NHS England takes too long to commission PrEP for HIV prevention

An effective treatment that can prevent HIV infection and reduce the human and financial costs of the preventable condition is taking too long to be commissioned and made available on the NHS, warns Deborah Gold, chief executive of the National Aids Trust, in an article published by The BMJ today.

Compelling evidence of the effectiveness of pre-exposure prophylaxis (PrEP) for HIV prevention has been known for over five years, but "we are still waiting for the NHS to embrace this potentially revolutionary intervention," explains Gold.

NHS England undertook a lengthy process to decide whether to commission the treatment, but after 18 months it announced that the specialised commissioning process was inappropriate for PrEP because it is a preventative intervention.

A legal argument put forward by the National Aids Turst (NAT) was rejected and NHS England reconfirmed its decision last month.

"Faced with this impasse, NAT has no choice but to take the matter before a court for judicial review," says Gold. "The public interest in resolving this is too great to ignore it."

Continued delays make NHS England appear discriminatory, she argues, especially towards men who have sex with men and people from black African communities who are at highest risk of HIV.

She continues: "NHS England's vacillating has thrown into stark relief a health system that is not designed to come to timely and confident decisions about nationally important preventive interventions, for all the talk we hear of prevention being the new health priority."

"PrEP highlights the lack of system-wide accountability. This is a health system failing to look at the bigger picture, with decision making dangerously fractured and with no one providing clear direction and leadership."

And even if the treatment is commissioned nationally by NHS England, the sexual health clinic service to prescribe and monitor PrEP would have to be separately commissioned by each local authority.

"Does it make sense for the prevention of infectious disease to be delegated to 150 local bodies, without any national strategic direction," asks Gold.

In November 2010, the iPrEX trial found efficacy of 92% among those who took PrEP.

The US Food and Drug Administration licensed Truvada for use as PrEP in 2012, and in 2014 the Centers for Disease Control and Prevention recommended PrEP for those at high risk of HIV infection.

Other countries such as France are now following suit. "In England, however, progress to issue PrEP is painfully slow," warns Gold.

"While we delay, 17 people a day are being diagnosed as having HIV," she explains, adding that the number of newly diagnosed individuals unchanged in the UK for the last decade.