Let's talk about staying safe as we get closer together.
It’s not what you’re thinking- no social distancing or face masks involved...well maybe some! Whilst we’ve been distracted by measures to combat covid-19 progress has been made in tackling a different epidemic- HIV.
Daniel is an 18yr old man who has just registered with your practice following the start of university. He has booked an appointment to talk about his longstanding psoriasis. Whilst on the phone he also drops in a query about sexual health. He is enjoying the new found freedom of independent living and nightlife opening up again. He reports that he is bisexual and has an active sex life involving regular new partners. Often he uses a condom but frequently forgets when caught up in the moment. He has heard about a new drug that can be used to prevent HIV and wonders whether he could have a prescription?
What is he referring to and can you prescribe it?
PrEP (pre-exposure prophylaxis) is medication taken by those who are HIV negative before and after sex to reduce the risk of contracting HIV. This is different to PEP (post-exposure prophylaxis) which is taken AFTER a high risk exposure. There are different patterns of dosing depending on the type of sexual interaction. It can be used daily long-term as a regular prophylactic medication or just during periods of increased risk. The CDC report that when correctly taken PrEP reduces the risk of getting HIV from sex by an astonishing 99%.
Now you may be thinking that PrEP is old news. The WHO guidance was first issued in 2012. Trial data supporting its efficacy has been building for years. For example, PROUD, a key UK based RCT, was published in 2016. This study looked at 544 men who have sex with men. One arm of the study took PrEP immediately, the other after 12 months. Results showed an 86% reduction in the incidence of HIV in the immediate PrEP group. Number needed to treat: 13. The evidence supporting PrEP is strong and has been present for a while.
However, for many years it was not available through the NHS. Many campaigned for access. Voluntary groups emerged to support those at high risk of HIV to purchase PrEP privately through online pharmacies. It was largely only available to those who could afford it, and often without monitoring. Some were able to obtain it as trial participants e.g. IMPACT trial in London.
Finally, there is now free criteria based access for individuals at high risk of HIV on the NHS across the UK. NHS Scotland led the way in providing routine access in 2017. Wales and England followed suit at the end of 2020. In all of these areas, PrEP is provided through level 3 sexual health clinics. In Northern Ireland, all GUM clinics can provide an initial assessment but provision is through a small number of centres.
So, how can we advise Daniel? Patients presenting to primary care should be advised to contact a local sexual health service for assessment. The initial review will involve HIV testing to ensure that the patient does not already have the virus, kidney function and sexual health/blood-borne virus screening as appropriate to the individual circumstances. Once started on PrEP they will have 3 monthly reviews
Information about local access can be found via this helpful website: www.iwantprepnow.co.uk/prep-on-the-nhs/. Of note, the website also offers guidance on buying PrEP privately for those who do not meet NHS criteria.
Alone, this is not the magic bullet against HIV. It needs to be seen alongside other measures to reduce transmission and increase early diagnosis. However, it is a key new weapon in the arsenal that we should discuss with patients who may be at risk.