Just yesterday, in my capacity as an editor of Aidsmap.com, I wrote a report about people attending a clinic in Los Angeles and using HIV pre-exposure prophylaxis (PrEP) to protect themselves against HIV. It was hugely effective.
This was not a rigorous scientific study: we already know from those that PrEP works. It simply looked at ordinary people, most of them gay men but not all, getting PrEP at an ordinary clinic. These people took a daily blue pill that combines two anti-HIV drugs, tenofovir and emtricitabine.
When their HIV infection rate was compared with people who stopped taking it or had never started, it was clear that PrEP stopped 95% of infections. For every 20 people who would have caught HIV, 19 did not, thanks to PrEP.
There are now roughly a quarter of a million PrEP users in the US. Add in about 120,000 in Africa, where Kenya has spearheaded an extraordinarily ambitious PrEP programme, and you have most of the half-million or so people known to be taking it in the world.
We might need to put a million people on PrEP in the US, plus get the majority of those already with HIV on treatment, before HIV is stopped in its tracks and AIDS becomes a rare disease. There are many barriers: the cost to the inefficient US healthcare system is high; people fail to negotiate the complex insurance procedures needed; and, of course, because HIV especially targets those already disadvantaged – the homeless, the mentally ill, the imprisoned, the outcast youth – the people who need to take a daily pill may be the people least able to.
But at least the US has decided that PrEP is a public health measure of the very highest priority, and that its healthcare system must supply it.
Or, rather, the ones we know about. Because elsewhere in the world, including in much of Europe, PrEP remains a largely underground phenomenon. There may be as many people accessing PrEP on the “grey market” of internet sites globally as can get it from their doctor.
Yes, France, which was the second country in the world to offer PrEP through its healthcare system, now has about 13,000 people on PrEP. In the UK, only Scotland and Wales offer open access, but England has about 12,000 people on what’s still called a “trial”. In Germany there may be a similar number, accessing PrEP through community pharmacies.
But in many other countries PrEP programmes are only just getting off the ground, or PrEP via the healthcare system is unobtainable.
Take two examples: Poland and Malta. We choose these because they are both countries that, historically, have had low levels of HIV. In the European Union as a whole, we are slowly getting the better of HIV, and the annual rate of HIV diagnosis has gone down in the last four years by 6%.
But in Poland it’s risen by 17%, and in Malta by 18%.
The reasons for this are many, but the increases have mainly been among gay men and are a lot to do with new-found prosperity and the opportunities for mobility this allows: in Poland’s case, travel to the richer and higher-prevalence countries of western Europe; in Malta, a small country that’s also a financial hub, travel from those countries (Luxembourg has experienced the same).
But is PrEP obtainable through these countries’ national healthcare systems? No chance.
In Poland, about 1500 people are accessing PrEP though pharmacies, supported by a network of sympathetic clinics, and another 500 people are buying it online, completely unsupported.
What the clinics offer is regular testing for HIV, sexually transmitted infections and kidney function (PrEP can in a few cases affect the kidneys). They’re not supplying the PrEP: the patients have to pay for that, at a price ranging from €25-55 a month, depending on what country you live in and what deal your pharmacy has struck with suppliers.
This situation is not restricted to Poland and Malta. Even comparatively wealthy countries like Spain are still making people buy their PrEP. As for further east in the former Soviet countries, forget it: they are still having enough problems getting treatment to people who already have HIV.
These prices are, I should say, one-tenth of what PrEP used to cost when it was a brand-name pill called Truvadasupplied solely by its original manufacturers, Gilead Sciences. Now it’s come off patent, it is at least affordable - for some people.
But that’s not the point. This is a preventative medicine against a pandemic that still causes close to a million horrible deaths globally. A virus that requires people who catch it to take a lifetime of HIV drugs more expensive than PrEP, in order both to avoid that horrible death, and to avoid infecting others. A disease that the US health system realises is worth paying to prevent (incidentally, the US still generally pays the higher price for patented Truvada).
Why won’t Europe pay for PrEP? Why, even in England, is PrEP still officially “on trial” and the National Health Service still not making a commitment to it being part of normal healthcare?
The answer is reflected in the one given by a senior oncologist in Hungary, Miklós Kásler, when asked if his country would pay for preventable diseases. “Ninety percent of serious illnesses could be prevented if people obeyed the ten commandments."
In other words: the model people have in their heads when they think of PrEP is not the polio vaccine, or TB prevention, or even the contraceptive pill, which is at least free to some women in most countries
They think of it the way they think of another blue pill: it’s like Viagra, maybe something that takes the worry out of sex, but essentially, at best, a lifestyle enhancer, a luxury, and at worst, something that enables people to be sinners. If that’s what they want to do they should pay for it, is the thinking.
Of course, you also hear people saying that smokers should pay for lung cancer, diabetics for obesity, and alcoholics for liver transplants and the price of policing. But in the case of PrEP, it’s usually said with more venom and sometimes by the type of politician who more normally realises that blaming people for their illnesses is not a solution to those illnesses.
Yet none of those conditions, life-shortening though they are, are infectious diseases. Because HIV is an infectious disease, PrEP has the potential to eliminate that disease. This is both because of its own efficacy, and also because it acts as a huge incentive to get an HIV test. This means that more people who have missed the opportunity PrEP offers and already have HIV can at least get life-saving treatment and thereby become non-infectious.
That’s why Europe needs PrEP now. And it’s why PrEP in Europe, a partnership of seven European HIV and sexual health organisations, is organising its second summit in October in Warsaw – see http://www.prepineurope.org/en/summit-2019/for details. We will be putting pressure on governments and healthcare systems to adopt PrEP, both as a human right, and as the right way to stop HIV.
By: Gus Cairns
Co-ordinator, PrEP in Europe