Could PrEP turn the tide on HIV?

Chris Smith spoke to Sheena MacCormack and Laura Waters about how the NHS was justifying the cost of the drug, and whether PrEP might turn the tide on HIV.

Sheena - That, of course, is something the NHS looks at very closely with any new drugs that are being introduced and, actually, the cost effectiveness of PrEP is really clear in the long term - the usual economic time line of 80 years. But, inevitably, the NHS is pretty concerned about their budget in the short and medium term and what might have to be sacrificed to pay for anything new.

So the models that the NHS reviewed, the cost effectiveness models of PrEP, suggested the only way that the NHS could be really confident of PrEP being cost effective in the short term was if the price was reduced from its current list price, which is pretty high, because Truvada at the moment, of course, remains branded. But that branding will end shortly, we believe, and then there will be several versions of Truvada made by generic manufacturers. There will be competition and the price should be coming down.

Chris - Why is the NHS funding this at all? When we were researching this programme a number of people put it to us they were unwilling to come and talk about it for reasons known best to them. But they were saying why is the NHS funding this at all - what’s the justification? One person said “well, if I had a drinking hobby I wouldn’t expect the NHS to pay for me to have a taxi home to prevent me from drink-driving and potentially placing myself and others at risk. So why do we pay for this form of personal recreation and not another?”

Sheena - The NHS makes decisions very carefully on two characteristics: clinical effectiveness and cost-effectiveness. We’ve shown this drug is incredibly effective at preventing HIV, which is an extremely expensive infection to manage because it’s a tablet a day, or more, for a lifetime and potential complications through ageing with HIV that we perhaps haven’t fully anticipated yet. But HIV is very costly for the NHS so, obviously, if you can save HIV infection it makes sense.

And, as I mentioned before, PrEP is something that people would take for a short period to support them through behaviour change, just in the same way that that we support people that have alcohol dependency or drug dependency. We support them with talking therapy or other means through their behaviour change. That seems entirely appropriate. But the decisions are made on clinical effectiveness and cost effectiveness. It’s actually just as simple as that.

Chris - Looking beyond the shores of our own country for a minute. This is a global problem and the bulk of the problem sits in Africa. Therefore, situations like we have here and solutions like we’re looking at here probably are beyond the reach of those people?

Sheena - Well, you’d think so but, actually, PrEP is being rolled out in Kenya and South Africa, so there are PrEP programmes. In some cases they’re targeted at particular populations where the rates of HIV are extremely high and in others it’s a little bit more generalised, and you’re trying to take advantage of people’s motivation to help to help themselves. Whether that’s to come and get tested for HIV and to go onto treatment or to prevent themselves, as I say, during a risky period of their life.

Chris - Indeed. And Laura our last thoughts from you…

Laura - I think that PrEP, combined with other strategies, we really do have the opportunity now and I really do think that the figures that we’ve described in London, we’ve got the opportunity to really turn this around and eradicate new HIV in places like the UK. And I think the people who criticise PrEP who are concerned that why should we support people’s bad behaviour, there are many, many conditions that the NHS spends millions of pounds on that are driven by behavioural choices that others may not think the best, and Sheena has mentioned them: smoking, and drug use, and alcohol etc. And I think the days we start rationing or limiting people’s access to really effective prevention and effective treatment based on the behaviour they’ve taken part in is a really dangerous and slippery slope. So it works, HIV infections were going up and they seem to be coming down, and we should have access to PrEP on the NHS, without a doubt.