Intended for healthcare professionals


Funding PrEP for HIV prevention

BMJ 2016; 354 doi: (Published 05 July 2016) Cite this as: BMJ 2016;354:i3515
  1. Jim McManus, director of public health1,
  2. Dominic Harrison, director of public health2
  1. 1Hertfordshire County Council, Hertford, UK
  2. 2Blackburn with Darwen Borough Council, Blackburn BB1 7DY, UK
  1. Correspondence to: D Harrison Dominic.Harrison{at}

Delays by NHS England will cost lives—it’s time to do the right thing

Despite overwhelming evidence that pre-exposure prophylaxis (PrEP) against HIV infection is largely safe, effective,1 2 3 4 and cost effective,4 5 6 7 NHS England has declined to make it available on the NHS, arguing that HIV prevention is the responsibility of local government.8

NHS England’s apparent appetite for legalistic cost shunting,9 and its argument that it does not have the legal power to commission PrEP,8 is regrettable. Such an approach confounds its advocacy of a health and care system integrated around the best outcomes for the citizen and perpetuates an incoherent national approach to HIV prevention.

PrEP has undoubtedly attracted some moral panic.10 11 Yet the clinical principle is not dissimilar to that of antimalarials, used to prevent malaria when travelling in at-risk environments. In population health, PrEP’s role is comparable to the function of vaccinations and immunisations, which NHS England does fund.

HIV risks do not just have personal health consequences. The more undiagnosed and untreated individuals there are, the greater the risk of continued population spread. By taking PrEP, people at high risk of HIV infection substantially reduce that spread.12 13 14 Prophylaxis cuts the risk of the virus entering cells and replicating, and helps prevent people becoming vectors for further transmission.

Although PrEP is not 100% effective, the US Centers for Disease Prevention and Control is unequivocal about its population health benefits.15 Studies show that PrEP reduces the risk of getting HIV from sex by more than 90% when used consistently.16 Among people who inject drugs, PrEP reduces the risk of getting HIV by more than 70% when used consistently.17 PrEP is a key reason why “treatment as prevention” is an attractive strategy to reduce or even end HIV transmission.18 As increasing numbers of commentators claim, the long term fiscal and health benefits of treatment as prevention strategies, including PrEP, will return substantial dividends for health systems.19

In the US many citizens now access PrEP through health insurance plans or for free via charity or voluntary sector agencies, but Europe languishes in indecision. Temporary orders in France enable some access, while private purchase, often online, remains a primary route in England. Clearly, this route is open only to those who can afford it.

NHS England has at least adopted a clinical policy of treatment as prevention for adults already infected,20 but England still lacks a coherent strategy to eliminate HIV or achieve the UNAIDS 90-90-90 aspirations that “by 2020, 90% of all people living with HIV will know their HIV status ... 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy [and] 90% of all people receiving antiretroviral therapy will have viral suppression.”21

PrEP has now been referred to the National Institute for Health and Care Excellence (NICE), and NHS England has put £2m into a pilot for a few areas “to research how PrEP could be commissioned in the most clinically and cost effective way.”22 This has been widely criticised as a delaying tactic.23

NHS England should admit that it can legally fund PrEP if it wants to. Under the Health and Social Care Act 2012, it can commission services directly with “specialised commissioning investment” after consideration of several factors, including “the number of individuals who require the provision of the service or facility; the cost of providing the service or facility; the number of persons able to provide the service or facility; and the financial implications for clinical commissioning groups.” PrEP should be allowed to compete on a level playing field against all other candidate interventions for such specialised commissioning investment.24

Local authorities are still reeling from a 9.6% cut in the public health grant up to 2020 on top of a 6.2% cut in year in 2015-16, which the Treasury imposed in November 2015 with no reductions in delegated responsibilities. If NHS England wants local authorities to fund PrEP, it has to give them the money to do it.

Whatever route is finally chosen to fund PrEP, bouncing the decision across systems that are all funded by the same taxpayer will inevitably result in the continued and preventable further spread of HIV. This will generate avoidable mortality and increase future NHS costs for treatment. Perhaps it is time for NHS England just to “do the right thing.”


  • Personal view: doi: 10.1136/bmj.i3160
  • News: doi: 10.1136/bmj.i3126
  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we are both responsible for local authority sexual health budgets. JMcM is a board member of the Association of Directors of Public Health, which represents the interests of directors of public health and is also a trustee of Catholics for AIDS Prevention and Support.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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