NHS can fund HIV prevention drug, court rulesBMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i6082 (Published 10 November 2016) Cite this as: BMJ 2016;355:i6082
NHS England does have the power to commission pre-exposure prophylaxis (PrEP) for HIV infection, the Court of Appeal has found in a ruling that will please local authorities but could cause anxiety for users of other specialised health services.
The case arose out of the refusal of NHS England to include PrEP in a list of specialist services it was considering. It argued that prevention of HIV infection was a public health obligation and fell outside its area of responsibility and therefore that local authorities should pick up the tab.1 2 3 4
The decision was challenged by the National Aids Trust, which won in the High Court and has now defeated an appeal brought by NHS England in the appeal court. The ruling does not mean that NHS England is compelled to commission PrEP, at a cost estimated to run between £10m (€11.2m; $12.4m) and £20m a year, but that it must consider doing so alongside other claims on the money.
NHS England responded to the judgment by saying that it would move quickly to consider whether it should commission PrEP. It would also open discussions with local authorities about how, if it decides to pay for PrEP, the treatment should be administered. In addition, it will open discussions with the manufacturer (Gilead Sciences) about the “excessively high pricing” of the drug used in PrEP, Truvada (tenofovir disoproxil/emtricitabine), and explore options for using generic versions.
Deborah Gold, chief executive of the National Aids Trust, said, “We are delighted to have been vindicated by the court a second time. HIV is a critical issue in the UK, where over 4000 people acquire HIV every year. PrEP works, it saves money, and most importantly it has the power to prevent HIV acquisition for thousands of people, at the same time as beginning to end the HIV epidemic. This judgment brings that possibility one step closer.
“We look forward to what we hope will be a balanced and evidence based decision on PrEP by NHS England, as well the opportunity to work alongside NHS England collaboratively for the benefit of people living with and at risk of HIV.”
Izzi Seccombe, chair of the Local Government Association’s community wellbeing board, said, “We are pleased that today’s ruling by the Court of Appeal confirms our position that NHS England has the power to commission the HIV treatment PrEP. We were disappointed that NHS England chose to challenge the High Court decision, at great expense to the taxpayer and at a time when council and health budgets are under huge pressures.”
The focus will now turn to NHS England’s Clinical Priorities Advisory Group (CPAG), which will consider PrEP alongside other claims. A refusal there would raise the suspicion that the lengthy legal arguments were simply a cover for a reluctance to fund PrEP that NHS England was unwilling to acknowledge or were a delaying tactic until a generic version became available.
One way out might be to recommend PrEP only before and after sex, not daily, an option that has been shown to work in a trial in France and Canada and would roughly halve the cost, figures from the National Institute for Health and Care Excellence show.5
Richard Torbett, executive director (commercial) at the Association of the British Pharmaceutical Industry, said that NHS England should make the drugs available without delay.
“This case shows that NHS England’s existing system for specialised commissioning is opaque and unpredictable. Instead of attempting to negotiate pricing through press releases, we believe that NHS England should comprehensively assess the value of a medicine to patients, through a clearly laid out commissioning and decision making process.”