HIV PrEP in Scotland - Free to end-user - First Year Report

[Jim Allen]

Spotted this on twitter this morning. Schotland published a report on its first year of free PrEP to end users today, very encouraging results and, hopefully a lesson other healthcare systems & nations camn learn from.

For those of you with twitter there is a 2 min video from HIV Scotland's Chief executive officer https://twitter.com/HIVScotland/status/1100335868705947648

Full Report: https://www.hps.scot.nhs.uk/pubs/detail.aspx?id=3669

In short:

Scotland is one of the first countries worldwide to have successfully established a HIV PrEP (HIV Pre-Exposure Prophylaxis) service which is national, free at the point of delivery and, to date, generally accessible to most deemed at highest risk of acquiring HIV. 

This report is published on behalf of the HIV PrEP National Coordination Group and is from the first year of the HIV PrEP service from July 2017 to June 2018

Monitoring the Uptake of PrEP in Scotland

• 1,872 individuals were prescribed PrEP at least once in the first year of the Scottish NHS PrEP programme
• 99% of those prescribed PrEP were MSM; the majority reported condomless anal sex with multiple partners as a reason for being eligible for NHS PrEP.
• 39% of those prescribed PrEP were in the age range 20-29 years and almost a third were aged 40 or above.
• The majority (74%) of those prescribed PrEP were prescribed a daily regimen rather than an event based one; around 1 in 10 patients were prescribed both types of regimen.
• Around one fifth of those prescribed PrEP were attending sexual health services for the very first time or for the first time in NaSH history; this suggests that PrEP is drawing patients in to services who are at high risk for HIV and other STIs.

Evaluating the Impact of HIV PrEP

• Less than five (1 to 4) MSM prescribed PrEP (at least once) HIV seroconverted; further investigations showed that PrEP drug levels were below protective levels at the time of suspected HIV acquisition.
• The majority of the 1,846 MSM prescribed PrEP were commenced on it during JulyDecember 2017; accordingly, around 1000 person years of exposure post-initiation of PrEP was experienced during the first year. This means that the incidence of HIV among this group for the period July 2017-June 2018 was 0.1% - 0.4% (1-4 per 1000).
• Among those prescribed PrEP, rates of gonorrhoea (including rectal) testing and numbers diagnosed positive increased between the two 12 month periods either side of NHS PrEP introduction but rates of actual infection remained similar. Such rates were higher among those ever versus never prescribed PrEP; this observation indicates that the former are at higher risk of gonorrhea (and therefore HIV) infection and that the eligibility criteria for PrEP are likely to be appropriate.
• Similar observations were recorded for chlamydia with an increase in testing and diagnoses among MSM ever prescribed PrEP but no overall change in the proportion positive pre and during the first year of NHS PrEP.
• The increases in gonorrhoea and chlamydia diagnoses could be attributed to either improved detection, an actual increase in the incidence of infection or a combination of both; the explanation is likely to be the “combination” one but the ratio of the contributions is uncertain.

Conclusion

• In conclusion, Scotland is one of the first countries worldwide to have successfully
  established a PrEP service which is truly national, free at the point of delivery and, to
  date, generally accessible to most deemed at high risk of acquiring HIV. In terms of HIV prevention, the early signs are favourable. While it is too early to draw conclusions on the impact of PrEP on high risk sexual behaviour and other STIs, there are some pointers suggesting an increase; but any possible increase is likely to be offset by PrEP’s HIV impact and its ability to attract people at risk of HIV who would not normally access sexual health services and who, consequently, can reap the benefits of these.
• On a cautionary note, the success of the service implementation, and the cumulative nature of PrEP uptake, means that pressures on sexual health services which have already caused difficulties affecting both users and providers will continue to increase unless additional resources or efficiencies are identified. In year two, a formal evaluation of that impact is being undertaken.