[Closed] Prep and the NHS

Take morals out of it, what delivers the best outcomes?

Either stop the heavy drinking or the unprotected sex?

Almost everyone agrees that prep should be provided but the question is who foots the bill. NHS England have a responsibility to treat patients with a disease but the responsibility for preventing disease lies with Public Health England. Prep is used in patients without HIV to recent them catching it, hence NHSEs stance PHE should pay for it.

Not read the full details but I think the court case simply means NHSE can provide prep if they choose to. It doesn't mean they must provide it.

Take morals out of it, what delivers the best outcomes?

Castration.

Oh, you meant partially take morals out of it....I thought you wanted the full Tory Conference version.

Lol, I've been doing some work in chronic and long term health for the future and in reality as a health service we need to do stuff that prevents chronic and long term problems and gets those in that situation out of it quicker even if the cost to do so looks high. The long term costs and implications will bankrupt countries at the rate we are going.

The ethics are complex but essentially prep benefits everyone; fewer people have HIV and the NHS (therefore taxpayers) spend less treating HIV and associated complications.

You'll never stop risky behaviour in this patient population and with a contagious disease saying 'you made your bed so lie in it' doesn't really work if that person also lies in lots of other beds

Driving, smoking, drinking alcohol, dangerous sports?

A similar argument was made about stains- 'make them eat salad', that didn't work either! Use of statins to reduce secondary cardiovascular events has saved lives and the NHS a fortune.

Yep. Prevention is better etc.

Would be interested to see how the outcome studies for this population were carried out. Is compliance with a daily pill any better than other forms of prevention? Also wondering if there is an initial 'lag' due to Prep, but eventually even this fails and those who would have contracted HIV do so anyway.

Presumably it's a drug that is suitable for long-term use in terms of side-effects.

Take morals out of it, what delivers the best outcomes?

This has to be the bottom line for health provision.

Related to this, and as an extension of mikewsmith's point just there, I think a health secretary in the near future is going to have to start a large debate about radical NHS future direction soon.

Choice will be, it's going to cost tax payers a lot more to keep up with the ever increasing benefits of new medicines and medical techniques, or you're going to have a much more basic, (i.e. 1980's) level of service and the exotic stuff will be paid for by the patient or insurance.

or you're going to have a much more basic, (i.e. 1980's) level of service and the exotic stuff will be paid for by the patient

It's already happening.

alpin - Member

Would you encourage heavy drinkers to keep drinking with the help of pills?

If there were a pill that'd stop or massively reduce the ill effects, sure. It wouldn't replace other methods of harm reduction but it'd be a valid part of the cocktail. So to speak.

The question's always whether it'll increase risk taking behaviour/prevent a reduction of risk taking I suppose, there's plenty of other STDs. Hard things to predict really but if we can have a reduction of harm AND a cost saving then it'd be mad not to. And just possibly a bit evil too, if you end up not helping people just because you don't like the way you're helping.

(oh, and politically, this falls right into the NHS vs Public Health thing- the government likes things to be Public Health, so that when they slash the budgets they're not cutting the NHS)

That debate should've started years ago but successive health secs were too frightened to suggest it. The main aim of the Health and Social Care Act 2012 was to increase the opportunity for the private sector to provide healthcare in competition with the the NHS

The budget shortfall for the next 10 years is something like £16bn

The public also needs to understand what the benefits of new uber expensive treatments are likely to be eg £100k to extend one persons life by 4 months. Although to their credit, the media are now talking about life-extending rather than life-saving drugs more and more

I think the heavy drinking analogy isn't right.

1) If you could find a drug that prevented the long term effects of drug or alcohol use then you would still be left with the societal effects of those, violence, loss of productivity, crime. Having unprotected anal sex is otherwise consequence free, it impacts no one else.

2) Drug or alcohol use is an addiction, and is often debated whether it is a health issue or a criminal one. Being gay is neither.

3) We don't ban other risky activities like mountainbiking.

On the other hand, what about all teenagers an 20somethings? What about mid life cricies, swingers, affairs, cuckolds, and all that allegedly happens in middle aged suburbia?

I presume though that this decision is based on it being cheaper to prevent all young gay men getting HIV than it is to treat the sizeable proportion who then need treatment for life (1 in 8 in London, 1 in 20 in the UK).

It's already happening.

This pace of change is only going to continue, and at some time the cost/service question is going to have to be tackled, 'cos it's not sustainable now.

Thin end of the wedge.

We're already seeing people castigated for "poor lifestyle choices", indeed Michael Gove himself tried to justify the existence of food banks because some of the people who rely upon them "made poor life choices".

It's quite right that smokers, drinkers and the obese are encouraged to attain a better level of health before being operated upon, but not at the expense of withholding treatment or being attacked in the press by some awful right wing rag.

When you think about it- almost every illness has a self-inflicted element. Breaking myself mountain biking is completely my fault and entirely preventable but I'd expect the NHS to patch me up

I'm also not totally convinced.

Also..won't it just encourage folks not to rubber up in future if they think they are 'safe'...

This pace of change is only going to continue, and at some time the cost/service question is going to have to be tackled, 'cos it's not sustainable now.

True, but if you have a generation of gay men without HIV, then there's no one to pass it on, so in 10-15 years maybe the program can be stopped.

HIV isn't restricted to gay men. Nor is it restricted to the promiscuous hetrosexual.

Is it really though?

Yes, the NHS won't prescribe me any thyroid meds so buy my own from outside the UK. Some people are forced to pay hundreds of pounds each month, it's common to have an allergic reaction to fillers used. Additionally I pay for my own Lyme disease treatment including a private doctor. As if that isn't enough I also buy my own meds for another permanent condition.

A very difficult one this.

Morally, I think it has to be funded one way or other - ultimately it's going to be publicly funded - the Government of course could have avoided this no doubt long and expensive court case by simply using the words "whether NHSE or PHE fund it is immaterial, the money is coming from the same source - we'll provide the funding centrally" rather than wasting money letting them argue about who has to make cuts elsewhere to pay for it, but well, it seems we can't do that - we'd rather pay lawyers to fight ourselves than use the money for good.

I do worry about it's effectiveness though, I can't really visualise the type of person who currently admits they're at high risk of HIV because of their lifestyle but has thus far refused to use needle exchanges, condoms or whatever, but is willing to take a pill every day.

tpbiker - Member
I'm also not totally convinced.
Also..won't it just encourage folks not to rubber up in future if they think they are 'safe'...

HIV isn't restricted to gay men. Nor is it restricted to the promiscuous hetrosexual.

^This. If we continue to treat it as someone else's problem then we perpetuate the stereotypes of the 1980s. Notables who died from infected blood transfusion during surgery for example included Arthur Ashe and Isaac Asimov.

Sorry to start waving the flag, but as soon as we start prejudging people's entitlement to healthcare then we're on a pretty slippery moral slope IMHO.

I think there are too many things that could be defined as 'lifestyle'.

An obvious contentious one is IVF. Should we pay for someone who, say, has a low sperm count to be able to produce offspring?

This whole argument smacks of the anti-cervical cancer argument a few years ago with the hand-wringers worried that giving girls a vaccine could cause promiscuity.

Driving, smoking, drinking alcohol, dangerous sports?

The majority of these are heavily taxed with two of them in a measure to prevent dangerous habits and pay the consequences of ignoring the risks. As sex isn't taxed, unless your married, then having HIV infected people either use condoms (cheaper) or Prep (more expensive) at their own expensive surely enforces that they still carry a risk and it's their responsibility to others.
Those that will take risks regardless will not wear a condom or take the pills. If they had paid for them I would assume like most people they would take them to ensure they benefited from the expense.
How would the law stand if someone was prescribed Prep but was hit and miss with taken it and assumed because they had taken one 30 mins before sex thought they were safe when they weren't and their partner become infected?

PJM1974 - Member

HIV isn't restricted to gay men. Nor is it restricted to the promiscuous hetrosexual.

^This. If we continue to treat it as someone else's problem then we perpetuate the stereotypes of the 1980s. Notables who died from infected blood transfusion during surgery for example included Arthur Ashe and Isaac Asimov.

Sorry to start waving the flag, but as soon as we start prejudging people's entitlement to healthcare then we're on a pretty slippery moral slope IMHO.

It's worth considering that when it comes to Prep it is very likely that it will only be given to people who are deemed to be 'high risk' of HIV.

In the Western World the group with the highest rate of transmission and infection are Gay Men, that's not 'gay bashing' that's fact.

You can cut it a hundred different ways, the reasons behind the risk in both 1) number of potential partners who carry HIV and 2) likelihood of transmission due to nature of sexual act. We don't need to glorify it.

Whilst it's very morally right-on to say it's everyone's problem equally, the NHS tend to be more pragmatic and it's a waste of resources to offer it to low risk people who avoid offending anyone else - they will no doubt focus on high risk people, that'll be people who have anal sex with numerous partners (male or female) people who have sex with partners from a high risk demographic and people who use needles.

Gay Men demographically are higher risk so a lot of the focus will go that way.

dangerousbeans - Member
Take morals out of it, what delivers the best outcomes?
This has to be the bottom line for health

😯 wow, no wonder the word dangerous is in your user name

Gay Men demographically are higher risk so a lot of the focus will go that way.

Forgive me if I'm leaping to a conclusion, but I read the crux of your argument is to withhold Prep and rely on fear alone to prevent gay men from getting pissed up and having risky sex with one another?

It's a bit like withholding contraception from teenagers in case they get tempted for a bit of rumpo?

I do worry about it's effectiveness though, I can't really visualise the type of person who currently admits they're at high risk of HIV because of their lifestyle but has thus far refused to use needle exchanges, condoms or whatever, but is willing to take a pill every day.

This is very true. It's a bloody good job the contraceptive pill works as something the woman in the relationship takes because if it was left to the men, we'd be bloody useless at it.

It would be good to know how much more effective it is than using condoms at preventing HIV transfer. Or is the true unspoken benefit the ability to go back to condom free sex? Or is it to stop those that 'forget' to use a condom to be safer; in which case I'd wager they'd be rubbish at remembering to take the drug too.

At what point is it reasonable to expect the individual to take responsibility for their sexual health.

Different for those who already have HIV. Prep prevents the virus replicating and so should help those who have HIV.

But for those who are currently clear. Prep should be available for private purchase, by the individual.

PREP is a good idea. The government has tried to shift activity from the NHS to public health, which is now paid for by councils. PH services including sexual health, are going down the pan. But because it ain't the NHS the government isn't on the rack about it... This is an organisational nightmare.

HIV isn't restricted to gay men. Nor is it restricted to the promiscuous hetrosexual.

No one argued it was/wasn't.

But we don't offer pedestrians motorcycle crash helmets, because by any measure I'm more likely to do myself a head injury on a motorbike than I am the other 99.95 of the time.

Some heterosexual people are at a greater risk than some homosexual men, but they're statistical outliers, and I'm sure if they went to their GP and explained their circumstances they'd probably have to offer them the drug also.

That said I'm still in the lose weight fatty / use a bloody condom camp, because statins don't protect against diabetes and prep doesn't protect against hepatitis.

An obvious contentious one is IVF. Should we pay for someone who, say, has a low sperm count to be able to produce offspring?

But it is limited to a specific number of treatments, after that you have to go private.

Prep doesn't sound at all similar.

But for those who are currently clear. Prep should be available for private purchase, by the individual.

Only available to those who can afford it? What a horrible thought.

What c_g says, NHS is covering the basic stuff and the people are either paying for or not having other treatments

As I have posted numerous times we need to have a serious adult conversation about health service provision. The model we have a broken and is onky getting worse

It's not broken, it's ideologically unfunded by right wing chimps with no plans for any viable alternative, much like another newsworthy issue.

"Only available to those who can afford it? What a horrible though"

Unless you're offering to pay for the whole of Africa, and every other poorer nation, to have it then that's inevitable.

Should we deny UK residents something because other people can't have it?

It's not broken, it's ideologically unfunded by right wing chimps with no plans for any viable alternative, much like another newsworthy issue.

^ This. One of the few things that would provoke me into outright civil disobedience would be for the NHS to be scaled back so that the wealthy might feel they're entitled to impose compulsory health insurance which will disadvantage the less well off.

crikey - Member
It's not broken, it's ideologically unfunded by right wing chimps with no plans for any viable alternative, much like another newsworthy issue.

What no smiley?!?

Crikey indeed

The NHS is the only Healthcare that 90odd % of the UK population will ever experience. I don't do smileys for important things, sorry.

One for the statistics people, if the cost of Prep is less that the cost of a lifetime of HIV\Aids treatment then it should be available on prescription.

Having sex is not a crime and having the choice of taking a tablet to assist is safer sex is a good idea. Most of the objections I've heard are horrible moralistic nonsence.

The cost of prescriptions and NHS funding is another discussion. There is a team of people somewhere who sit and process application forms and sends out nice little plastic cards, for a variety of conditions so that patients can get all their prescriptions free.

I would suspect that making those medicines necessary for life long conditions free at the point of collection would be far more cost effective than continuing processing forms and issuing plastic cards.

I'd be bankrupt if I had to pay for my diabetes medication, but I'd have no problem paying for any short term medication unrelated to diabetes.

(Oh and for the lose weight fatty comment above, don't believe all you read in the media, I'm Type 2 diabetic and had a BMI of 23 when diagnosed. Probably the main "lifestyle" choice was a career in desk based IT Support and a liking for rice.)

The cost of prescriptions and NHS funding is another discussion. There is a team of people somewhere who sit and process application forms and sends out nice little plastic cards, for a variety of conditions so that patients can get all their prescriptions free.

Don't know if folk are aware but people like myself who have an Exemption Card (cos my condition is on the list) we're able to get any other meds free of charge even if they're not related to the condition.

Think of the savings that could be made there!

Sorry, just re-read and that's what you've said. Nurse - I need my meds!

Hmm haven't read up on it so forgive my ignorance, but how many people are you actually going to help with this?
People who have safe sex now are already "safe" so if a load of people switch to prep then you're incurring a greater cost (and I'm guessing this is a rather large cost) for the same effect. If, as I suspect, prep isn't as effective as condoms then potentially you have greater expense and a slightly higher infection rate.
Lazy people who have unprotected sex now probably aren't going to remember to take their medication so what's the point?
Wreckless people who like danger are by definition not safe, you can't "fix" that.

Shirley the only demographic you're going to have a meaningful effect on are those who know the risks but think the feeling of condom free sex is worth the risk but are conscientious enough to take their meds. How many people are we talking about? A lot? I've no idea. Is it even possible to get honest enough answers to find out that number?

Shirley the only demographic you're going to have a meaningful effect on are those who know the risks but think the feeling of condom free sex is worth the risk but are conscientious enough to take their meds.

....or the heterosexual partners of people who're HIV positive but find themselves unable to have children?
Sure it'll mean something to someone in that position.

Don't know if folk are aware but people like myself who have an Exemption Card (cos my condition is on the list) we're able to get any other meds free of charge even if they're not related to the condition.

Think of the savings that could be made there!

Sorry, just re-read and that's what you've said. Nurse - I need my meds!

I could have been clearer 🙂

It has always surprised me that all my medication is free, not just the stuff I need. I'm fairly healthy other than the crap pancreas so haven't really used the card for anything else.

I was a bit surprised at a friend who was pro NHS but openly admitted trying to get medication for her husband on her free prescription card which just seem a bit double standard to me. I think they've cracked down on checking the cards more recently because of things like that.

Getting rid of the cards and just making certain medications free would possibly save.

or the heterosexual partners of people who're HIV positive but find themselves unable to have children?

But it is limited to a specific number of treatments, after that you have to go private.

It is still 'lifestyle' (the desire to have a child). It isn't to cure a disease. In that case it is similar.

I guess contraception too should be banned based on this. Do people have to go private to get the pill?

It's all a bit of a mess this 'free' NHS stuff though. I pay for my glasses and eye test. I pay for my dentist. All are more 'essential' than the item we are discussing now.

If we are into this preventative thing, can we all get a free NHS helmet, knee and elbow pads for mtbing?

PJM1974 - Member

Gay Men demographically are higher risk so a lot of the focus will go that way.

Forgive me if I'm leaping to a conclusion, but I read the crux of your argument is to withhold Prep and rely on fear alone to prevent gay men from getting pissed up and having risky sex with one another?

It's a bit like withholding contraception from teenagers in case they get tempted for a bit of rumpo?

Oh no, quite the opposite.

I noted some posters were keen to point out that HIV isn't just a 'Gay thing' and we shouldn't start thinking HIV is a problem for other people (providing you're straight or female), but at the same time we have to remember PREP is a preventative drug and at the moment an expensive one one so it will have to be a limited resource, to make the most of the resource it will be used in a very focused way.

HIV is more prevalent with Gay/Bi men than any other demographic so it should be 'promoted' towards them and needle users other high-risk people will also be likely be given it on a case by case basis. Uninfected partners of HIV carriers etc, rather than just prescribed carte blanche to anyone who asks for it.

The other way to look at it, would be that if it was supplied cart blanche around the world, it probably could/would eradicate the disease.

Also is the price a true reflection of the research and production costs, or is it an exploitation of the market. There are things far more important than freemarket ideology.

The other way to look at it, would be that if it was supplied cart blanche around the world, it probably could/would eradicate the disease

also what are the side effects? Sounds like some nausea and vomiting short term, long term? Eradicating hiv will take some time, maybe a generation or two?

*admittedly the herd in this case is only the parts of the population that are sexually active, needle sharers or some other transfer vector, so dunno if the usual rules apply.

i've read a little more on prep since yesterday but still much so feel free to point out if I'm talking cobblers.

HIV is more prevalent with Gay/Bi men than any other demographic so it should be 'promoted' towards them and needle users other high-risk people will also be likely be given it on a case by case basis.

Ah! Apologies for misconstruing your point.

I can't argue with your logic, in fact that makes perfect sense to target risk groups and offer Prep to them.

Surely just comes down to cost benefit ratio. Is the cash best spent on this measure or others.

, NHS England is holding in readiness funding to cover PrEP – but has warned that this will come at the expense of funding some other specialised services provisionally identified as priorities by the NHS England Clinical Priorities Advisory Group, such as prosthetics for lower limb loss and ivacaftor (Kalydeco) for children (2 to 5) with cystic fibrosis.

http://www.aidsmap.com/High-Court-rules-NHS-England-is-responsible-for-funding-PrEP/page/3076337/

As to it's cost effectiveness

whether PrEP in the UK will be cost-effective or not depends on what one thinks is likely to happen. Will it gradually be taken up, initially by the gay men at the highest risk of HIV infection and then in time, by lower-risk gay men and other people such as at-risk heterosexuals? Or will there be mass adoption of PrEP from the start? In the latter scenario PrEP would be unaffordable without immediate substantial reductions in drug cost. In the former it may even save money, as long as the expected future falls in drug prices keep pace with increased numbers on PrEP.

http://www.aidsmap.com/Second-UK-cost-effectiveness-study-finds-that-large-PrEP-programmes-may-need-drug-price-cut-to-be-affordable/page/3000951/

 

irc - Member

Surely just comes down to cost benefit ratio. Is the cash best spent on this measure or others.

Well, that's all the financial argument comes down to. But that's not the only decision when you're dealing with healthcare. (cost/benefit ratio for my diabetes is terrible, I was only 7 when I was diagnosed so it'd have made more sense to put me down and grow a new one)

For.

The NHS should be doing more preventative care. In the western world in general we do far far too much "wait for something to go wrong and then treat" when we should be doing far far more intervention and education.