Voices: Why are we wasting our most valuable tool in the fight against HIV?

PrEP is one of the best tools we have at our disposal to end HIV transmission. Studies have shown that, when taken as prescribed, it reduces the risk of getting HIV by 99 per cent.

As gay and bisexual men use PrEP more and more widely, we’ve also seen a sharp drop in new diagnoses among this population. The efficacy of PrEP is beyond debate. Yet despite its boundless potential, navigating the path to get this trailblazing drug to all who need it has been fraught with challenges.

National Aids Trust – along with One Voice Network, Prepster, the Sophia Forum and Terrence Higgins Trust – recently reported new data showing the significant barriers people face in accessing PrEP. Of more than 1,100 people who had tried to access the treatment over a 10-month period in 2021-22, two-thirds had been unable to do so.

It was 2016 when we won a court case against NHS England that cemented their ability to deliver this intervention. We share the deep frustration of those unable to access PrEP, that six years later, people are resorting to sharing pills with friends or paying out privately to access something that should be freely and simply accessible.

Survey respondents commonly reported 12-week waiting times for PrEP, while many people were forced to wait even longer, or else were turned away due to a lack of appointments. One person we spoke to acquired HIV after attempting to access PrEP at his local clinic and being denied. This is completely unacceptable, and I fear that this won’t be an isolated case.

Not only are these barriers placing people in additional and unnecessary risk of getting HIV, the process of trying and failing to access PrEP can itself be so stressful that almost half (48 per cent) of respondents experienced an impact on their mental health. Many reported changing their sexual behaviour, including abstaining from sex – even though we know with certainty, from our 40-year history fighting HIV, that enforced abstinence is not a durable, effective or humane means of tackling sexual health issues.

These are just the problems faced by people actively trying to get PrEP. But this is just one side of the story. There are still enormous racial and gender disparities in terms of who is taking it (the vast majority being white gay and bisexual men) and many are either unaware of its benefits or being led to believe they are ineligible.

Not a single local authority we surveyed told us that they have more than five women taking PrEP. At a time when heterosexual women account for a growing number of new cases, this represents a major failure of public health. While most services who took part told us they are attempting to reach underserved communities and demographics, it’s clear that there needs to be much more done.

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None of these problems exist in isolation: they are all the result of an overstretched and under-funded NHS and public health system that will only get worse if further cuts come. Still reeling from the impacts of Covid-19, since the research for last week’s report was conducted the monkeypox outbreak has also hit our sexual health system with already over-capacity services leading the response.

Investment and support for system leadership could alter the trajectory. Currently, PrEP can only be prescribed through sexual health clinics, but it could be safely and effectively delivered through GPs and community pharmacies if policy barriers were removed. This would not only take some pressure off sexual health to bear the weight of delivery, but it could also enable us to reach some of the many people we are not reaching now because they don’t go to sexual health clinics.

This is a small step in designing PrEP services that are visible and acceptable to many more people who have a right to it.

PrEP is currently failing to deliver the results it could, and that we need if we want to meet the government’s target of ending new transmission by 2030 – for reasons which have nothing to do with pharmacology. We can’t continue wasting such a valuable resource.

Deborah Gold is chief executive of the National Aids Trust