Richard Angell on bringing PrEP closer to communities

Commissioning services to deliver the HIV prevention drug PrEP has been in the hands of local councils since the Government first published details of the PrEP grant determination in September 2020.

In this month’s Sexual Health, Reproductive Health & HIV Policy ebulletin's eFeature, Richard Angell, Campaigns Director at Terrence Higgins Trust, looks at the story of PrEP to date, highlighting current inequalities in PrEP provision that need to be addressed and identifying key opportunities for councils to bring PrEP closer to communities through improved education and access.

The story of PrEP in the hands of national government has been a frustrating one. While health insurers in New York and California were rolling the HIV prevention drug out to gay and bisexual men in huge numbers, the NHS in the UK was reticent.

Scotland and Wales pioneered the way, while our friends at the National AIDS Trust had to take NHS England to court to get a change in policy. Westminster has now changed tack and is getting itself on the front foot. With PrEP availability in the hands of Directors of Public Health and commissioners, there is hope the next chapter will be about education and access.

Thankfully a 26,000 person trial in England has given way to a full national roll out of PrEP in sexual health services. Indications are that all but four clinics in England have processes in place to prescribe the HIV prevention drug for those who test HIV negative. This is welcome but insufficient.

In particular, the inequalities in the trial are yet to be addressed. All but 4% of the PrEP Impact Trial were gay and bisexual men. Of the 17,962 people recruited in the first two (of three) years of the trial, only 44 were heterosexual Black African cis people. This is despite the fact we are still diagnosing over 500 Black African women and men each year. While late diagnosis is worse among this population group there are still numerous new transmissions. The reality is many could have been stopped by awareness and availability of PrEP.

Funding for PrEP in the Public Health Grant has gone from £11.2m for year one to £23m for year two. This must be spent on two important improvements to provision.

Firstly, some of that money should be going to raising awareness of PrEP among groups where knowledge is low but the potential is high. To this end Terrence Higgins Trust (THT), as part of HIV Prevention England, is running its ‘PrEP Protects’ campaign, which has been optimised for a Black African audience. Raising awareness of the opportunities of PrEP among these groups is key to reducing new HIV cases. Local commissioners in Hampshire and Brighton are leading the way on this with great impact and important outcomes. This must be a priority for commissioners of public health nationwide.

In the same vein, something has to be done on the awareness among women, especially those who struggle to negotiate condom use or want to stay HIV free while trying for a baby. The benefits could be life changing for the women concerned and increase the chances of ending new cases by 2030. Antenatal services are leading the way with opt-out HIV testing – checking for HIV in 99% of pregnant women and birthing parents. Could midwives and health workers add PrEP to their repertoire?

Secondly, while there is a need to improve knowledge around PrEP, putting its provision out of the way only exacerbates the problem. PrEP has to become available in sexual health services AND primary care, especially GPs and pharmacies.

Only making the drug available from sexual health services is a serious part of the problem. The services are almost exclusively urban, cutting off swathes of the country from meaningful access. While the reception on arrival is warm and professional, with exceptional care during your appointment, GUM clinics are often the ‘dirty secret’ of the hospital estate – at the back, round the corner and through the hidden door. I jest, but only slightly. On many occasions I have been for a regular test, it has felt like I am doing something wrong by crossing that threshold. This has to change. But more importantly, these are services disproportionately not used by women, and women of colour, and when they are, these women are the least likely to be offered an HIV test and the most likely to decline one when offered. Until this changes, there is no chance PrEP is getting a look in.

So we have to get PrEP closer to communities. Commissioners could support an enhanced renal testing service in our GP surgeries and give GPs and pharmacists access to at-home HIV sample testing and the same NHS drugs fund so PrEP can be provided without attracting a prescription charge. Together this network could really get PrEP within touching distance of most people in the country.

This is the transformation PrEP, and HIV services, needs. At the moment, HIV is brilliantly supported in the health service by sexual health services and HIV clinics, which means some GPs and pharmacists consider it sorted ‘elsewhere’. At times, knowledge of the latest in HIV is poor, especially the U=U (undetectable = untransmittable) message that those on effective treatment can’t pass on the virus. Understandable under the current set up, maybe, but PrEP provides an ability to bring services closer to people and equip these key health professionals with the latest knowledge and the ability to fight HIV-related stigma.

An HIV test is essential before PrEP is started – often this is the first time someone has taken a test. Many commissioners have embraced at-home HIV sample testing through COVID-19. This is an important service development which needs to deliver for all. Since 2018, THT’s at-home self-testing service has offered a free Click and Collect option, with 4,000 collection points across the UK. This has been used by nearly 10% of those ordering, with high take up with Black African people (13%) and BAME men who have sex with men (13%). Click and Collect options should be integrated into the at-home testing services that are being commissioned by local public health. It is an improved service that improves equity.

Local commissioners have done a remarkable job rolling out PrEP since October 2020 – even more so considering the immediate issues they faced and continue to face due to COVID-19. They need to take this to another level and be led by our joint objectives: to end new cases of HIV by 2030 and the inequalities in PrEP provision that are currently very stark. As they embrace this opportunity, the frustration associated with PrEP access will transform into hope that this epidemic can be ended for all communities before the decade is out.

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Published in the August 2021 edition of the Sexual Health, Reproductive Health and HIV Policy eBulletin. The content of all eFeatures represents the views and opinions of the authors. FSRH and coalition partners do not necessarily share or endorse the views expressed within them.