The power of PrEP
pharmafile | August 8, 2016 | Feature | Manufacturing and Production, Medical Communications, Research and Development, Sales and Marketing | NHS, PrEP, high court, lifestyle drug
Many among the general public may not have heard about PrEP, or pre-exposure prophylaxis, before last week when a high court judge ruled that the NHS can fund the treatment for those at highest risk of contracting HIV.
Put simply, PrEP is a course of treatment that can prevent the contraction of HIV infection in men and women alike. The most well-known, and efficacious, of these treatments is Gilead’s Truvada (tenofovir disopoxil/emtricitabine). In a range of clinical trials, Truvada has been shown to reduce the risk of contracting HIV in high risk groups, such as gay men, by as much as 99% if taken daily. In a study published last year in the New England Journal of Medicine, PrEP reduced the risk by 86% when taking a median of 15 pills per month.
So, it reduces the risk of developing a disease that barely a generation ago had such a devastating effect on whole communities before effective treatments became available. The problem of AIDS certainly hasn’t gone away and, while HIV is now a treatable infection, any measure to reduce the risk sounds like it would be most certainly welcomed. In the case of PrEP, however, that has not been the case.
Rather unsurprisingly, right-wing media and religious groups were quick to condemn the UK’s court ruling on the matter but, perhaps more surprisingly, some AIDS activists have been vehement opponents of Truvada in the past
Early opponents
In the US, Truvada was approved several years ago but initial uptake was quite slow, despite the clear evidence of its efficacy in reducing the risk of infection (Bloomberg ran an article in 2015 titled “Gilead’s pill can stop HIV. So why does almost nobody take it?”). This was due to a perceived fear that it worked so well that it would mean that condom use would fall, risking the development of other sexually transmitted diseases.
Christopher Glazek, writing in The New Yorker, sums up initial reaction to PrEP in the US quite well. He says: “Regan Hofmann, the former editor-in-chief of Poz, a magazine for people living with AIDS, called PrEP a “profit-driven sex toy for rich Westerners.” Michael Weinstein, the head of the AIDS Healthcare Foundation (A.H.F.), the world’s largest AIDS organization and the primary-care provider for more than two hundred thousand patients around the world, predicted a public-health catastrophe; Out magazine provoked a backlash when it printed a positive report on PrEP in early September, called “Is This the New Condom?” Commenters berated the author, Tim Murphy, and accused the magazine of irresponsibly promoting an unproven medicine at the expense of condoms.”
Fears emerged that Truvada would lead to reckless sexual promiscuity but these initial theories have thankfully been debunked by several recent studies. Gladstone Institutes’ Dr Robert Grant writes: “Our results suggest that HIV prevention strategies such as Truvada don’t result in risk compensation because they provide an opportunity for participants to actively engage in and reduce the risk of HIV infection.”
As with all risks, education is key. But, due to the sheer effectiveness of PrEP, it makes a compelling case to be made available on a wide basis.
Tired arguments
When the news hit the morning papers the following day, the reaction wasn’t overly positive. In quite typical fashion, the Daily Mail did a Daily Mail by labelling it a “lifestyle drug” and lamented the expensive cost of the drug which could be used elsewhere on the NHS, calling it a “skewed sense of values”. They set off in search for the moral high ground with the subtext of rebuking gay men for their “choice” of “lifestyle”, quoting Conservative MP Philip Davies (“You’ve got to wonder what reaction you’d get if you looked a cancer patient in the eye to explain you haven’t been able to fund their treatment because you’ve prioritised other treatments”) and Christian Medical Fellowship chief executive Dr Peter Saunders (“Making PrEP freely available to already promiscuous homosexuals could well encourage more sexual risk taking”).
While these arguments may seem old and tired, they embody a narrative that has fuelled much of the public discourse around the NHS in recent times. It’s usually the story of “Why are we funding treatments for these insert-minority-here when that money could help elsewhere?” The NHS itself embodied this in its recent statement, saying that funding PrEP may lead to less funding for other treatments. The statement says: “Given the ruling, NHS England cannot confirm funding for those treatments and services in levels three and four.” Again, the subtext is clear. This would, without actually naming specific conditions, refer to rare conditions such as cystic fibrosis. Funding PrEP will be a drain on public health spending. Deborah Gold, chief executive of the National Aids Trust, called the statement “deeply unhelpful”.
With the NHS appealing the high court ruling, PrEP may face a long battle to make it onto national health programs in England.
The road ahead
While so many can benefit, much of the debate has centred on the behaviour of one of HIV’s highest risks groups: gay men. Instead of focusing on the behaviours of a certain group, the emphasis of the debate should lie on a drug that has been shown to be highly effective and can prevent a disease which has killed almost 40 million people worldwide since it came to prominence in the 1980’s. It affects gay men disproportionally compared to other demographics, but to label PrEP as the solution to a certain lifestyle choice is inherently wrong.
Truvada has been and will continue to be lucrative for Gilead, with sales of $1.8 billion worldwide for the first half of 2016. The issue of cost and access are the debates that need to be happening now, not the rights and wrongs of the treatment itself. When a new, efficacious cancer drug is approved, cost and access are the main topics of conversation. With PrEP, it is the victim of the social and cultural baggage that comes with it. The high court ruling is a landmark step in the right direction. But a lot more remains to be done.
Sean Murray
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