PrEP: Ireland’s issues with the anti-HIV pill
Comhall Fanning gives an overview of the preventative drug’s history and why it is still not widely available in Ireland
PrEP stands for pre-exposure prophylaxis. It is a drug that can be taken orally once a day by HIV-negative people at high risk of contracting HIV. It is mainly aimed at men who have sex with men, trans people who have sex with men, injecting drug users and sex workers. It is sold under the brand name Truvada, though Truvada’s patent on the drug expires later this year, meaning that cheaper generic pills may soon be available. However, it remains unclear when they may come on the market and whether there will be legal challenges to this. Truvada has been used for years to treat HIV-positive patients but its use in HIV-negative people is relatively recent. Studies have shown that when PrEP is taken consistently by high risk groups, it reduces their chances of becoming infected with HIV almost completely. Of course, this is boosted when combined with the use of condoms.
Since July 2012, PrEP has been available by prescription in the United States. It is widely available in New York City, San Francisco and Los Angeles through subsidy programmes. In August 2016, the European Commission cleared Truvada for use as PrEP in the European Union. At present, PrEP is available for free through the public healthcare system in France. Many clinical trials are ongoing in countries across the world. However, the use of PrEP has consistently been shown to be extremely effective and safe. In the United Kingdom, the NHS has fought the introduction of PrEP, mainly due to how expensive it is. The NHS has recently lost a court case following claims it made that it did not have a responsibility to provide PrEP. The NHS is now launching large scale clinical trials.
PrEP in Ireland
“Doctors in Ireland may write a prescription for Truvada to be used as PrEP; however, this would be a private prescription and it costs hundreds of euro for a 30-day supply”
I met with Andrew Leavitt of ACT UP Dublin to discuss PrEP. ACT UP has mainly been focusing on educating the LGBT community, and the community as whole, around the issue of PrEP. The group has been encouraging the LGBT community to increase its expectations when it comes to state provision of sexual health services. He explained that at present, the National Sexual Health Strategy is developing guidelines for the prescription of PrEP and criteria for who would be able to receive it through the HSE. Their work is also subject to a pharma-economic analysis by the HSE. This is potentially a multi-year process. The HSE is also currently planning a small demonstration project on the use of PrEP.
HIV has been described as a public health emergency in Ireland. The number of HIV diagnoses have been steadily increasing over the past few years. There was a 25% increase in the numbers diagnosed with the virus between 2014 and 2015. The rate of HIV infection in Ireland now stands at 10.6 per 100,000; this is worryingly above the EU average of 6.3 per 100,000. Eamon Ryan, leader of the Green Party, recently stressed the need for PrEP in the Dáil, highlighting the fact that prevention is always better than treatment and management of the virus.
TCDSU voted to lobby for PrEP in the January Council. LGBT Rights Officer, Seán O’Carroll, told me that TCDSU has since worked with ACT UP Dublin to obtain posters and information on PrEP. The SU presented a motion to the USI Congress to get the USI to lobby the government for PrEP, having already begun to place posters around campus with information about the drug.
The cost of prevention
“The lifetime cost of a new HIV diagnosis for the NHS in the UK is £360,000 and requires Truvada, regular medical consultations and blood tests”
Doctors in Ireland may write a prescription for Truvada to be used as PrEP; however, this would be a private prescription and it costs hundreds of euro for a 30-day supply. Unlike in Ireland, generic pills may be bought from online pharmacies by people resident in the UK for personal use. This greatly improves access to PrEP in the UK. For people in Ireland who do manage to get access to PrEP, the GMHS on Baggot Street will provide medical checks. Andrew Leavitt raises the concern that it is not clear whether clinics in other parts of the country will also provide this service free of charge.
It has been estimated that providing PrEP in the UK would cost £5,000 (€5,740) per patient per year, though this cost could soon lower dramatically if generic Truvada comes on the market. However, the lifetime cost of a new HIV diagnosis for the NHS in the UK is £360,000 (€413,080). A HIV diagnosis requires Truvada, regular medical consultations and blood tests. I reached out the HSE to confirm annual cost of treating someone with HIV in Ireland but received no response. Despite the initial cost, providing PrEP seems like a sensible long-term investment as it would dramatically reduce HIV diagnoses.
PEP, post-exposure prophylaxis, is available through the HSE for free in Ireland. This is a high dosage of anti-retroviral, including Truvada, three times daily, that can be used for 28 days after a potential HIV exposure. It is highly successful in preventing HIV from infecting people. However, this high dosage is not ideal for frequent usage and has been likened to using the morning-after pill as contraception. Anyone who thinks they may have been exposed to HIV should attend their local A&E Department within 72 hours of exposure, though the faster the better, and ask for PEP.
“Other groups that could use PrEP, like injecting drug users and sex workers, stand on the edge of society.”
It stands to reason that when there is an effective preventative available people should not be put through needless suffering. It is clear, however, that PrEP is not a mainstream topic as its availability affects a relatively small part of the population. It is commonly argued that PrEP may encourage casual sex and promote engagement of high-risk sexual activities. However, the same argument could be made about the contraceptive pill, something that is legal, readily available and completely normalised. One reason for the resistance to PrEP could be stigma surrounding homosexuality. Despite huge advances in Ireland following the marriage referendum, gay sex is still often viewed as taboo. HIV is still often dubbed a “gay disease” and tied up with irresponsibility. Andrew Leavitt also makes the point that condoms alone have not been effective enough to stop the spread of HIV in Ireland, and that PrEP would provide high-risk groups with an extra level of cover. Other groups that could use PrEP, like injecting drug users and sex workers, stand on the edge of society. Those who are at a high risk of contracting HIV do not stand as a united political front, and it is therefore quite easy for the government to overlook PrEP without huge repercussions.
It is clear that the provision of PrEP through the HSE would help to overcome some of the stigma that these groups face. It would make for a more inclusive society and show marginalised groups that the state cares about their sexual health and wellbeing. It would also facilitate a national conversation on HIV, which is an often-taboo subject. We have already had the “pill debate”, so what makes this debate any different?