The case for the use of HIV drugs before sex to prevent transmission is clear but they remain inaccessible to many parts of the community. Access is the much needed first step, writes Michael Brady
HIV remains a major concern in the UK, with an estimated 107,000 people living with the condition; 23 per cent of whom don’t know their status. For those with the virus, the impact can be life changing.
HIV remains a highly stigmatised condition in many communities and its impact can manifest itself not only in physical or mental ill health, but also as direct discrimination in the workplace and broader society, including in the health and social care sector.
We need a much greater emphasis in the UK on preventing HIV transmission. Despite the proven benefits of promoting condom use and the impact HIV therapy has on reducing transmission, the number of gay men infected with HIV each year has remained relatively stable over the last decade.
Prevention is better
At Terrence Higgins Trust we’ve been campaigning for PrEP (pre-exposure prophylaxis) – the use of HIV drugs (Truvada) before sex to prevent HIV transmission. Our campaign: “STOP HIV. PrEP NOW” is so called because that, quite simply, is what PrEP has the potential to do – stop HIV transmission by offering protection to those at greatest risk.
The PROUD study in the UK demonstrated an 86 per cent reduction in HIV transmission in men who have sex with men (MSM) taking PrEP, with total levels of protection seen when taken as prescribed. Last month’s Lancet publication of these data marked an essential step towards ensuring access to PrEP on the NHS for those who need it.
The PROUD study is not the only evidence we have. It was one of two recent randomised controlled trials conducted in European MSM populations.
‘There was an 86 per cent reduction in HIV transmission in men who have sex with men taking PrEP’
PROUD was an open label design in which half the participants had immediate access to daily Truvada while the other half deferred starting PrEP for a year. IPERGAY, a PrEP study conducted in France, was a placebo controlled trial where Truvada (or placebo) was used intermittently (two tablets before anticipating sex and one a day for the two days following sex).
IPERGAY demonstrated that an event driven regimen, which required half as much drug as the daily regimen used in PROUD, also reduced HIV transmission by 86 per cent.
Both studies showed virtually no difference in reports of condom use between the two groups and no difference in rates of other STIs – contradicting the claim that access to PrEP would encourage an increase in risky sexual behaviour and acquisition of other infections. We are not proposing that PrEP replaces condoms. It would instead be an additional supplement to our existing range of HIV prevention tools.
The PROUD study also demonstrated that sexual health clinics can easily integrate PrEP into routine clinical practice. The barrier now between those at highest risk of HIV and accessing PrEP is, of course, cost.
The NHS spends over £500m a year on HIV treatment with estimated individual lifetime HIV treatment costs of up to £360,000. A year of PrEP (Truvada) costs £4,331 and the PROUD data shows that we would only need to treat 13 men for a year to prevent one HIV infection.
In reality it is unlikely that all men would need to take Truvada all the time as HIV risk, and therefore PrEP need, changes over time. Two health economic analyses, while taking different approaches, have agreed that fundamental to ensuring PrEP is cost effective is both our ability to focus treatment on those with the highest HIV incidence and the cost of the drug.
One model demonstrated that a reduction in drug cost by 50 per cent would even make PrEP cost saving. This could be achieved by negotiating price reductions, utilising the IPERGAY regime where men took half as much Truvada as in the PROUD study and using generic drug when it is available in 2017.
‘A reduction in drug cost would even make PrEP cost saving’
In our resource limited, publicly funded NHS these financial considerations are understandably important for policymakers, clinicians and commissioners. The HIV clinical reference group sub-group on PrEP is currently considering its cost effectiveness, and is due to make its recommendation to NHS England this month.
We’re hoping for approval by April – but that cannot come soon enough. We have the tools at our disposal now to make a significant impact on HIV transmissions in gay men and those at greatest risk should not be denied access.
We already have inequity of access to PrEP as it is available privately at a price of £400 for a 30 day supply of Truvada, which is vastly out of the price range of most people who need it. Others are resorting to sourcing lower cost generic Truvada online which may be of unreliable quality and means they don’t get the benefit of regular monitoring, health improvement interventions and screening for other STIs they would get if seen in a sexual health service.
The World Health Organisation recommends the use of PrEP for those at substantial risk and it has been available with Food and Drug Administration approval in the US since 2012. The case for PrEP in high risk MSM is clear and we can no longer afford not to provide it as part of our approach to HIV prevention.
Access to PrEP for high risk MSM is a much needed first step and needed now. Having said that, we must not forget that, in the UK, HIV is not an epidemic solely concentrated in one community. The black African community remain disproportionately affected by HIV and work is also needed to understand how to identify other groups at high risk who would also benefit from PrEP.
Our need for PrEP on the NHS is clear. We cannot afford to wait. Stop HIV: PrEP NOW.
Dr Michael Brady is medical director at Terrence Higgins Trust. You can follow Dr Brady on Twitter via @drmbrady