High Court rules in favour of NHS providing 'HIV prevention drug' but big questions remain

The High Court has today ruled that the NHS in England can fund a drug that can reduce the chance of people catching HIV whilst engaging in high-risk sexual activities.

NHS England had previously argued that local councils should provide PrEP ('pre-exposure prophylaxis') as 'health prevention' is their responsibility.

But Mr Justice Green said that NHS England had ‘erred’ and that both it and the local authorities were able to fund the drugs. Summing up, he said:

‘No one doubts that preventative medicine makes powerful sense. But one governmental body says it has no power to provide the service and the local authorities say that they have no money. The clamant [the National Aids Trust] is caught between the two and the potential victims of this disagreement are those who will contract HIV/Aids but who would not were the preventative policy to be fully implemented.’

The ruling has understandably evoked praise from gay rights campaigners and AIDS charities but consternation from NHS England which intends to appeal the decision. They are concerned about the effectiveness of the strategy, the precedent it creates for funding other 'disease prevention' measures and the way resources might be drawn from other health priorities were it to get the go-ahead.

The once a day pill known as PrEP, trade-named Truvada, consists of two antiretroviral medications used for the treatment of HIV/AIDS (tenofovir and emtricitabine or TDF-FTC) and costs £400 a month per person. The total cost to the health service could be in the order of £10-20m.

It is currently used in the US, Canada, Australia and France to help protect the most at-risk gay men.

According to the CDC (Centers for Disease Control) PrEP is for people who do not have HIV but who are at substantial risk of getting it.  It should be used in combination with other 'HIV prevention' methods, such as condoms, but even in these circumstances is not foolproof.

The CDC reports studies have shown PrEP reduces the risk of getting HIV from sex by more than 90% when used consistently. Among people who inject drugs, PrEP reduces the risk of getting HIV by more than 70% when used consistently.

But these figures are what is achievable with good adherence (consistent use), and many of those most at risk are very likely not to adhere with taking the pills regularly.

An authoritative Cochrane review is far less reassuring. Overall, results from four trials (Baeten 2012; Van Damme 2012; Grant 2010; Thigpen 2012) that compared TDF-FTC versus placebo showed a reduction in the risk of acquiring HIV infection by about 51%.

Marked differences between the studies were attributed to differences in levels of adherence.

As one major review has concluded:

‘The efficacy of PrEP is dependent on adherence, and adherence to PrEP medications in efficacy studies has been variable, raising questions about whether persons who are prescribed PrEP in clinical settings will be adherent enough to derive protection.’

Furthermore the drug’s use may in fact lead to a paradoxical increase in other sexually transmitted infections (gonorrhoea, chlamydia etc) by encouraging more high risk behaviour from those who have been lulled into a false sense of security.

This well-known phenomenon whereby applying a prevention measure results in an increase in the very thing it is trying to prevent is known as ‘risk compensation’.

I have previously blogged on the fact, surprising to some, that morning-after pills don’t actually cut teen pregnancy rates and instead increase the incidence of sexually transmitted infections (see also here). 

The term ‘risk compensation’ has also been applied to the fact that the wearing of seatbelts does not decrease the level of some forms of road traffic injuries since drivers, feeling more secure, are thereby encouraged to drive more recklessly.

In the same way making PrEP freely available to already promiscuous homosexuals could well encourage more sexual risk-taking and more sexually transmitted disease as a result. Any effect on decreasing HIV transmission rates is then cancelled out by rising levels of promiscuity.

Many will be shocked at the levels of promiscuity reported in these high-risk groups. In one study in the Cochrane database, during screening, participants reported an average of 12 coital acts per week with an average of 21 sexual partners in the previous 30 days.

It is only when these facts are known that the highly addictive nature of high-risk sexual activity, especially amongst male homosexuals, becomes evident. PrEP is not a prevention strategy at all. It is rather a harm reduction strategy aimed at lessening the damage that people addicted to high-risk sexual behaviours are doing to themselves. More akin to clean needles for drug addicts, filter cigarettes for smokers, protective gloves for compulsive burglars or seatbelts for habitual joy-riders.

As has been recently argued with respect to PrEP for drug addicts, 'PrEP is not ready for our community and our community is not ready for PrEP'. We need instead to address the underlying structural drivers and social context of the HIV epidemic and ask what it is that actually leads people to behave in this way. 

PrEP may reduce the risk of HIV transmission significantly but it does not eradicate it. That is because it is not actually a 'prevention' strategy at all but a 'harm reduction' strategy. And lack of adherence and ‘risk displacement’ simply add to the problem. This means that those who rely on PrEP for protection against HIV are still effectively playing Russian roulette, with the willing assistance and collaboration of health professionals.

NHS England is right to challenge this judgement. We will need much more evidence that PrEP is truly effective in practice before embarking on this strategy, which brings us back to the bottom line in all this: The only way of preventing HIV infections, as opposed to reducing the chance of catching them, is by avoiding the high-risk sexual behaviours that lead to them.

How should Christian doctors vote?

On 7 May the UK goes to the polls for the general election. Whoever assumes power as a result will have a profound influence in shaping public policy in matters which affect us, our families, churches, patients and colleagues.

Some claim that politics and religion should not mix but God is intimately involved in politics.

He is sovereign over the rise and fall of nations (Isaiah 40:15-14; Daniel 2:21, 4:17, 5:21). He both establishes governing authorities, and holds them ultimately accountable (Romans 13:1).

As Christians we should both pray for our political leaders (1 Timothy 2:1-3) and be subject to them (Romans 13:1; Titus 3:1). But God has also given us a part to play in who actually exercises civil authority. Each of us, before God and in good conscience, must make our own decisions about voting; but we have a duty before God to ensure that we exercise our votes wisely, thoughtfully and in an informed way.

For some the key question will be about who they would prefer as prime minister for the next five years. But for others it will be a matter of which specific issues they care about most and how the various parties and candidates stand on these.

Whether we choose to vote for, or against, a particular party or candidate, or on a specific issue, there are lots of resources to help us reach our decision.

The Economist/IPSOS Mori Issues Index ranks political issues in order of importance as seen by the British public. In September 2014 Race Relations/Immigration was top with 39% followed by the Economy (30%) and the NHS (25%). The next seven were defence (23%), unemployment (21%), education (16%), housing (15%), crime (14%), poverty (13%) and inflation (11%).   

The BBC’s ‘Manifesto Watch’ helpfully outlines where the seven main parties stand on each of these ten top issues.

With the economy and the NHS ranking two and three respectively, it is also worth remembering how the two are closely interrelated.

Most of us are employed by the NHS and almost all of us, along with our patients, rely on it for our healthcare.

In June 2014 the NHS was declared the best healthcare system in the world by an international panel of experts who rated its care superior to countries which spend far more on health.  The Commonwealth Fund, a highly respected Washington-based foundation, examined an array of evidence about performance in eleven countries, including detailed data from patients, doctors and the World Health Organisation.

In the Commonwealth Fund study the UK came first out of the eleven countries in eight of the eleven measures of care the authors looked at. It got top place on measures including providing effective care, safe care, co-ordinated care and patient-centred care. The fund also rated the NHS as the best for giving access to care and for efficient use of resources.

The 30 page report titled ‘Mirror, Mirror on the Wall’, concluded, ‘The United Kingdom ranks first overall, scoring highest on quality, access and efficiency’.

But financial pressures are now squeezing the ability of the NHS to deliver.

The Nuffield Trust has shown that because of population growth, ageing and cost increases, by 2020-21 the NHS will require some £30bn (25%) more than it is getting now just to maintain services at their present level.

But whilst real average NHS spending has increased by at least 3% per year since 1951, this has fallen to 0.75% per year since 2010.

The major driver of this fall has been the UK’s national debt which is now at its highest peace-time level.

When the coalition government took office in 2010 our total government debt was £811bn. But by December 2014 it had reached £1,483.3 billion (80.9% of GDP), an over 80% rise in just five years, with much more to come.

This rise is the result of accumulating annual deficits. Although the gap between annual government income and expenditure is gradually falling the total debt is actually rising.

This national debt matters. It must be serviced with regular interest payments, diverting money from front-line public services.

Even at rock-bottom interest rates, the Government will spend almost half as much on debt interest in 2014/2015 as it will spend on the NHS (£52bn cf £113bn).

As the national debt escalates, courtesy of £100bn-plus annual deficits, and as interest rates inevitably rise, we may yet end up spending more on government debt service than on health.

This situation clearly cannot continue and a key question must be what kind of government is best placed to put our balance of payments in order. Debt is a moral issue with serious consequences for families, communities and countries. 

We also face other moral threats in the health service, not least the legalisation of assisted suicide. On this and other issues of conscience we will want to know where our own MP stands. Recent parliamentary votes on same-sex marriage, sex-selective abortion and three parent embryos, for example, have been deeply disturbing.

The Public Whip website tells you exactly how your own MP has voted on a range of crucial issues and the Christian Institute and CARE have also compiled very valuable online databases on past voting records.

Let’s make use of all this valuable information in making an informed vote that really counts this May. 

But let’s also pray for the future of our country, and health service.