Preparing for PrEP; the cost of delaying universal access in England

Abstract

ObjectivesPre-exposure prophylaxis (PrEP) is not commissioned within National Health Service (NHS) England. Individuals can access it privately online or by enrolment into a clinical trial. We established a list of individuals not enrolled in trials, awaiting PrEP. In response to the observation that patients awaiting PrEP trials were being referred with newly diagnosed HIV, we aimed to measure attendance, incident HIV, STI acquisition and missed opportunities for prevention.MethodsThe search was conducted for patients on the list from November 2017 to November 2019. We examined the electronic clinical records of those on the list and extracted demographic information, STI and HIV diagnoses. In addition, for those diagnosed with HIV, we reviewed risk factors including chemsex and prior postexposure prophylaxis.ResultsThere were 1073 patients on list, and 520 (48.6%) were still awaiting recruitment in a PrEP trial. Eight (0.75%) had an enrolment appointment booked while 200 (18.64%) had been contacted and deemed ineligible according to PrEP trial criteria. 45 (32.15%) had not responded to contact. We identified 15 new HIV infections in patients awaiting PrEP. Of these, 9/15 (60.00%) did not meet eligibility criteria at point of contact, though had been eligible at first referral.ConclusionIt is unacceptable that 15 patients acquired HIV while waiting. The individual lifetime cost of treating HIV is estimated at £360 800(1). This equals £5 412 000 for these 15 infections notwithstanding the psychological and physical burden. We advocate the immediate role out of universal PrEP for those who need it on the NHS. While this decision is delayed, harm is coming to those waiting. Wider provision of PrEP may encourage increased attendance, but must consider additional resources to accommodate added visits. We are relieved that at the point of final submission (21 March 2020) NHS England have recently announced funding of PrEP for eligible patients from, further details are pending.

PrEP for women in Europe: a systematic literature review

“…Finally, 44 original studies represented in 45 peer‐reviewed articles were included. See Figure 1 [10–42] [43–53].…”

How do we measure unmet need within sexual and reproductive health? A systematic review

“… 40 A study in Papua New Guinea defined individuals who had fallen through gaps in the 90-90-90 cascade as having unmet need for HIV prevention or treatment. 41 The four studies investigating unmet need for PrEP all used different definitions: non-use of PrEP despite eligibility, 42 disparity between regional PrEP use and regional STI prevalence, 43 new HIV infection while waiting for inclusion in a PrEP trial, 44 and increased PrEP demand after reduction in the cost of PrEP. 45 …”