UK National AIDS Trust: “NHS shouldn’t withhold PrEP any longer”

Following the release of the latest Public Health England report on HIV in the UK, the National AIDS Trust (NAT) called on the National Health Service to “provide PrEP without delay.”

According to the latest figures, there were 3,360 new HIV diagnoses among gay and bisexual men in the UK in 2014—the highest number ever recorded.

Emphasising that “current prevention work is making no dent on these numbers,” the NAT joins a growing chorus of organisations and individuals urging the NHS to act swiftly to make Truvada available for pre-exposure prophylaxis (PrEP) in the UK.

Approved access to PrEP in the UK has been limited to participants in the PROUD Study. The study, which published its results in The Lancet in September, observed an 86% reduction in new infections among participants who had access to PrEP compared with those in the deferred arm.

It’s important to make clear that this was an indication of PrEP’s effectiveness as a public health intervention, not its efficacy on an individual level. Of the three infections that occurred among people with access to PrEP, two do not appear to have been using PrEP at the time, the third was most likely infected before the start of the study. At the individual level PrEP is at least as effective as condoms with an estimated reduction in the risk of infection of more than 99% when taken daily.

Besides the PROUD participants, an unknown number of people in the UK are already using PrEP by purchasing Truvada or a generic equivalent at their own cost. Although the price of Gilead-branded Truvada is quite high (around £400 for a 30-day supply), the UK allows the import of limited quantities of generic versions of medications for personal use, which brings the cost into reach for many more people.

A new website has just been launched to provide guidance for people in the UK wishing to start using PrEP before the NHS makes it available. A similar site was launched recently in Australia as well. In addition, London’s 56 Dean Street clinic has begun offering a PrEP support service (including the necessary blood tests) for people who want to access PrEP on their own.

These efforts are inspiring examples of community-led initiatives to fulfil unmet needs and they suggest that there is a strong demand for PrEP in the UK. But they are merely stop-gap solutions, of use only to those who have the resources to pay for medical care and medication themselves. Until the NHS makes PrEP widely available, too many people in the UK will be denied access to this highly-effective prevention measure.

One final aside: NAT’s Director of Strategy, Yusef Azad, cites San Francisco as an example of successful PrEP implementation. While I agree wholeheartedly that making PrEP available in the UK (and here in Ireland) is an urgent priority, I’m concerned that it is slightly misleading to attribute San Francisco’s recent success in reducing new infections primarily to PrEP.

San Francisco has been pursuing a comprehensive and multifaceted approach to HIV for quite a while. Even before the introduction of PrEP in the US in 2012, the city was seeing a steady decline in the rate of new diagnoses. Meanwhile diagnoses among gay men in London have remained high and been increasing in the past few years.

Numerous factors besides the availability of PrEP distinguish the response to HIV in those two cities. For instance, HIV-negative gay men in San Francisco get tested for HIV at higher rates than men in London, and HIV-positive men are more likely to be open about their status. The percentage of men who are HIV positive is smaller in London’s gay community, but the percentage of men who are undiagnosed is significantly higher.

Making PrEP available in the UK will undoubtedly make a difference—potentially a big difference—but it is unlikely that it alone will be enough. The use of condoms by gay and bisexual men has been an enormously successful prevention strategy, but we now recognise that condoms alone cannot stop the epidemic. We should be wary of overselling PrEP, of expecting more from it than it can deliver. We need to sustain and expand all available measures and not simply shift our focus to the newest one at the expense of others.

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