Is latent homophobia behind NHS England’s decision to fight the recent High Court judgement on the provision of PrEP?
I’ve been quiet about PrEP for a while now, but earlier this year, at the National HIV Nurses Association conference in Manchester, I spoke passionately in favour of its implementation for those most at risk of HIV, angry at the way the NHS was attempting to wriggle out of commissioning PrEP by claiming it was the responsibility of local councils, none of which were likely to be able to afford it.
Furthermore the NHS refused to offer any support to those of us on the PROUD study who would no longer have access to PrEP. Well things have moved on a bit since then. In August, in a huge victory for the National Aids Trust, who brought the case, the High Court ruled that the NHS does have a responsibility for commissioning PrEP. In his summing up, Mr Justice Green stated that,
“No one doubts that preventative medicine makes powerful sense. But one governmental body says it has no power to provide the service and local authorities say they have no money.
“The claimant is caught between the two and the potential victims of this disagreement are those who will contract HIV/Aids but who would not were the preventative policy to be fully implemented.
“In my judgment the answer to this conundrum is that NHS England has erred in deciding that it has no power to commission the preventative drugs in issue.”
Unfortunately, NHS England responded that they would appeal the decision with a cynically worded statement to the effect that PrEP was, “to prevent HIV transmission particularly for men who have high risk condom-less sex with male partners”.
The NHS also stated that they would not now be able to confirm funding for treatments and services in levels three and four, which just happen to include treatments for children who are deaf and have cystic fibrosis. Not surprisingly the statement resulted in some of the most vituperatively questionable headlines in recent years from, predictably, the Daily Mail, but also in The Times.
Not only was NHS England giving out inaccurate information, but it was failing in patient responsibility by pitting one patient group against another, and one has to ask what was the motive behind issuing such a sensationalist statement.
I am beginning to think someone at NHS England has a personal axe to grind. In the event, Ian Green, Chief Executive of the Terrence Higgins Trust, wrote a strongly worded letter to NHS England’s Chief Executive, Simon Stevens, expressing extreme “concern” with the wording of the NHS press statement.
He concluded that,
“PrEP is not a moral issue. PrEP is a treatment which can stop a population with ongoing major health inequalities from contracting a life threatening disease with lifetime treatment costs of up to £380,000. That is all and it should be treated as such.”
As it happens, NHS England have now issued a statement to the effect that they have launched a consultation into the future of HIV-preventing PrEP, though the statement document notes that the consultation is being run without prejudice to the outcome of their appeal following a judicial review, and that their contention is still that it is not responsible for commissioning PrEP.
In the meantime, NHS England’s latest proposal that it will routinely commission PrEP for the treatment of adults at high risk of HIV acquisition is good news indeed.
Those considered at high risk and covered by the policy are high risk men who have sex with men, or MSM (a phrase I dislike intensely, though it seems we are stuck with it for the moment), trans women and trans men who have had anal sex without a condom in the last three months and are likely to again in the next three months; also partners of people living with HIV where they are not known to be on successful HIV treatment, and heterosexuals assessed to be at similar high risk to MSM.
Those of us already on the PROUD study also received some good news when Gilead, the company which produces Truvada, agreed to provide the drug free of charge for existing PROUD participants for the next six months.
I know I’ve banged on about it before, but I am convinced that the reason we are still having to fight for the implementation of PrEP, why we are even having this discussion at all, comes down to latent homophobia and a distaste for what we do in bed, and that moral judgements are getting in the way of facts.
We already know that getting people with HIV onto treatment as soon as possible means that they can’t pass on the virus. Coupled with making those most at risk immune, we have a real chance here of bringing down HIV infection rates considerably. In San Francisco, a two-pronged strategy, using TasP (treatment as prevention) and increasing access to PrEP resulted in a staggering 34% reduction in new infections between 2012 and 2014, a figure that is likely to increase as the new treatments take effect.
Yes, PrEP is expensive, though the price will come down considerably once Truvada comes out of patent in 2017, but, it is far more expensive to treat someone with HIV for the rest of their lives.
And we’re not even taking into consideration the hidden costs of dealing with mental health issues that invariably follow a positive diagnosis. Now as it happens, my situation has changed over the last year or so. Whereas, when I started on PrEP, I was having lots of sex with multiple partners, I am now in a monogamous relationship and don’t need to be on it anymore.
And here’s the point.
HIV is something that will be with you for the rest of your life. PrEP is something you might need at certain points in your life. What’s more, the Ipergay study in France came up with a different model from the daily regimen. They found that if you took 2 pills prior to having sex, and then one more for two days afterwards, you would still be protected, which is something that would work for people who have organised sex lives.
On the other hand PEP (post exposure prophylaxis), as I hope everyone knows, has been available for some time now. I was on it twice before going onto PrEP. I know of people who are accessing PEP three or four times a year, which is already costing the NHS more than putting these people onto PrEP; and I’m now hearing about guys presenting themselves for PEP several times a year in an attempt to stock pile Truvada to use as PrEP. This too is far more costly than putting them on PrEP.
It is my fervent hope that NHS England will lose their appeal and we can finally begin to bring down the escalating increase in new HIV infections in this country.
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