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Getting PrEP to those who need it

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Where are we with HIV and prevention in the UK?

Last year we saw a decline in the number of people newly diagnosed with HIV for the first time, after more than 30 years of the HIV epidemic.

The decline has been sustained for a second year, which is a great success and has been driven by falls in the number of new diagnoses among gay and bisexual men, particularly those in London.   Achieving this fall was due to the hard work and commitment of many across the system.

A combination of HIV prevention efforts has been a key reason for the decline.

Increasing HIV testing has led to earlier diagnosis and once people know they have HIV, they can be linked into care and offered treatment.  Successful HIV treatment means HIV positive people with an undetectable viral load cannot pass on the infection to others.

Alongside correct and consistent condom use, early diagnosis through testing, and treatment of HIV to stop onward transmission, we now have PrEP- an HIV prevention drug.

PrEP (full name HIV pre-exposure prophylaxis) is the newest component of the HIV prevention landscape and is a drug taken by individuals before they have sex to stop them acquiring HIV in the first place.  It is a particularly important option for people do not to use condoms all the time.

Where are we with PrEP?

In 2016 and 2017 there was in increase in the amount of PrEP being used in England through individuals purchasing the drugs online from overseas.

The PrEP Impact trial began in October 2017 and is jointly co-ordinated by Chelsea and Westminster Trust and PHE and funded by NHS England.

As part of the trial, participating sexual health clinics in England can provide PrEP to patients who meet the trial criteria and consent to participate.

The result of this trial will inform service commissioners on how PrEP can be implemented in the longer term. It can also be accessed privately and sexual health organisations are providing advice on how to do this safely to people who want to take it.

Who benefits from PrEP?

The populations most impacted by HIV acquisition in the UK are gay and bisexual men, and people from black and minority ethnic (BAME) communities.

It is common perception that only gay and bisexual men will benefit from PrEP and while they do make up a high percentage of those who will receive it, there are a number of other very important groups that could benefit. This includes women of black African ethnicity and transgender individuals among others.

Awareness of PrEP and other HIV prevention methods by communities at a higher need is important in order to address health inequalities. Therefore an important element of making PrEP available is considering how best to increase knowledge of the availability and benefits, especially among those who may not be so engaged with traditional sexual health services.

Alongside this there is a need to raise awareness among professionals.  The sexual health service workforce may not always be aware of all the population groups who are at risk of acquiring HIV.

At the same time,  those working in community organisations who  regularly come into contact with these groups may not be aware that PrEP exists or how to advise people on accessing it.

How is awareness being increased?

There are examples at a national and local level of health promotion to increase PrEP awareness in key populations. The National HIV Prevention England Programme is helping address awareness of PrEP through a combination prevention approach to raise awareness and promote actions to take on the various ways to prevent HIV.

The London Do It campaign is a local example of a combination prevention campaign (including PrEP) across London implemented by the London HIV Prevention Programme (LHPP).

PHE engages with the community sector on a wide range of issues, not just HIV, to learn how to better address health inequalities among under-served communities.  As part of this work, in collaboration with the community based group PrEPster, we have recently conducted a mapping exercise to assess what other health promotion work is being conducted by community organisations and the NHS around PrEP.

In March of this year, 5 months after the start of the PrEP Impact Trial, we sent an online survey to more than 300 NHS and community organisations in England, including all NHS sexual health services, requesting information on any PrEP-related health promotion activities they were conducting.

We wanted to find out if there were any areas of the country or particular population groups where little health promotion was being conducted.

In total we received information on more than 100 separate activities; 35 being done by NHS organisations and 71 by community organisations.

What did we learn?

Just over a third of the activities reported had a wide geographic reach, covering multiple regions and these were mainly online activities.

However, almost two thirds of activities were focussed within a specific geographic region with London having the greatest volume of PrEP health promotion. Of note, some areas appeared to have very little activity occurring; in particular the West Midlands, North East and East of England.

Most reported activities did not focus on providing health promotion to one specific group, but rather targeted a number of population groups perceived to be at increased risk of acquiring HIV. Gay and bisexual men had the largest number of activities focussed on them and also the largest number of activities which were focussed solely on them as a population groups.

While there were a number of activities which included women as a target group, few focussed on single groups such as BAME women or female sex workers.  There were no activities focussed solely on heterosexual men and only two focussed solely on transgender individuals.

What next?

Full results of the PrEP Impact trial will be available in early 2021, and will inform the best way to roll-out PrEP across England.  In the meantime, the range of health promotion activities being conducted is encouraging but not sufficient to increase awareness among all those who may benefit.

Moving forward, it will be important to find out how much people already know about PrEP and ensure that all population groups receive appropriate information explaining why PrEP might be relevant to them and how they can access it.

To this end, all organisations involved in the provision of sexual health and HIV preventions services should aim to continue learning from each other about what works while addressing the needs of the communities they serve.

It is important to consider those geographic areas and population groups who currently appear to have fewer activities targeted towards them.  PrEP has a real potential to further decrease the numbers of people acquiring HIV, but only if those who need it know about it.

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  1. Comment by Dr. Eamonn O'Moore posted on

    Great to see the work PHE is leading on PrEP and increasing evidence about use and prevention of transmission of HIV. There is a good point being made about knowledge but also need to consider access. There are many people who are vulnerable and currently under-served or excluded from services, by their social circumstances or status, including people who are homeless, people in prisons and immigration detention, people who are vulnerable migrants etc. There is much work to be done still in this area generally but point about inequalities in access needs to be considered further and as HIV prevention strategies become more impactful for many, we still need to consider ensuring equal access to interventions for those socially excluded.