Access to PrEP is uneven and problematic, and not just in the United States. Although health care in the United Kingdom is administered under a socialized system known as the National Health Service (NHS), PrEP is not currently covered in England. This omission has become the subject of ongoing debate.
By 2016, the 5,164 HIV diagnoses in gay and bisexual men living in England represented an 18% decline compared to the 6,286 diagnoses in 2015. With successful integration of pre-exposure prophylaxis (PrEP), HIV infections in England will continue to decrease.
Public Health England (PHE) reports that by combining prevention strategies of condom use, HIV testing, and PrEP optimization, HIV transmission could be eliminated. However, access to PrEP in England has been an ongoing debate recently and improved access is dependent upon sustained efforts from National Health Service England (NHS). From 2012–2014 PHE funded the Pre-exposure Option for Reducing HIV in the UK: Immediate or Deferred (known as PROUD) that enrolled 544 participants in an open-label randomized trial at 13 sexual health clinics throughout England. Participants were assigned to receive PrEP starting immediately at enrollment or after deferral of one year. Providing PrEP immediately was 86% effective in preventing HIV, which strongly supports the idea of adding PrEP to the standard of prevention care for those at risk. Despite these results, those most at risk remain unable to easily access this intervention in England.
NHS England has argued that it cannot legally commission PrEP because services that prevent the spread of HIV lie with local authorities. However, the High Court ruled that NHS England does have the legal power to commission PrEP. As a result, the HIV PrEP Impact Trial began as a new program within PHE and NHS England. In October 2017, the three-year trial aimed to enroll up to 10,000 participants who are interested in accessing PrEP. Two hundred level 3 GUM (genitourinary medicine) clinics are involved in the trial. The eligibility criteria for the trial includes the following: 16 years or older, cis- and transgender men who have sex with men (MSM), transgender women who are HIV negative and report sex without condoms in the past three months, HIV-negative partners of an HIV-positive person when the positive partner is not known to be virally suppressed and sex without condoms is anticipated, or heterosexual people at high risk.
In January 2018, more than 3,200 participants had enrolled across England. Will Nutland, founder of PrEPster, believes that placing cap numbers on clinics made it difficult for eligible people to enroll. Plus, individuals with the highest levels of HIV and PrEP literacy are usually the ones who seek access to the trial. Nutland also stated that he does not want to see the trial end because if it does, the NHS could stop distributing PrEP altogether. One of the most visited sexual health clinics in London, 56 Dean Street in the city’s Soho neighborhood, filled its allocation of 1,700 places in just weeks, and the Colchester Sexual Health clinic in East England also filled its allocation quickly.
Therefore, NHS England allotted additional spaces and sites that are in demand. As of June 2019, the trial expected to have recruited just over 13,000 participants. 147 clinics are open to recruitment, of which 109 clinics are open to MSM recruitment. While there are still many sites open for recruitment, the sites are not evenly distributed geographically across England. The distribution of clinics poses an issue for people at risk for HIV who may require long journeys to one of the openly recruiting clinics. For example, there are no sites in or around Cambridge recruiting MSM, and sites are not open yet outside Birmingham.
The Impact Trial was intended to answer questions about the use of PrEP in England, and ultimately its goal was to ensure that those who want to access PrEP are able to do so without difficulty. However, many of those who are at highest risk for contracting HIV are still not able to access PrEP due to the constraints of the trial.
Learn more about how to access PrEP in the U.K.: aidsmap.com/about-hiv/how-get-prep-uk.
Kimberly Levitt, BS, MPH, DHS(c) is a student at the Massachusetts College of Pharmacy and Health Science in the Doctor of Health Sciences program. She has experience in LGBTQ health, HIV education, and PrEP awareness in the U.S. and internationally.
Lindsay Tallon, BS, MSPH, PhD is an assistant professor of Public Health and Assistant Director of the MPH program at the Massachusetts College of Pharmacy and Health Science. She has experience in research focused on environmental health, specifically air pollution, water quality, and vascular health in older adults, and in public health practice.
Disparities here and abroad
The U.S saw a less substantial decrease in HIV diagnoses. According to Centers for Disease Control and Prevention (CDC), 26,570 gay and bisexual men were diagnosed with HIV in 2016, which represents only a 1% decline from the 26,950 diagnoses in 2015. Despite the decrease in diagnoses in both England and the U.S, accessibility to proper medication remains an issue in each country.
Findings suggest that there may be a correlation between access to PrEP and wealth distribution within the U.S. The CDC data shows that HIV diagnoses are not evenly distributed geographically. The South continues to have the leading rate of HIV diagnoses per 100, 000 people (16.8), followed by the Northeast (11.2), the West (10.2), and the Midwest (7.5). The South was not only reported to have the lowest median annual income, but over 50% of new HIV diagnoses occurred within the region, and only 30% of PrEP users reported to live there. —Julie Taddeo