Lords can’t say the “B” on HIV

Last night at 7.23pm the House of Lords held a short debate around HIV and access to PrEP, pre-exposure prophylaxis, the drug treatment currently considered one of the effective ways of minimising transmission and infection.

It was a good debate but notable for only ever talking about “gay men” – bisexuals were pretty thoroughly erased.

Lord Black of Brentwood opened the debate with a question:

To ask Her Majesty’s Government what plans they have to move toward the elimination of HIV infection in the United Kingdom.

He continued:
Black_BrentwoodIt is just over 35 years since the first reports in the US media of an unidentified illness that seemed disproportionately to affect gay men and to kill them. What was identified as the human immunodeficiency virus, an incurable disease, left a generation of those infected facing certain death. Many more living in its shadows had their lives shaped by it. However, 35 years on we have turned the horror of HIV/AIDS from a death sentence into a manageable chronic condition through the use of antiretroviral treatment. That we can today even begin to contemplate its elimination is a tribute to many brave and visionary people. There is not time to name them all tonight but I want to make two exceptions. The first is to praise the campaigning groups, especially the National AIDS Trust and the Terrence Higgins Trust, which fought tirelessly to keep this issue on the front line of the public health agenda. The second, on this very important day for him, is to recall the vital role that our new Lord Speaker played in the earliest days of this epidemic. As Secretary of State Fowler, he showed enormous courage in tackling the issue, and in doing so saved thousands of lives. Our gratitude to him is eternal.
And considered the state of sex education today:

Improving education about HIV and sexually transmitted illnesses more generally would also be of real benefit, especially as the increase in HIV incidence among young people is particularly sharp, up 70% in the last three years. It is time to look again at what is being taught about this issue, particularly as Department for Education guidance is now 16 years old.

It is really important for young people to understand about HIV and to learn how to avoid it through condom use, but also to be taught the importance of being supportive of those living with HIV and not to fear or stigmatise them.

Lord Scriven also challenged the government:

I am not going to concentrate significantly on the key issues already raised about education, access to testing, treatment and stigma—although I shall come back to the point about stigma. I will major on one issue—that of PrEP, a treatment to stop the replication and transmission of HIV within the UK. It is a treatment widely available in France, the United States, Israel and Kenya, and other countries are using it. It is a treatment that Public Health England modelled: if PrEP were widely available to high-risk groups, particularly men who have sex with men, it could prevent 7,400 cases by 2020.

Noble Lords have already referred to the PROUD study, which showed that the treatment is 86% effective in preventing HIV transmission, and also to the cost. The noble Lord, Lord Black of Brentwood, made it very clear that the lifetime cost of treating somebody with HIV is up to £380,000; the cost of PrEP is £400 a month. That is the equivalent of 83 years’ worth of PrEP to treat one person living with HIV. The economics are not questionable in terms of the costs of PrEP.

So how have we got to the position whereby two parts of government are slugging it out in court over who is going to pay for this preventive treatment? Interestingly, as I am sure the Minister is aware, both parts of government are funded by the Department of Health. Local government’s prevention is funded by the Department of Health, as is NHS England. In July, I asked House of Lords Question 1425—what stops the Secretary of State intervening and asking the Department of Health to commission PrEP? I got a very nice Answer about NICE, but I did not get the answer to my Question. So I will ask the Minister: what legislation stops the Secretary of State tonight telling NHS England that it can commission PrEP?

Baroness Walmsley commented:

Joan_WalmsleyWhy, then, when the number of diagnoses is rising, does the NHS refuse to make use of or fund PrEP—the most effective preventive treatment yet devised, as we have heard very clearly—and then appeal the decision of the High Court? I find it very difficult to understand why the NHS wants to spend its money on lawyers instead of treatments. We have to balance the cost of treating a patient pre-infection against the cost of treating the disease if it happens, as well as against the loss to the public purse of the talents of that person and the taxes that would be paid if he or she was fit and healthy and not suffering from HIV.

[…]

Surely, pre-infection prophylaxis of such a dangerous disease corresponds to many of the vaccination and supplement programmes that have saved the lives of babies and children over the years.

In a lengthy reply for the government, Lord Prior of Brampton observed:

My Lords, this has been a very good debate and everyone who contributed to it has had something of interest to say. For me it has been a wake-up call. As has been reflected in a number of speeches, I thought this problem had somehow been sorted out, but clearly it has not been.

He noted further that:

There is no intention at all on the part of NHS England or the Government to discriminate in any way against the use of PrEP because of people’s lifestyle choices. I can give that absolute assurance to noble Lords. The appeal is taking place on 15 September and I cannot comment further on the court case, but I can assure noble Lords that the decision on whether or not to use PrEP will be assessed in an absolutely normal way.

I will make just one last comment, which I do not expect some Members of this House to agree with. The decisions about which drugs to prioritise and how to prioritise drugs should surely be made by clinicians and NHS England, not politicians. The noble Lord is shaking his head but that is the whole thrust of the way that the NHS has been set up, and the involvement of politicians in picking one drug against another is surely not the right way forward. I have to leave it as it stands.