Earlier in August, a high court decision ruled that a new HIV preventative medication could legally be commissioned on the NHS.
The new medication called “Pre-exposure prophylaxis” or PrEP for short, offers a promising development in preventing HIV infection. Previously, HIV prevention efforts have focused on changing sexual behaviours and promoting condom use. A “post- exposure prophylaxis” (or PEP) medication is already available on the NHS. This consists of a short course of antiretroviral medication that can be taken in the 72 hours after a possible HIV exposure, for example unprotected sex.
PrEP will differ from PEP in that it’s taken by HIV-negative people before sex as a daily preventative medication. Research to date has found it to be very effective at reducing the risk of HIV infection.
The High Court decision has been celebrated by the National Aids Trust, who had fought NHS England’s original decision to park PrEP commissioning. But the fight is far from over with NHS England appealing the court decision and PrEP commissioning still causing lots of debate regarding its cost-effectiveness.
So how well does PrEP work? And if it works well, how expensive will it be for the NHS?
There have been two big studies that have looked into PrEP’s effectiveness:
The first, was a British study was called the PROUD study. A form of PrEP called Truvada (an antiretroviral normally used to treat HIV infection) was found to be 86% effective at reducing the risk of infection with HIV. A European study, called IPERGAY, produced similar results.
Critics of PrEP raise concerns at the cost to fund PrEP for a disease that is contracted by human behaviour. They argue that the emphasis should be on health responsibility – wear a condom, limit promiscuity, and you don’t have the problem in the first place. A fair point, but an ethically difficult stance when you extrapolate it to other patient groups. A huge sum of NHS money is spent on the prevention and treatment of other diseases that also result from human behaviour. Consider type two diabetes, obesity, alcoholic liver disease and smoking-related diseases, to name a few.
The economic arguments for PrEP are also compelling. In 2014, 103,700 people in the UK lived with HIV and 91% of those infected take antiretroviral medication.3 That’s a lot of people needing treatment each year. We must also remember that HIV treatment is life-long. HIV infection may be incurable but life expectancy has improved dramatically over the last 20 years and patients can expect to have a near-normal lifespan. In 2015, the annual cost of antiretroviral treatments was £411 million, with costs expected to increase to £559 million by 2019.4 In a patient’s lifetime, costs are estimated at £350,000 for treatment alone and significantly more when you consider other social factors.
With HIV treatment costs so high, surely a preventive medicine would save the NHS money? Well at current costs, PrEP is expected to cost in the region of £350 a month.5 It sounds like a lot, but the cost of antiretroviral medication is expected to fall over the next 20 years as drug patents expire and more generic options become available on the market. Truvada’s patent expires as early as 2017.6
There have been several cost-effectiveness analyses conducted and many do show cost effectiveness of PrEP. However, they also comment on many variables that could affect this.7 For example, would men begin to undertake riskier sexual behaviour and would condom use decline? Could interest in PrEP lead to an upsurge in HIV testing? Would PrEP be preserved for the higher risk groups (e.g. recent STI, multiple sexual partners) or would there be blanket availability? It is clearly complicated to predict.
As we await the outcome of NHS England’s appeal, PrEP remains unavailable on the NHS but can be self-funded privately. For now, condom use should be prioritised in the fight against HIV infection. For those who have possibly been exposed, PEP is available through your GP or local Sexual Health Clinic.
If you are interested in purchasing PrEP see http://www.iwantprepnow.co.uk/ for more information.