience are also mentioned, such as Tenofovir, Emtricitabine, among others (p. 38), these first two are included among the lists of health services financed with government resources. the Capitation Payment Unit (UPC) as mentioned in resolution 2292 of 2021 (p. 156)
- 3“ … history of an acute sexually transmitted infection, history of transactional sex , having sex without a condom with someone whose HIV status is unknown or positive, having received PEP”. p. 103.
- 4p. 101
- 5Que es memory protocol
- 6a governemantal survey to categorize the socio-economic conditions (means the poverty) of households by levels