NHS England has just been instructed that it is their legal duty to offer pre-exposure prophylaxis(PrEP) against HIV, to high-risk individuals, free at point of care. Media outlets left, right, and centre have come out in support of this: The Daily Mail called it an ‘HIV wonder drug’; Owen Jones wrote in the Guardian that the High Court’s decision shows that “gay lives matter”.
Indeed: gay lives do matter — so do all lives — but that is not what the decision shows, and a reversal of the decision would not imply the opposite, that gay lives do not matter (for a start, of the 103,700 with those in the condition in the UK, 52% were infected by heterosexual sex). The NHS plans to appeal the decision; its original argument against considering the drug — Truvada — for the specialised services annual prioritisation programme, was that it did not have the legal power to commission PrEP: local authorities are responsible for HIV prevention services. Moreover, the NHS feared that they risked a legal challenge from proponents of other ‘candidate’ treatments that might be displaced by PrEP. Perhaps they are right to: nine new treatments that the NHS had planned to make available have been suspended pending the outcome of this appeal. For the cost of Truvada would be considerable, depending on the parameters of the group deemed at high-risk, it could be from £10-20 million a year — £400 per month for each individual, plus the costs of prescription and monitoring. The final cost could be much higher if HIV drug-users and/or HIV positive heterosexual couples who want to reproduce were found to qualify.
The NHS is already too large — the 2016/17 budget for NHS England is £116.4 billion; part of the problem is the widening scope for healthcare. Founded in 1949 with the mandate to prevent, diagnose and treat illness, the NHS has always exceeded the its financial provisions; 1952 saw the introduction of prescription charges to limit this. But the problem has grown worse: at its inception in 1949, the NHS had declined to provide a simple circumcision due both to the cost and the non-therapeutic nature of the operation; in 2016, there are many more advanced (and more expensive) options for treatment; expected standards of living and care are higher; definitions of illness are more fluid. The NHS now pays for certain types of breast augmentation, cosmetic surgery, and gender reassignment. Although prophylaxis against HPV, another sexually-transmitted disease, is already available, it is cheap by comparison — around 0.01% of a ten year course of PrEP — and also assures lifelong protection. Providing Truveda, a much more resource-intensive prophylaxis — that involves providing continuous treatment and monitoring — would act as a precedent for future expansion, another landmark on a paradigm shift from gratitude for basic care to a sense of entitlement to the best available. The NHS are to fear challenges from individuals requiring specialist cancer or arthritis care — those challenges will be built on sound arguments.
Questions regarding the NHS’ mandate aside, what is most important for the time being is whether the treatment actually works — whether it prevents cases of HIV and in so doing saves the NHS money on treatment. The Independent is quite right in saying: “when taken consistently, [PrEP] has been shown to reduce the risk of infection in people who are at high risk by more than 90 per cent”. But in base-case scenarios this is much reduced — relative risk reduction with expected adherence to PrEP is 0.44, cutting the annual probability of HIV acquisition to 0.02. In this case, to prevent a single HIV infection, the NHS would have to treat 64 people. Where condoms are used, this number grows to 212 — estimated by a 2014 U.S. study to be a cost of $840,000 per additional quality-adjusted life year (QALY). NICE's official threshold for a QALY is between £20,000 and £30,000 (though even this has been criticised by new research that finds that spending over £13,000 per QALY does more harm than good to NHS services as a whole). One has to ask why all those at a high-risk of HIV are not using condoms already: even with standard PrEP adherence their risk factor is four times greater than a condom-user who has never taken the drug.
Proponents of PrEP argue in its favour that its adoption rate may be greater than that of condoms, due to the fact that it does not inhibit pleasure, and is taken in advance of any other inhibition-lowering activities that might cause men to eschew condoms. However, most who trialled PrEP did not strictly adhere to it, resulting in the aforesaid reduction in efficacy from 0.92 to 0.44. Yet even basic adherence to the drug eased participants’ risk perception to the extent that they were actually more tempted to neglect condoms. In this scenario, PrEP is seen as an alternative to condoms — even if its usage is greater than condoms its efficacy will remain lower, and, more worryingly, condom usage will be discouraged. Thus, PrEP gives a false sense of security to those who are potentially most at risk of being infected, as shown by a 2010 study on PrEP and predicted condom use among high risk men who have sex with men, of whom over 35% reported that they would be likely to decrease condom use while using the drug. Further, the composition of the 35% defy basic intuition: they were more likely to be college educated, more likely to earn over $50,000 a year, and less likely to be substance dependent. They also scored higher on tests measuring both arousal barriers and risk perception motivations for condom use. Among this large minority of people then, taking PrEP may actuallyincrease the risk of acquiring HIV, as those who care the most for safety have their fears eased relatively the most by the promise of PrEP — a less effective prophylactic displaces a more effective (and vastly cheaper) one. Of course, this also greatly increases the risk of acquiring other STDs such as hepatitis B, hepatitis B, hepatitis D, chlamydia, gonorrhoea, and syphilis.
The elephant in the room where this debate is held, is rationing of health care. We recoil from the admission that we cannot afford to provide everything possible for everyone for free. Yet finite resources can only fund finite provision, and the closer to being a gratis a service is, the more gratuitous its use will become, spiralling inevitably into inefficiency and bureaucratic excrescence. Can we prioritise a treatment which is so expensive, has relatively poor compliance rates, and which will probably serve to increase the incidence of a range of other serious conditions which will require further expensive management? Unfortunately, it seems that political motives and emotional appeal rank higher than do pragmatic QALY standards. However mechanical and inhuman these standards may seem, setting them intelligently —and adhering to them strictly — is essential to safeguarding the longterm viability of a free NHS.