Skip to main content

Main menu

  • HOME
  • ONLINE FIRST
  • CURRENT ISSUE
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • SUBSCRIBE
  • BJGP LIFE
  • MORE
    • About BJGP
    • Conference
    • Advertising
    • eLetters
    • Alerts
    • Video
    • Audio
    • Librarian information
    • Resilience
    • COVID-19 Clinical Solutions
  • RCGP
    • BJGP for RCGP members
    • BJGP Open
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers

User menu

  • Subscriptions
  • Alerts
  • Log in

Search

  • Advanced search
British Journal of General Practice
Intended for Healthcare Professionals
  • RCGP
    • BJGP for RCGP members
    • BJGP Open
    • RCGP eLearning
    • InnovAIT Journal
    • Jobs and careers
  • Subscriptions
  • Alerts
  • Log in
  • Follow bjgp on Twitter
  • Visit bjgp on Facebook
  • Blog
  • Listen to BJGP podcast
  • Subscribe BJGP on YouTube
Intended for Healthcare Professionals
British Journal of General Practice

Advanced Search

  • HOME
  • ONLINE FIRST
  • CURRENT ISSUE
  • ALL ISSUES
  • AUTHORS & REVIEWERS
  • SUBSCRIBE
  • BJGP LIFE
  • MORE
    • About BJGP
    • Conference
    • Advertising
    • eLetters
    • Alerts
    • Video
    • Audio
    • Librarian information
    • Resilience
    • COVID-19 Clinical Solutions
Debate & Analysis

HIV pre-exposure prophylaxis: the primary care implications of prescribing restrictions

Ryan Wereski
British Journal of General Practice 2017; 67 (660): 324-325. DOI: https://doi.org/10.3399/bjgp17X691541
Ryan Wereski
University of Glasgow, Glasgow.
Roles: Honorary Clinical Fellow
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info
  • eLetters
  • PDF
Loading

With a recent (2/8/16) high-profile court ruling backing funding for pre-exposure prophylaxis (PrEP) for HIV prevention, what is PrEP, why is it so controversial, and why should every clinician be advocating for this blockbuster drug?

HIV IN THE UK IN 2017

The public health impact of HIV in the UK is immense. Record numbers of people are now living with the virus and over 4000 new cases are identified each year.1 With recent studies estimating lifetime treatment costs to be over £360 000 per person, each new HIV diagnosis only adds further to this already immense, yet preventable, burden in our over-stretched health system.2

Men who have sex with men (MSM) are at the highest risk for HIV acquisition in the UK. Of the 4155 new diagnoses, over 81% were MSM, translating to a staggering 1 in every 20 MSM males aged 15–44 years having HIV, rising even further to 1 in every 11 in London.1

Although Public Health England (PHE) has invested significantly to curtail this epidemic, we are still seeing a rise in both incidence numbers and rates year on year. Why is this, and can more be done? Could PrEP be the magic bullet at our fingertips?

WHAT IS PrEP?

PrEP is a novel way of using antiretroviral medication (ARV) in people who are HIV negative to avoid contracting HIV. Multiple studies have confirmed its efficacy in reducing HIV acquisition in MSM,3 heterosexual couples (where one partner is HIV positive),4 and in people who inject drugs (PWID),5 all of whom are high-risk patients we encounter in our daily practices.

It was in 2015 that the UK-based Pragmatic Open-Label Randomised Trial of Pre-exposure Prophylaxis (PROUD) study gave a platform to PrEP by showing how it would work within the UK and the NHS. The study showed a staggering 86% reduction in HIV incidence when on PrEP as well as finding the number needed to treat with PrEP to avoid one HIV infection was only 13.6

Although this study’s results mirrored other international research in the US and beyond, PROUD specifically showed how PrEP could easily be used to specifically benefit UK-based patients.7 This finding is astonishing when, more than 18 months after data were published, PrEP is yet to be approved in the UK.

WORLDWIDE UPTAKE OF PrEP

Worldwide, the reception to PrEP has been overwhelmingly positive. International bodies such as the World Health Organization (WHO) and UNAIDS now advocate its use as a core and essential part of HIV prevention strategies. A recent Lancet study has even suggested that PrEP could be the most powerful intervention to prevent HIV, independent from every other measure we use.8 The US has over 25 000 individuals now taking PrEP since approval in 2012,9 while in France it’s been available since January 2016 with good uptake rates.10 Several other countries in South America and Asia are also preparing to license this medication for use over the next 12 months (Figure 1).

Figure 1.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 1.

Timeline of PrEP around the world.

CONTROVERSY SURROUNDING PrEP

Despite a garrison of study evidence supporting PrEP, as well as international community approval, here in the UK scepticism towards PrEP is still rife. What are these myths and do they have a grain of truth?

‘PrEP will increase risky sexual behaviour’

Repeated studies show that PrEP does not increase risky sexual behaviours or undermine other safe sexual practices, such as condom use. The landmark PROUD study showed that MSM were no more likely to develop other bacterial sexually transmitted infections (STIs) (an ideal marker for risky sexual behaviour) when on PrEP. Reported condom use when on PrEP compared with when not was also equal.6 Similar results have even been shown in heterosexual couples.4

‘There are many drug side effects’

Although some people may experience short-term nausea and headaches after starting treatment, many large studies have shown no serious toxicity from the medication. Furthermore, and really quite essential in both the high-risk MSM and PWID groups, PrEP does not interact with alcohol or other drugs including methadone and buprenorphine, nor does it alter the effectiveness of the oral contraceptive pill.

‘HIV resistance will develop’

Concerns have been raised that resistance could develop in people taking PrEP if breakthrough infections occurred. Although some data do suggest that resistance could develop if PrEP was started during the period between acquiring HIV and detectable virus (seroconversion), a rational approach must be taken.11 For example, the 2015 Partners PrEP Study found that, for every drug-resistant infection caused, 25 new HIV infections were prevented in the first place.11

Furthermore, with WHO guidelines advocating routine HIV testing not only before starting PrEP but also every 3 months, such resistant infections should be minimised.

‘PrEP is not cost-effective’

Cost-effectiveness drives the 21st-century NHS. Indeed it is expenditure that lies at the heart of the controversial delays for PrEP approval in the UK. Despite much argument to the contrary, evidence-based data have shown that, for those at highest risk of infection, generic PrEP reduces both immediate and long-term costs to the NHS.12 Currently, lifetime HIV treatment costs over £360 000 per person, but for only £43 per month a person can buy generic PrEP from abroad.2,13 With UK patent expiration in 2017, similar affordable generic versions should soon be available to our own patients.

NHS AND THE PrEP SAGA

So the evidence is clear — PrEP works. Even NHS England and PHE have backed its use. So why, if we all agree, are we not seeing our at-risk patients being protected from HIV here in the UK? In essence, cost and responsibility distribution are the issues.

Beginning in spring 2016, NHS England manipulated a legislative loophole in the Local Authority Regulations Act, stating that local authorities, not the NHS, were responsible for the ‘commissioning of HIV prevention services’. The National Aids Trust, like many others, argued that this stance was bizarre and frankly incongruent when the NHS actually does fund HIV prevention measures (post-exposure prophylaxis and mother-to-child transmission, for example).

It was not until a High Court ruling in August 2016 year that the tables were turned in favour of PrEP again. The ruling by Mr Justice Green argued that NHS bosses ‘had erred in deciding’ it was not their responsibility and ‘commissioning of PrEP is within the power of NHS England’ under current legislation already.

NHS England subsequently appealed against this ruling, followed by the announcement that they would indeed fund PrEP but irritatingly only in ‘trial settings’.

While further data are amassed, sorted, analysed, reported, published, and criticised further, we are forced to sit and simply allow vulnerable patients to face unnecessary harm.

IMPLICATIONS FOR GPs

GPs are the true bastions of public health, acting as the mortar between government targets, scientific research, everyday clinical practice, and patient needs. Free condoms, routine STI checks, hepatitis A vaccinations, and counselling are already part of our comprehensive HIV prevention strategies in primary care. As knowledge of PrEP becomes more widespread, however, where does this leave GPs?

For patients who are requesting PrEP, it is not licensed for prevention outside clinical trials and so cannot be prescribed on the NHS. For those who can afford it, however, private clinics are offering treatment for £400/month, which is most likely out of reach for our most vulnerable patients, who would reap the most benefit from this medication.

Second, many people in the UK are already buying PreP online and multiple campaign group websites have dedicated support pages to sourcing it legally from outside the UK. For those patients who are already buying online, do we have a responsibility for monitoring them?

From a solely medical view, guidelines from the US suggest these patients require an HIV test prior to commencing PrEP and quarterly follow-up. Aside from this, however, we should also be aware of the psychological issues associated with PrEP, with much higher rates of HIV breakthrough infections reported in MSM aged 18–22.13

Although more research is clearly required on PrEP prescribing and monitoring, as well as comprehensive guidelines for primary care, what are we expected to do in the meantime for these young, sexually active men who have online access to PrEP? We cannot continue to bury our heads in the sand.

CONCLUSION

A shift to online dating apps has moved the once more restricted onto the open internet. The combination of this with increasing rates of HIV brings a wave of new risks, and sadly, new HIV infections. As clinicians we must be able to keep pace with this and not engulf ourselves in a mountain of more data.

PrEP forms only one part of our defence. Nobody is suggesting anything else. Shown to be both a cost-effective and powerful drug, it could be the strongest single intervention that we use to stop the spread of HIV in the UK.

For a virus first identified just over 32 years ago we have made huge scientific advancements in both detection and treatment, saving thousands of lives in the process. Until now the last hurdle was prevention. Let us not fall behind the rest of the world in controlling the spread of this devastating virus. The roll-out of PrEP across the UK will go a long way in achieving control of HIV. Further delays will only cost lives.

Notes

Provenance

Commissioned; externally peer reviewed.

Competing interests

The author has declared no competing interests.

  • © British Journal of General Practice 2017

REFERENCES

  1. 1.↵
    1. Skingsley A,
    2. Yin Z,
    3. Kirwan P,
    4. et al.
    HIV in the UK — situation report 2015 Incidence, prevalence and prevention, https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/477702/HIV_in_the_UK_2015_report.pdf (accessed 5 Jun 2017).
  2. 2.↵
    1. Nakagawa F,
    2. Miners A,
    3. Smith C,
    4. et al.
    (2015) Projected lifetime healthcare costs associated with HIV infection. PLoS One 10(4):e0125018.
    OpenUrlCrossRefPubMed
  3. 3.↵
    1. Anderson PL,
    2. Glidden DV,
    3. Liu A,
    4. et al.
    (2012) Emtricitabine-tenofovir concentrations and pre-exposure prophylaxis efficacy in men who have sex with men. Sci Transl Med 4(151):151ra125.
    OpenUrlAbstract/FREE Full Text
  4. 4.↵
    1. Baeten JM,
    2. Donnell D,
    3. Ndase NR,
    4. et al.
    (2012) Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med 367(5):399–410.
    OpenUrlCrossRefPubMed
  5. 5.↵
    1. Centers for Disease Control and Prevention
    (2013) Update to interim guidance for preexposure prophylaxis (PrEP) for the prevention of HIV infection: PrEP for injecting drug users, http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6223a2.htm?s_cid=mm6223a2_w (accessed 15 May 2017).
  6. 6.↵
    1. McCormack S,
    2. Dunn DT,
    3. Desai M,
    4. et al.
    (2016) Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): effectiveness results from the pilot phase of a pragmatic open-label randomised trial. Lancet 387(10013):53–60.
    OpenUrlCrossRefPubMed
  7. 7.↵
    1. IPERGAY
    , http://www.ipergay.fr (accessed 15 May 2017).
  8. 8.↵
    1. Punyacharoensin N,
    2. Edmunds WJ,
    3. De Angelis D,
    4. et al.
    (2016) Effect of pre-exposure prophylaxis and combination HIV prevention for men who have sex with men in the UK: a mathematical modelling study. Lancet HIV 3(2):e94–e104.
    OpenUrl
  9. 9.↵
    1. International Association of Providers of AIDS Care
    (2015) Dissemination of PrEP Innovations. http://www.iapac.org/ (accessed 31 May 2017).
  10. 10.↵
    1. Molina JM
    (2016) in AIDS Conference PrEP Roll-out in France, http://programme.aids2016.org/PAGMaterial/PPT/5839_3168/PrEP%20Roll%20Out%20France.ppt (accessed 31 May 2017).
  11. 11.↵
    1. Lehman DA,
    2. Baeten JM,
    3. McCoy CO,
    4. et al.
    (2015) Risk of drug resistance among persons acquiring HIV within a randomized clinical trial of single- or dual-agent preexposure prophylaxis. J Infect Dis 211(8):1211–1218.
    OpenUrlCrossRefPubMed
  12. 12.↵
    1. Cambiano V,
    2. Miners A,
    3. Dunn D,
    4. et al.
    (2015) Is pre-exposure prophylaxis for HIV prevention cost-effective in men who have sex with men who engage in condomless sex in the UK? Sex Transm Infect 91:A1.
    OpenUrlAbstract/FREE Full Text
  13. 13.↵
    1. Hosek S,
    2. Rudy B,
    3. Lanovitz R,
    4. et al.
    (2015) ATN 110: An HIV PrEP demonstration project and phase II safety study for young men who have sex with men in the United States, http://cdn.hivguidelines.org/wp-content/uploads/20160825081052/Bill.Kapogiannis.AdolescentForum.11.18.151.pdf (accessed 15 May 2017).
Back to top
Previous ArticleNext Article

In this issue

British Journal of General Practice: 67 (660)
British Journal of General Practice
Vol. 67, Issue 660
July 2017
  • Table of Contents
  • Index by author
Download PDF
Download PowerPoint
Email Article

Thank you for recommending British Journal of General Practice.

NOTE: We only request your email address so that the person to whom you are recommending the page knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
HIV pre-exposure prophylaxis: the primary care implications of prescribing restrictions
(Your Name) has forwarded a page to you from British Journal of General Practice
(Your Name) thought you would like to see this page from British Journal of General Practice.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
HIV pre-exposure prophylaxis: the primary care implications of prescribing restrictions
Ryan Wereski
British Journal of General Practice 2017; 67 (660): 324-325. DOI: 10.3399/bjgp17X691541

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
HIV pre-exposure prophylaxis: the primary care implications of prescribing restrictions
Ryan Wereski
British Journal of General Practice 2017; 67 (660): 324-325. DOI: 10.3399/bjgp17X691541
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One
  • Mendeley logo Mendeley

Jump to section

  • Top
  • Article
    • HIV IN THE UK IN 2017
    • WHAT IS PrEP?
    • WORLDWIDE UPTAKE OF PrEP
    • CONTROVERSY SURROUNDING PrEP
    • NHS AND THE PrEP SAGA
    • IMPLICATIONS FOR GPs
    • CONCLUSION
    • Notes
    • REFERENCES
  • Figures & Data
  • Info
  • eLetters
  • PDF

More in this TOC Section

  • SAFER diagnosis: a teaching system to help reduce diagnostic errors in primary care
  • An Australian reflects on the Collings report 70 years on
  • GP home visits: essential patient care or disposable relic?
Show more Debate & Analysis

Related Articles

Cited By...

Intended for Healthcare Professionals

BJGP Life

BJGP Open

 

Tweets by @BJGPjournal

 
 

British Journal of General Practice

NAVIGATE

  • Home
  • Current Issue
  • All Issues
  • Online First
  • Authors & reviewers

RCGP

  • BJGP for RCGP members
  • BJGP Open
  • RCGP eLearning
  • InnovAiT Journal
  • Jobs and careers

MY ACCOUNT

  • RCGP members' login
  • Subscriber login
  • Activate subscription
  • Terms and conditions

NEWS AND UPDATES

  • About BJGP
  • Alerts
  • RSS feeds
  • Facebook
  • Twitter

AUTHORS & REVIEWERS

  • Submit an article
  • Writing for BJGP: research
  • Writing for BJGP: other sections
  • BJGP editorial process & policies
  • BJGP ethical guidelines
  • Peer review for BJGP

CUSTOMER SERVICES

  • Advertising
  • Contact subscription agent
  • Copyright
  • Librarian information

CONTRIBUTE

  • BJGP Life
  • eLetters
  • Feedback

CONTACT US

BJGP Journal Office
RCGP
30 Euston Square
London NW1 2FB
Tel: +44 (0)20 3188 7400
Email: journal@rcgp.org.uk

British Journal of General Practice is an editorially-independent publication of the Royal College of General Practitioners
© 2023 British Journal of General Practice

Print ISSN: 0960-1643
Online ISSN: 1478-5242