Experts call for England's National Health Service to fund PrEP

Issue: August 2016

A pair of editorials recently published in The BMJ are urging England’s National Health Service to begin publicly funding pre-exposure prophylaxis for HIV prevention.

The first — written by Jim McManus, AFBPsS, FFPH, CSci, CPPsychol, director of public health for the Hertfordshire County Council, United Kingdom, and Dominic Harrison, Dip H Ed, MPH, FFPH, director of public health for Blackburn with Darwen Borough Council, U.K., and published on July 5 — pointed to evidence confirming the safety and efficacy of PrEP. The writers also argued that the risk for HIV’s spread extends beyond personal or local health.

“Despite overwhelming evidence that [PrEP] against HIV infection is largely safe, effective and cost-effective, NHS England has declined to make it available on the NHS, arguing that HIV prevention is the responsibility of local government,” they wrote. “Such an approach confounds its advocacy of a health and care system integrated around the best outcomes for the citizen and perpetuates an incoherent national approach to HIV prevention.”

McManus and Harrison said that, although NHS England has adopted treatment as prevention as a clinical policy, a more coherent strategy is still needed to achieve the UNAIDS 90-90-90 goal by 2020. They described NHS England’s recent PrEP pilot testing initiatives as a “delaying tactic,” and argued that if the public health service insists PrEP is the duty of local health authorities, it should at least provide them with adequate funding.

“Whatever route is finally chosen to fund PrEP, bouncing the decision across systems that are all funded by the same taxpayer will inevitably result in the continued and preventable further spread of HIV,” the two wrote. “This will generate avoidable mortality and increase future NHS costs for treatment. Perhaps it is time for NHS England just to ‘do the right thing.’ ”

AIDS advocacy group initiating judicial review of NHS decision

McManus’ and Harrison’s arguments echo those made in June in another editorial by Deborah Gold, MA, chief executive of the National AIDS Trust. Along with noting the growing evidence of PrEP’s efficacy, she said the lack of action to protect affected communities would demonstrate the public health body’s unequal priorities.

“Any further delay may appear to reflect a lack of value placed on the health of these most affected communities,” she wrote. “The stigma that still surrounds HIV and its sexual route of transmission cannot be allowed to trump evidence.”

Gold also discussed the administrative difficulties sexual health clinics would face prescribing and monitoring PrEP, regardless of whether or not NHS England decided to commission the preventive drug. However, due to the public health authority’s recently reaffirmed decision not to invoke its specialized commissioning process, Gold said her organization had “no choice” but to bring NHS England’s claims of legality before a court for judicial review.

“This is a health system failing to look at the bigger picture, with decision making dangerously fractured and with no one providing clear direction and leadership,” Gold wrote. “The provision of PrEP for those at high risk, who need it and want it, could reduce the human and financial costs of this preventable condition. While we delay, 17 people a day are being diagnosed with HIV. ”

PrEP-based strategy could prevent 7,400 MSM HIV infections by 2020

The case for PrEP in the U.K. was proposed earlier this year by Narat Punyacharoensin, PhD, of the department of infectious diseases and epidemiology at the London School of Hygiene & Tropical medicine, and colleagues. The researchers’ analytical model estimated that a national strategy consisting of PrEP, expanded testing and early treatment programs could prevent nearly 7,400 new HIV infections among men who have sex with men by 2020.

To predict the future burden of new infections and the impact prevention, Punyacharoensin and colleagues used demographic data from national and community-based surveys to construct a deterministic, partnership-based model of HIV transmission. With this, they simulated the impact of seven interventions on infection rates for 2014 to 2020.

Without additional interventions, Punyacharoensin and colleagues’ model estimated 16,955 (interquartile range, 13,156-21,669) new HIV infections among U.K. MSM by 2020, with 52,268 (interquartile range, 45,982-59,794) infected MSM living in the country. Among the more practical scenarios examined by the researchers, a combined strategy of PrEP, annual testing and a test-and-treat program among only 25% of high-activity MSM was estimated to prevent 7,399 (interquartile range, 5,587-9,813) new infections among MSM.

The researchers wrote that this level of coverage is feasible, as previous data have shown that as many as half of U.K. MSM are interested in PrEP and treatment-as-prevention program participation.

“Current prevention efforts in the U.K. that focus on correct and consistent condom use and regular HIV testing have been falling short,” Punyacharoensin said in a press release. “HIV rates among MSM remain high with around 2,800 MSM becoming infected with HIV in 2014, and the trend shows no sign of abating. Our results show that PrEP offers a major opportunity to curb new infections and could help reverse the HIV epidemic among MSM in the U.K.” – by Dave Muoio

References:

Gold D. BMJ. 2016;doi:10.1136/bmj.i3160.

McManus J, et al. BMJ. 2016;doi:10.1136/bmj.i3515.

Punyacharoensin N, et al. Lancet HIV. 2016;doi:10.1016/S2352-3018(15)00056-9.

Disclosures: Gold reports that his organization receives funding from Gilead Sciences. Harrison and McManus are responsible for local authority sexual health budgets, and McManus is a board member of the Association of Directors of Public Health as well as a trustee of Catholics for AIDS Prevention and Support. Punyacharoensin and colleagues report no relevant disclosures.