"PrEP: the story so far" - Kelsey Smith for HIV Scotland
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This presentation was given by HIV Scotland volunteer researcher Kelsey Smith at the HIV Scotland 'PrEP roundtable discussion day' on 25 August 2015. The aim was to set the scene for discussion about PrEP in Scotland. For more information visit www.hivscotland.com
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"PrEP: the story so far" - Kelsey Smith for HIV Scotland
- 1. PrEP: The story so far Kelsey Smith, Volunteer Researcher
- 2. PrEP trials > France and Canada > UK > 353 MSM and transgender women who have sex with men > 545 MSM > Event driven regimen, 2 pills before sex and 2 pills after > Daily pill regimen > 2 participants in active arms of the study contracted HIV > 3 participants in active arm of the study contracted HIV > 14 participants in placebo group contracted HIV > 19 participants in deferred group contracted HIV > First trial to demonstrate event based regimens were effective. 86% efficacy rate. > First trial measuring efficacy of taking daily dose in the UK. 86% effective rate. IPERGAY PROUD
- 3. - How much does PrEP cost? > Truvada – 1yr supply £4330, or discounted £3000 (NAM) > Dean Street Clinic in Soho provides privately purchased PrEP for £450 for a month supply, or between £50-£70 for an event driven supply (4 pills in total).
- 4. Is PrEP cost effective? > Key determinants > Selective use: cost effective if prioritised for people at very high risk > Cost of the drugs used: cost effective for a greater number if prices lower
- 5. Risks associated with PrEP > Long term health risks? o Truvada selected because of low side effects o Minimal reported side effects in both trials > Adherence? o High levels of adherence reported in both trials > Changing sexual behaviours? o Little change in participants’ sexual behaviour o Participants considered PrEP as additional layer of protection, not a replacement for condoms
- 6. PrEP in Scotland > Who would benefit? o World Health Organization has recommended PrEP be offered to men who have sex with men, as an additional HIV prevention choice. > What is being done now? o Due to licensing restrictions, PrEP only available if privately purchased or prescribed off-label. o With no prescribing criteria for PrEP, the number of PrEP users in Scotland remains low.
- 7. Pride Survey: Awareness, attitudes and experience of PrEP
- 8. Pride Survey – awareness of PrEP When asked to name three ways to prevent contracting HIV, 45 people (14%) mentioned PrEP without prompting.
- 9. Pride Survey – opinions about PrEP 261 (83%) felt PrEP should be made available. 204 people (65%) wanted more information about PrEP.
- 10. Pride Survey – appetite for PrEP 70 people (22%) said they or their partner would be interested in taking PrEP – another 28% said they were unsure.
- 11. Pride Survey – experience with PrEP 46 (16%) said they knew someone who had taken PrEP. 9 people (3%) said they had taken PrEP.
Notes de l'éditeur
- Welcome participants Introduce self About HIV Scotland: Established 1994 National HIV policy NGO for Scotland We provide a voice for people living with and at risk of HIV in Scotland HIV Scotland was set up as the Scottish Voluntary HIV and AIDS Forum in September 1994, a crucial stage in the development of Scotland’s response to HIV, some 12 years into the epidemic. The organisation’s establishment by leading figures in the third and HIV sectors was a response to the Scottish Office AIDS Task Force call for improved provision and coordination of services. HIV Scotland is the national HIV policy charity for Scotland: we speak out for people living with HIV. We want a society which is well-informed about HIV and devoid of HIV-related stigma and discrimination. HIV Scotland provides: Knowledge and expertise to help inform and deliver strong policies and effective strategies; Expert advice and a voice for HIV in Scotland; Information, training and resources; Signposting to evidence, expertise and community experience; and Opportunities to engage with others in shaping policy and practice. OUR VISION is a society which is well informed about HIV, devoid of HIV related stigma and discrimination, and where everyone living with or affected by HIV has access to and helps shape excellent services.
- Truvada is a fixed-dose combination which contains two drugs, tenofovir and emtricitabine. At present, a year’s supply officially costs £4330 per person, although the NHS obtains a discount and may pay around £3000 per year. The annual cost of healthcare, including antiretroviral drugs, for a person living with HIV is around double that of the annual cost of providing PrEP. People need to take HIV treatment for the rest of their life but PrEP will generally be needed for a much shorter period.
- Given the high price tag, there has understandably been a lot of focus on whether PrEP is cost effective - this was an issue raised by a number of people in advance of attending today. In particular, discussion has focused on two key issues: the selective use of PrEP and the actual cost of the drugs used. Taking the first point about selective use - PrEP has only so far proven cost-effective if it is prioritised for people at very high risk of HIV. A recent UK analysis of the PROUD study (Valentina Cambiano) found that PrEP could be cost-effective and even cost-saving if it was provided to gay men who have recently had a sexually transmitted infection or condomless sex with at least five casual partners in the past three months. However, PrEP would not be cost-effective if used by people at lower risk of HIV infection. The cost of providing PrEP to larger numbers of people would not be offset by a significant reduction in new infections. A second determinant however is the cost of the drugs used, showing the importance of using generic drugs and of pharmaceutical companies lowering their prices. The same UK analysis found that if drug prices were halved, PrEP could still be cost-effective even if it were offered to a wider range of gay men (for example, any man reporting condomless sex with a casual partner).Also, this data relates to the PROUD study – as Kelsey has shown other options such as event driven PrEP regimens (IPERGAY) could offer less expensive and equally as effective alternatives. Although PrEP is much more expensive than most other HIV prevention methods, studies suggest that it may be cost-effective in some circumstances. Moreover, it may sometimes be cost-saving, in other words costing less to prevent one HIV infection than the lifetime healthcare costs of that infection. For the UK, there are no relevant analyses of the cost-effectiveness of PrEP in groups other than gay men.
- Lastly, to give some sense of how PrEP is perceived, and what current attitudes and awareness levels are like among some of those who may benefit most from PrEP, we conducted a survey. Survey about HIV prevention – taken by 314 people across Edinburgh and Glasgow Pride. To give a sense of those who took part: 4% of respondents identified as transgender; 72% of respondents were men, 90% of whom identified as gay or bi. In following slides we’ll take a quick look at some of the most interesting data.
- Survey was promoted as a survey on ‘HIV prevention’, with no initial mention of PrEP. When asked to name three ways to prevent contracting HIV, 45 people (14%) mentioned PrEP without prompting. Other answers include using condoms, sharing needles, abstinence, fewer sexual partners and our favourite: “Wearing Chinos”.
- After explaining PrEP, we asked for respondents opinion about it. 261 (83%) felt PrEP should be made available. Only 6 people (2%) said they did not believe it should be made available. Also, 204 people (65%) wanted more information about PrEP. This was backed up by the fact that 50 people left their contact details for more information.
- Then we asked respondents directly if they or their partners would be interested in taking PrEP. 70 people (22%) said they would, another 28% were unsure.
- Finally, we asked if people had come across PrEP. A surprisingly high 46 (16%) said they knew someone who had taken PrEP. And 9 people (3%) said they had taken PrEP themselves – with one person saying they got it from a friend, three as part of a medical trial, and five others not listing how they accessed it.