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Making more of medicines in the drive to end new HIV infections
Four decades ago, the first cases of HIV were diagnosed in the UK. At that time, coupled with societal prejudice against affected people and communities, very little was known about the virus, including how to test for it, how it was transmitted and how to treat it. As a result, the average survival time for a person diagnosed with AIDS-related illnesses was only 1-2 years.
Since then, we have learnt a lot about HIV. It is a virus that damages the cells in the immune system and weakens the ability to fight everyday infections, disease and other viruses. As our understanding of the virus has grown a number of highly effective HIV treatment drugs have been developed and approved for use in the NHS. We have great scientists, professionals in the NHS and remarkable activists and advocates to thank for this. These expert patients and their allies raised awareness of HIV and AIDS, fought misinformation head-on and tackled stigma with bravery and great dignity. By the mid-1990s, antiretroviral treatment (ART) had become so effective that patient outcomes began to improve significantly.
The ART offered to NHS patients today has transformed how we treat HIV – which is now seen as a long-term condition. Over 87,000 people are now receiving ART in England. ART can reduce the amount of virus in the blood to such an extent that the virus is both undetectable – no longer attacking the immune system – and cannot be passed on to sexual partners¬, also known as untransmissible. In other words, those on successful HIV treatment cannot pass it on. Testing of expectant mothers and birthing parents and this ART treatment has virtually eliminated vertical transmission of HIV in the UK. Now, a diagnosis is no longer seen as a death sentence as it once was – with people living with HIV in the UK having a normal life expectancy.
There have also been major scientific breakthroughs in preventative drugs for HIV. Unimaginable for most of the epidemic, when taken as prescribed pre-exposure prophylaxis (PrEP) can prevent people who test negative for HIV from getting the virus during sex. People who suspect that they have been exposed to HIV have 72 hours to access post-exposure prophylaxis (PEP or PEPSE). This will dramatically reduce their risk of getting HIV.
Together, ART, PrEP and PEP are all the tools we need to have zero new HIV infections in England by 2030. In the UK, 95% of those living with the virus are already diagnosed, and an even higher proportion of those are in treatment and not able to pass on the virus. Without a cure or vaccine, this ambitious goal is possible and a national priority for the NHS, the Department for Health and Social Care and a huge number of HIV charities.
As ART has traditionally been purchased on a regional basis, similar patients in different parts of England could be offered different treatments and some newer treatments were not available everywhere.
Furthermore, as new HIV-prevention options have increased and become better known, the number of people wishing to access PrEP has grown. By the end of 2023 over 35,000 people are expected to be using PrEP, so this will be over 120,000 people receiving some form of HIV medication.
The NHS therefore needed to act to ensure we have the resources and drugs available for everyone who needs them. This must be on an equitable basis, so that regardless of where someone lives they are able to access the HIV treatment or HIV-prevention drugs they need.
In the drive to make England the first country in world to achieve no-new HIV transmissions, the NHS has developed a national framework to ensure equitable access to both HIV treatments and preventative drugs.
The clinically led national agreement has fostered competition between companies supplying branded HIV treatments, ensuring the NHS pays a single best value price for each medicine in every part of the country. It also includes a number of generic HIV treatments. Generic, or non-branded medicines are just as safe and as effective as more expensive branded drugs but offer far better value for the NHS and taxpayers.
By making better use of generics, where available and clinically appropriate, this agreement has ensured drug supplies are reliable and resilient. This has the benefit of enabling patients to access the most appropriate treatments and building confidence among NHS clinicians in the NHS’ robust supply chain.
Furthermore, the savings generated by this ‘smart procurement’ has meant that the NHS can afford to expand patient access to innovative and effective HIV treatments. For example, the NHS now also offers the first NICE-approved long-acting injectable HIV-1 treatment, cabotegravir and rilpivirine, to eligible patients. The same approach will expand patient access to preventative drug options too.
What patients can expect
To make the most of the new medicines available, clinicians have been speaking to their patients to determine which medicine is the most effective and appropriate for them. This is in line with national guidelines from the British HIV Association (BHIVA) and the British Association for Sexual Health and HIV (BASHH). Patients wanting to stay on their current medication can do so. All available options will be discussed and the decision appropriate for a patient will be a shared one, between the individual and their clinical team.
It is important for patients to keep taking their HIV medicines to stop the virus attacking their immune system and transform HIV into nothing more than a long-term condition. The stopping and starting of medication can cause complications and modifications in the virus. Regularly taking ART medication also means the virus cannot be passed on during sex. During pregnancy, the benefit of ART in preventing mother-to-baby transmission outweigh the risks of not taking them.
Ending new HIV cases
By ensuring equitable access to these treatment options across the country, along with better testing, diagnosis and support, the NHS will help people with HIV live well with the virus and prevent thousands of people from contracting HIV and getting seriously ill. It gives us a very real opportunity to be the first nation in the world to reach zero new HIV transmissions by 2030.
The national agreement for HIV treatment and preventative drugs builds on NHS England’s approach to Hepatitis C elimination, which saw a unique agreement with a number of pharmaceutical companies to make Hepatitis C curing drugs available to everyone who needs them.
As a result of this world-first deal, there has been a dramatic fall in the number of people living with Hepatitis C, down by nearly 40% since 2015. In the same period, the number of liver transplants needed as a result of Hepatitis C has been cut by over half and the NHS has reduced Hepatitis C-related deaths by nearly 40%. This means the NHS in England is on track to eliminate Hepatitis C as a major public health threat in England before the global goal of 2030. As the NHS, we want to help achieve similarly ambitious goals in HIV.
Terrence Higgins Trust is Europe’s first HIV-response organisation and the UK’s leading HIV and sexual health charity. Their Chief Executive Ian Green, himself living with HIV, said about the changes:
“The NHS has allowed experts to lead the change in HIV medicines options and put patients at the heart of their consideration – crucially no one has to change their medication, and nothing will happen without the agreement of the individual living with HIV. Your clinician will talk to you about the options, so keep taking the drugs you currently have until a change is agreed. This is vital for keeping the virus under control and ensure you can’t pass it on.
“It is welcome that new treatments and HIV prevention drugs will now be available to everyone everywhere. As new innovations – injectable and the like – become available this agreement should allow quick adoption and more choice.
“We now have treatment that means people can live well with HIV and all the tools needed to end new cases of HIV by 2030 – in fact, we could be the first country to reach this global goal. These changes can only help this and the experience with Hepatitis C elimination to shows what is possible.”
The National Aids Trust (NAT) is the UK’s HIV rights charity working to stop HIV standing in the way of health, dignity and equality and to end new HIV transmissions. NAT said:
“These changes in medicines procurement by the NHS should mean that no matter where you live in the country, you can access the same range of medications and the latest treatments. This change should help increase the choice available to everyone living with HIV and mean that in discussion with their health team, people can identify the best medication to meet their needs.”
• Contact your local sexual health service for more information about PrEP, PEP and ART: www.nhs.uk/service-search/find-a-sexual-health-clinic/
• Terence Higgins Trust: www.tht.org.uk/
• National Aids Trust: www.nat.org.uk/