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Further update on commissioning and provision of Pre Exposure Prophylaxis (PREP) for HIV prevention

PrEP is a way of using anti-retroviral drugs – usually used for treating people with diagnosed HIV-  to stop viral transmission. Evidence of effectiveness is strongest for men who do not use condoms in sex with multiple male partners.

On 21 March 2016, a statement was placed on the NHS England website explaining that PrEP could not be considered for the specialised services annual prioritisation process. Specifically, it said that:

As set out in the Local Authorities (Public Health Functions and Entry to Premises by Local Healthwatch Representatives) Regulations 2013, local authorities are the responsible commissioner for HIV prevention services.

Including PrEP for consideration in competition with specialised commissioning treatments as part of the annual CPAG prioritisation process could present risk of legal challenge from proponents of other ‘candidate’ treatments and interventions that could be displaced by PrEP if NHS England were to commission it.’

In light of representations from stakeholder groups NHS England agreed to reconsider the decision. This took place on 31 May 2016 at the Specialised Services Commissioning Committee. In summary, the Committee:

  • considered and accepted NHS England’s external legal advice that it does not have the legal power to commission PrEP;
  • remains committed to working with other commissioners to explore the possible provision of prep. This includes working in partnership with Public Health England to run a number of early implementer test sites, backed with up to £2m investment over the next two years, to research how PrEP could be commissioned in the most clinically and cost effective way.

A full copy of the paper and legal advice considered by the Specialised Services Commissioning Committee can be found below.

It should further be noted that, even if this were not the legal position, there is no guarantee that the annual prioritisation round would result in a decision to invest millions of pounds in PrEP over new treatments and interventions in other service areas which are also competing for funding.

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12 comments

  1. Mark Turner says:

    I am neither gay nor HIV positive, but it seems obvious to me that if you reduce the prevalence of HIV in all groups of the population, the entire population benefit and money is saved in the long term.
    In my own field short-sighted, short-term decision making is the best that NHS England can offer. If clinicians performed at this level we would be subject to CQC criticism. This is just one more example of poor decision making.

  2. Andrew Sigley says:

    n extremely disappointing decision by NHS England (who had previously indicated it was their responsibility to fund PrEP). This is not a debate about the drug’s effectiveness – that’s already been proven. This is a dispute about which pot of public money should be used to fund a drug widely available other countries. While the bureaucrats bicker, people continue to get infected. It’s an unacceptable situation that our elected officials need to step in and sort out.

  3. Peter Matthews says:

    Medical funding….really ? Is life that clear cut – I think not ? Surely it is worth giving life a chance. Whatever happened to that glorious vision called hope that drives society forward ? I fear institutional judgementalism is creeping in….not good. Not good at all. Turn the clock forward a 100 years and your ancestors will curse the legacy that is your decision today.

    It is OK to change your mind – so do it – change it. Change it now and give hope that chance 🙂

  4. harleymc says:

    “risk of legal challenge from proponents of other ‘candidate’ treatments and interventions that could be displaced by PrEP” = Treatments might get displaced by prevention.

    It’d be a bad PR day for any pharmaceutical company to bring that lawsuit.

    Clearly there needs to be urgent overhaul of legislation around who has responsibility for STI prevention.

  5. Bryn Thomas says:

    This is a ridiculous situation. The cost of PrEP would be tiny compared to the cost of treating people diagnosed.

    It’s not just MSM either. I am in a serodiscordant relationship with a woman who is negative. We are aware these days that TAsP vastly reduces transmission rates once fully undetectable and would like to enjoy condomless, monogamous sex. Relying on TAsP is one thing, but the option of PrEP would be a boon and remove any risk of my wife becoming infected at some point and adding to the NHS treatment burden.

    The above may sound selfish, but there are many discordant couples who want to try conceiving etc, and whom PrEP would be ideal.

    It’s just so very short-sighted

  6. Aaron says:

    “Evidence of effectiveness is strongest for men who do not use condoms in sex with multiple male partners.”

    And in that sentence we have precisely why this drug was not approved. It seems unfathomable that if a drug was as effective in the general population as PrEP is among gay men, that it wouldn’t be approved. Clear institutional homophobia

  7. Freddie Cotton says:

    NHS England refuses to break law on behalf of noisy people who don’t understand it.

    Good stuff. We cannot have medical funding decisions made on the basis of who had the best campaigning operation.

  8. Charles Reid says:

    This is absolutely disgusting. NHS England should be ashamed. The estimated cost of HIV treatment over lifetime is £360,000 (source: UCL), and that leaves aside the emotional cost. Please take me through your thinking once again.
    The NHS once stood tall, leading the western world in treatment and vanguarding prevention. This stinks of cost cutting… We’re not talking about BBC3 here, or slightly less regular bin collection. We are talking about people’s lives.

    • Erik Landwehr says:

      Even 100% protected gay sex puts you at 50% increased risk of contracting HIV. Period. I lost a dear friend to AIDS, he was from a commonwealth state. He NEVER had unprotected sex. He was raped. PEP DOESN’T always work. Get the facts. This is why, over here, across the pond, the CDC recommended Truvada/PrEP for ALL gay men under 50; that are sexually active, and healthy enough to take Truvada. I’m taking it. I’ve never had bareback sex. NEVER… But, now I can have sex; while staying protected, and not live with the debilitating fear, of HIV/AIDS, that has kept me from dating, for many years. I feel so sorry, for the men in Britain. I have to say, there is one no longer with us, you men know who I mean, that fine lady, would not have let this stand. I have not seen any of you invoke her name; and I’m left wondering why. Freddie Mercury was who I wanted to be when I grew up, my mother was a music major; when did the fight become a political one? It’s about death, nothing else. You need to stand up; and call out the ghosts of old. If you’re waiting for someone to do it for you; it won’t happen. Not while Dan Savage, his gay tea-party, and their opposite number, on your shores, hold their sway; and chant their horrid mantras. This is wrong. It’s wrong on every level. Free clinics, here, are getting charity money to hand Truvada out, for free. That’s what she would want; you all know I’m right. If THEY won’t say it; say it for them. Being from San Francisco, born and bred, I’ve lost more friends than most, including one so dear. The struggle, that fine lady, and those like her, taught me one thing, and one thing only; NEVER SURRENDER, NEVER…

  9. Mark says:

    By the NHS not commissioning Prep they are treating Gay and Bi sexual men as second class citizens of this country. This is sexual discrimination against gay and bisexual men

  10. Paul Kirwan says:

    You bottled it again!

    Your reluctance to proceed with commissioning Truvada as PrEP seems to rest on the grounds that some other, cheaper or more effective drug manufacturer would sue. Let them.

    Do you really think that the USA, France, Kenya et al hadn’t considered this possibility? The public interest defence would have easily over-ridden any challenge by big (or small) Pharma. This is Public Health we’re talking about. Grow a spine and let them sue. You’d win.

    I hope that the National Aids Trust revives their threat to take this to Judicial Review. Your reasons (which come across as thinly-disguised excuses without foundation and as possibly discriminatory homophobia) are bogus.

    I am incandescent about your decision. It smacks of short-termism and bigotry.

    • Matt Morisson says:

      Paul Kirwan: who would sue whom? Have you actually read the reasons for the decision? This is nothing to do with costs, lawsuits, generic version of Truvada, or whatever else you’re implying.

      The reason they give is that they got legal advice that says that as PrEP is not a *treatment* for an existing condition, but is a *preventive* tool against acquiring a condition, it follows that NHS England has no legal power to commission PrEP, since it’s a matter of preventive public health which is devolved to other parts of Government, notably local authorities. Basically, the NHS will treat you if you’ve got something, not if you want to avoid getting something.

      Now, this might be disingenuous, or downright false, and that’s something worth discussing (for starters, the NHS offers vaccines, from flu to many other things, including Hepatitis B — all of which are preventive!), but let’s discuss what they actually said and not what they didn’t.

      (For the avoidance of doubt, I am a member of the public who supports the commissioning of PrEP; I just think that if one is to argue with NHS England successfully, the least one can do is read carefully what they say and argue with them on their actual arguments, and not on stuff they didn’t say or imply.)