The extraordinary power of PrEP – the HIV drug the NHS took to court

On trial

I’m one of the people in England trialling a new drug that virtually stops the spread of HIV

7th November 2017

There’s a quiet revolution going on in sexual health at the moment. I’m one of thousands of people are taking a pill every day to stop unwanted consequences of sex. Last month, the NHS in England started a trial of PrEP (pre-exposure prophylaxis) – a daily pill of two HIV drugs that has been shown to virtually stop people contracting HIV through sex. The trial isn’t to test whether it works – we know that already. In fact, the original trial was so successful that it became unethical to delay some participants from taking PrEP.  The trial is to assess its impact on the NHS.

Thousands of people, mostly gay men, have been self-prescribing PrEP for months now. Websites like IWantPrepNow were set up to help people source generic versions of the drug from pharmacies in Thailand and India and Sexual Health Clinics agreed to support people taking the drug.

PrEP, along with other interventions are having a remarkable effect on the fight against HIV.  Last year, 56 Dean Street, one of the biggest sexual health clinics in the country based in the heart of London’s gay scene in Soho, saw a 42% reduction in new diagnoses. Early evidence suggests even better results this year – this September they diagnosed just 11 new cases – compared to around 70 in a single month in 2015.

Condoms

Many people’s response to PrEP is: why not just use condoms? And sure, condoms are definitely the best form of protection as they protect against other sexually transmitted infections (STIs) like syphilis, gonorrhoea and chlamydia, but the rising number of new diagnoses showed that people just aren’t always using them. If you’re drunk, if you’re high, if you’re just very horny, you often don’t think rationally and that includes interrupting sex to put on a condom. If instead, you can take a pill every morning, many people are much more likely to do that.  There’s a reason why the contraceptive pill is much more effective at preventing pregnancy than condoms alone. People just aren’t good at reliably using them.

Until this year I would never have considered PrEP.  I would include myself in the group that didn’t understand why people don’t use condoms. But then mistakes happen and you realise how easy it is to just forget to use them. That’s putting aside the fact that they can be difficult to use, and make the sex itself harder and sometimes more painful. Having had a stressful three-month wait for an HIV test I decided I didn’t need to put myself through that again. PrEP puts me back in control. It hasn’t had a massive impact on my behaviour, I still usually use condoms, but the times that I don’t no longer leave me worried and regretful when I wake up the next day.

Other criticisms of PrEP were about whether there’d be a rise in other STIs if there was a drop in condom use. So far this just isn’t happening. In fact, at Dean Street they saw a fall in new diagnoses of gonorrhoea. One reason for this could be that support for PrEP includes 3 monthly sexual health screen meaning that any other STIs caught can be picked up quickly and treated before you’re able to pass it on to others. Given that very few people use condoms for oral sex, this can only be good news for everyone as, unlike HIV, few STIs are only caught through anal or vaginal sex.

Court

The question now is why this is not yet available on the NHS in England, when it is available in Scotland and Wales. In fact, NHS England spent £100,000 fighting in court so that they wouldn’t have to provide PrEP.  Their opponents, the National Aids Trust, spent just £8,000. To put it into context – generic PrEP would cost the NHS around £300 per person a year. Treating someone with HIV will cost around £360,000 over their lifetime. In 2015, about 101,200 people were estimated to have HIV, with 13% of those not knowing they were infected with the disease. Two-fifths (39%) of people diagnosed with HIV in 2015 were diagnosed late, after they should have already started treatment, according to the Terrence Higgins Trust.

In their fight against providing PrEP, NHS England allowed news stories to be run comparing the cost of PrEP with other treatments they carry out, pitting vulnerable group against vulnerable group. Its lawyers said PrEP would be competing with renal dialysis, secure inpatient mental health services, treatment for rare cancers and life-threatening genetic disorders such as a drug for children with cystic fibrosis. A nasty PR tactic that risked setting back work to reduce the stigma of sexual health many years.  At no point did they talk about the cost to the NHS of NOT reducing the number of new diagnoses of HIV.

Having lost in court, the PrEP impact trial now feels like a delaying tactic. It does allow it to prescribe a generic, unbranded version of the drug costing about £30 per person a month, while drug company Gilead still has a patent on PrEP until 2021. However, if the trial is successful, the NHS will need to negotiate with Gilead, which charges as much as £400 per person a month.

The trial is likely to be oversubscribed soon – Dean Street has around 1,300 places and expects to be full by the end of this month. Some other clinics around the country haven’t started recruiting yet but have very limited places. Manchester has just 20 places for the trial.  You can still buy the drug online, and sexual health clinics will still support you with regular blood tests and check-ups if you choose to do this.  

PrEP won’t stop the HIV epidemic alone, but it’s one incredible tool, along with condoms, that is already making an incredible difference. Hopefully, soon it will be as commonplace as the contraceptive pill – and will likely have just as dramatic an effect on people’s lives.

7th November 2017