Barriers to accessing HIV pre‐exposure prophylaxis for Medicare‐ineligible people in Melbourne, Australia: analysis of patients attending the PrEPMe Clinic

Vincent J Cornelisse, Jude Armishaw, Mike Catton, Dean Murphy and Edwina J Wright
Med J Aust 2022; 216 (6): 320-321. || doi: 10.5694/mja2.51455
Published online: 4 April 2022

To the Editor: People without Medicare coverage cannot access Pharmaceutical Benefits Scheme (PBS)‐subsidised human immunodeficiency virus (HIV) pre‐exposure prophylaxis (PrEP) or associated clinical care. Rates of HIV infection diagnosis are disproportionately higher among overseas‐born gay and bisexual men compared with Australian‐born gay and bisexual men.1 In response, in June 2020, the Alfred Hospital and the Victorian Infectious Diseases Reference Laboratory established the free PrEPMe Clinic for Medicare‐ineligible people. Data were collected using proformas after patients provided verbal consent (Alfred Health Ethics Committee approval No. 656/18).

The first 100 consecutive patients were all born overseas (Box). Melbourne’s only public sexual health clinic referred 65 patients. Almost all patients were male, all patients had sex with men and reported a median of three sexual partners in 3 months at baseline; 76 patients inconsistently used condoms for anal sex. Fifty‐eight patients reported previous sexually transmissible infections (STIs); STIs were diagnosed in 12/100 patients at baseline, a rate similar to that found in Medicare‐eligible PrEP users.2 Thirty‐four patients had previously accessed HIV post‐exposure prophylaxis (PEP), and 49 patients had previously unsuccessfully attempted to obtain PrEP. The reported barriers to access mainly included costs of medical appointments and pathology, and difficulties navigating Australia’s health care system.

All patients received a non‐PBS PrEP prescription. At 3‐month follow‐up, 87 patients had commenced PrEP. Local pharmacies supplied PrEP at cost price (A$40–55 per month) or free to patients with financial hardship; other patients purchased PrEP online (US$20–30 per month) or obtained free PrEP online using assistance coupons (; Box). Most patients who ordered PrEP online experienced delivery delays of 4–6 weeks, leaving them at risk of HIV infection.

We report that Medicare‐ineligible gay and bisexual men and transgender women were at high risk of HIV infection, yet faced significant financial barriers to accessing PrEP. PrEP uptake has been associated with significant population‐level declines in incident HIV infection in Australia.3 Australia’s Eighth National HIV Strategy aims for virtual elimination of HIV transmissions by 2022,4 and to achieve this goal, Australia must provide universally subsidised PrEP medication and clinical services, irrespective of Medicare status.5 Medicare‐ineligible gay and bisexual men often already attend publicly funded sexual health clinics for free HIV/STI testing and treatment, as reported here. In a high income country like Australia, the additional cost of providing universally subsidised PrEP care would likely be lower than treating preventable new HIV infections, with an estimated lifetime cost of more than US$350 000 per HIV infection diagnosis.6


Box – Demographic characteristics, immunodeficiency virus (HIV) acquisition risk, and prior efforts to obtain pre‐exposure prophylaxis (PrEP) in the first 100 consecutive patients to attend the PrEPMe HIV prevention clinic at the Alfred Hospital in Melbourne, Australia*



Total number of patients


Demographic characteristics


Region of birth




 Latin America






Age, years, median (IQR)

28 (26–31)



 Cisgender male


 Transgender female


Visa status


 Student visa


 Working visa




Referral sources


Melbourne Sexual Health Centre


Word of mouth






HIV risk at initial clinical assessment


Sexual partners (3 months), median (IQR)

3 (1–5)

Condom use for anal sex (3 months)




 Mostly or sometimes




 Not applicable




Previous STIs (ever)






Previous STIs (ever, specific STIs)










STIs diagnosed at baseline


 Chlamydia only




Previous attempts at HIV risk reduction


Previous use of PEP








Previous unsuccessful attempts to obtain PrEP








PrEP commencement by 3‐month follow‐up


Commenced PrEP


 Local pharmacy




 Online order did not arrive, then purchased at pharmacy


PrEP not commenced


 Online order did not arrive




Lost to follow‐up


COVID‐19 = coronavirus disease 2019; IQR = interquartile range; PEP = post‐exposure prophylaxis; STIs = sexually transmissible infections.  * Enrolment dates: 1 June 2020 to 26 October 2020.  † Includes general practices, internet search, “PrEP Access Now” Facebook page, Alfred Hospital PEP program.  ‡ Includes herpes simplex virus, Mycoplasma genitalium, hepatitis B virus.  § Includes syphilis, hepatitis B virus, both chlamydia and gonorrhoea.  ¶ Includes lost prescription, no sex due to COVID‐19.


  • Vincent J Cornelisse1,2
  • Jude Armishaw1
  • Mike Catton3,4
  • Dean Murphy1,5
  • Edwina J Wright1,2,4,6

  • 1 Alfred Hospital, Melbourne, VIC
  • 2 Monash University, Melbourne, VIC
  • 3 Victorian Infectious Diseases Reference Laboratory, Melbourne, VIC
  • 4 Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC
  • 5 Kirby Institute, UNSW Sydney, Sydney, NSW
  • 6 Burnet Institute, Melbourne, VIC


We thank Brian Price (Department of Infectious Diseases, Alfred Hospital) for assisting with the logistics of setting up the PrEPMe Clinic; and Ali Mafi (Commercial Road Pharmacy, Prahran) and Joseph Tesoriero (Health Smart Pharmacy, the Alfred Hospital) for providing advice on obtaining PrEP for Medicare‐ineligible people, and assisting with the practicalities of providing PrEP for PrEPMe patients. We also thank the team at, a not‐for‐profit organisation that assists people without Medicare to purchase PrEP online, as permitted by the Therapeutic Goods Administration’s Personal Importation Scheme. We acknowledge Jason Ong, who contributed by referring participants to the PrEPMe Clinic and is undertaking further research with PrEPMe participants. Edwina Wright has received funding from the Victorian, Tasmanian and the South Australian governments for the PrEPX study.

Competing interests:

Vincent Cornelisse has received speaker’s fees and advisory board fees from Gilead Sciences, and advisory board fees from ViiV Healthcare. Edwina Wright reports receipt of grants from Gilead Sciences (free study drug for the VicPrEP study, compensation to her institution for chairing a nursing education session and for attending an advisory board meeting, and uncompensated attendance for attending two Gilead meetings regarding listing of Truvada on the Australian Pharmaceutical Benefits Scheme); grants from Gilead Science and Merck Sharp and Dohme outside the submitted work; and financial support from Gilead Sciences, Abbott Laboratories, Janssen‐Cilag, Boehringer Ingelheim, ViiV Healthcare, and Merck Sharp and Dohme.

  • 1. Medland NA, Chow EPF, Read THR, et al. Incident HIV infection has fallen rapidly in men who have sex with men in Melbourne, Australia (2013–2017) but not in the newly‐arrived Asian‐born. BMC Infect Dis 2018; 18: 410.
  • 2. Traeger MW, Cornelisse VJ, Asselin J, et al. Association of HIV preexposure prophylaxis with incidence of sexually transmitted infections among individuals at high risk of HIV infection. JAMA 2019; 321: 1380–1390.
  • 3. Grulich AE, Jin F, Bavinton BR, et al. Long‐term protection from HIV infection with oral HIV pre‐exposure prophylaxis in gay and bisexual men: findings from the expanded and extended EPIC‐NSW prospective implementation study. Lancet HIV 2021; 8: e486–e494.
  • 4. Australian Government, Department of Health. Eighth National HIV Strategy; 2018–2022.‐bbvs‐1/$File/HIV‐Eight‐Nat‐Strategy‐2018‐22.pdf (viewed Feb 2022).
  • 5. Australian Federation of AIDS Organisations. Agenda 2025 — ending HIV transmission in Australia. AFAO, 2021.‐content/uploads/2021/06/Agenda‐25‐Technical‐Paper.pdf (viewed Feb 2022).
  • 6. Tran H, Saleem K, Lim M, et al. Global estimates for the lifetime cost of managing HIV. AIDS 2021; 35: 1273–1281.


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