A recent BMJ editorial condemns the NHS position that it will not consider PrEP for direct NHS funding. The decision was first communicated in an NHS statement issued in March, then confirmed by a review on 31st May, following reconsideration in response to objections raised by interested groups. This brought to an end an eighteen-month process of discussion between Department of Health, doctors and patients groups, Public Health England and other stakeholders. The NHS decision is currently under judicial review – which no doubt explains the timing of the BMJ editorial.
Advocates of PrEP argue that the NHS has powers under the Health and Social Care Act (2012) directly to commission services ‘prioritized for investment’, and that PrEP should qualify for consideration on this basis. But the conclusion of the NHS is that PrEP does not qualify to be so considered because the Local Authorities Regulations (2013) clearly stipulate that commissioning for sexual health prevention is legally the responsibility of local government.
Technically, then, the argument turns on whether the NHS can commission for PrEP directly, given that PrEP is a form of sexual health prevention. Needless to say, in the eyes of the advocates of PrEP, this is a mere technicality invoked by the NHS in order to shirk its responsibilities. The NHS statements also include the proposal to work with local government authorities on exploring how they should go about commissioning PrEP services most effectively, and to dedicate £2m to the establishment of local pilots. The problem here is that local authorities, having lately had £200m shaved off their funding for sexual health services, are presumably not in a hurry to pick up the tab.
So what about the case for PrEP? As regards effectiveness for high-risk MSM populations, PrEP has emerged with flying colours from recent trials, including the UK PROUD study (PrEP Highly Effective/STIs/blog; PROUD/STIs/blog) and trials with similar populations undertaken in France (IPERGAY) and California (Volk & Hare). Cost effectiveness, however, is another matter – and here PrEP has failed to make the grade. Recent studies have shown that in the UK PrEP is not even borderline cost-effective without substantial reductions in the cost of the drugs (Cambiano & Phillips/STIs; PrEP Highly Effective/STIs/blog; PrEP cost effectiveness study). And, of course, even cost-effectiveness is not the same as affordability. When it is borne in mind how much in the way of demonstrably very cost effective services have recently been rendered unaffordable by government cuts (Unprotected Nation/Report), the case for PrEP in the present climate does not look strong.