Health: HIV

Lord Patel Excerpts

Monday 5th September 2016 Lords Chamber

[Lord Patel (CB)]

My Lords, I thank the noble Lord, Lord Black, for initiating this debate. I agree with him and the noble Lord, Lord Maude, that prevention, testing and treatment are part of the same healthcare, which needs to be joined up. We are talking today about prevention, particularly the use of PrEP, the pre-exposure anti-viral treatment to reduce the incidence of HIV. This debate is about the elimination of HIV. We now have the possibility to do that. However, we will fail to do so if we do not address this issue urgently.

Reducing the incidence of and eliminating HIV requires biomedical, behavioural and structural intervention. However, we also have to adopt any new treatments or preventive treatments that come along. I was interested to read what the Health Committee had to say about our public health strategy in its recent report, published last week:

“We welcome the focus on public health but recognise that reducing health inequality will also need to address the wider determinants of health, such as … the environment. This will require cross-Government working. We recommend that a Cabinet Office minister be given specific responsibility … at national level”.

Will the Minister comment on what the Health Committee said? It also said:

“Local authorities face a number of challenges and have had to cope rapidly with major system change. In addition they face real terms cuts … of £200 million … Cuts to public health and the services they deliver are a false economy as they not only add to the future costs of health and social care”,

as exemplified by the cost of treating a patient with HIV as opposed to the cost of prevention, as many others have mentioned.

The committee goes on to say:

“Commissioning for certain services is divided between different bodies, creating the potential for confusion and fragmentation. Where … progress on resolving them is in the best interests of patients and the public. Sexual health provides a clear example of such fragmentation”.

The committee refers to the,

“responsibility for and funding of preexposure prophylaxis, PrEP, for HIV”,

as many other noble Lords have mentioned.

I come back to why PrEP is so important. Others have mentioned the evidence that is now public in two studies, one conducted by PROUD and the other by Ipergay. They both found that PrEP was 86% effective, as has already been mentioned—that is, it stopped 17 out of every 20 HIV infections. They tested different ways of taking PrEP. In the case of the PROUD study, it was a daily dosage. In the Ipergay study it was an intermittent dosage. Despite that, both ways of taking PrEP are effective, so it does not have to be taken daily. Studies with heterosexual men and women equally show that PrEP works well in people who are able to take it consistently. For example, an African study showed that it was 75% effective—that is, it stopped 15 out of 20 HIV infections that would have occurred without PrEP.

PrEP is needed if HIV infections are to start going down in the UK and even to be eliminated, especially in gay men. It is estimated that 2,800 gay men in the UK acquired HIV in 2014—about eight gay men got HIV every day. PrEP is necessary in England because while condoms, testing and treating HIV-positive people are just about containing the HIV epidemic at its current level, infections in gay men are not decreasing, and more and more gay men are living with HIV every year. PrEP will save money, as has already been mentioned, because the cost of treating HIV patients is so high compared to prescribing.

I will also address some of the other issues that have come out in the debate on who pays: NHS England or the local authorities. Instead of having a debate about who pays, we have got confused about the clinical efficacy of PrEP. Absolutely convincing, good studies show that it is highly effective, so that should not cloud judgment about who pays. Concerns have been expressed that it could lead to other unintended consequences; for example, what about condoms and PrEP? There is little evidence that providing PrEP will result in big changes in condom use. People who use condoms carry on using them. People who do not use them, particularly gay men having sex with other men, need to be targeted. Another concern was about other sexually transmitted infections—none of which, by the way, are as serious as HIV. There is little sign that PrEP causes rises in other STIs.

Side-effects were also mentioned, but PrEP rarely causes them. Clinical resistance to the drug was another issue, but there is no evidence that PrEP will lead to many more cases of HIV drug resistance. The cost-effectiveness models have already been mentioned but, in the studies conducted, other, different cost-effectiveness models were used, and all of them were found to be effective.

The bottom line is: given to gay men at high risk of HIV, PrEP will be cost effective or could even start saving money now, especially if it is as effective as it was in the PROUD study and if at least a proportion of users take it intermittently. Even taken intermittently, it is effective. Therefore, there is no reason why we should not introduce this now. The argument about who pays needs to stop. The same taxpayer pays at the end of the day. The only issue is who tells whom to start introducing this treatment. I hope that the Minister will respond positively to that.