Several large sexual health clinics in London and Brighton have responded to the growing numbers of people importing PrEP medications from overseas by offering free safety monitoring to PrEP users. This is in a context of increasing frustration with delays to the official NHS process to approve PrEP.
Last August the 56 Dean Street clinic announced that it could provide non-NHS prescriptions for PrEP and the necessary monitoring and clinical support that goes with it. However a month’s supply of branded Truvada costs £400.
Individuals have discovered a more affordable alternative – importing, for their personal use, generic PrEP medications. Tenvir EM, manufactured by the Indian pharmaceutical company Cipla, is available from several online pharmacies for around £45 a month. The active ingredients, tenofovir and emtricitabine, are identical to those in Truvada. While the tablet is primarily manufactured for use in HIV treatment programmes in resource-limited countries, it can be legally imported, for personal use only, into the UK. Individuals can order enough tablets to cover three months, each time they make an order.
Individuals buying generic tablets online have turned to NHS sexual health clinics for support with PrEP, including tests for kidney function and therapeutic drug monitoring (a test which shows whether PrEP drugs are in the bloodstream). While many people have reported a very sympathetic response from particular clinics, others have been refused support or found individual staff members unclear on what their clinic’s policy was.
Yesterday 56 Dean Street announced that they are stepping up the support they will offer to people buying PrEP drugs online. From Monday, they can provide free therapeutic drug monitoring for users to check that the drugs they have purchased are genuine. While Greg Owen of www.iwantprepnow.co.uk hasn't yet heard of anyone being sold counterfeits, this is clearly a point which users may want reassurance on.
The clinic will also continue to provide regular testing for HIV, sexually transmitted infections and kidney function to those using PrEP. They recommend a urine dipstick test to check for protein in the urine every three to four months – if needed this can be followed up with a blood or urine test of kidney function. Once a year, a blood test for kidney function will be provided.
The same services are also available at the John Hunter Clinic (in the Chelsea & Westminster Hospital) and the West London Centre for Sexual Health (in the Charing Cross Hospital) – both are part of the same NHS trust.
Last week the Mortimer Market Centre publicised the fact that it also offers support to PrEP users, including the kidney and sexual health checks. (The Archway Centre, part of the same NHS trust, will offer the same service). This week Mortimer Market clinicians have written pieces in the gay community magazines Boyz and Dirty Boyz on the PrEP service.
Mortimer Market do have some funding to provide therapeutic drug monitoring but need some time to work through the logistics of its provision. 56 Dean Street’s offer of this test is being supported by a grant from the charitable St Stephens AIDS Trust.
Dr Mags Portman of the Mortimer Market Centre commented: “We are aware that people at risk of HIV are accessing PrEP in different ways, including obtaining generic (non-brand) versions cheaply online. We cannot fully endorse this, but are reassured by the fact that the pharmaceutical company Cipla, a commonly used generic supplier, has been approved by the US FDA. At Mortimer Market we believe that we have a responsibility towards people who are buying PrEP online, to keep them as safe as possible and are happy to see people who need PrEP monitoring.”
In Brighton, the Claude Nicole Centre is able to offer advice on PrEP and regular kidney and sexual health checks to users.
A number of London clinics, including the Burrell Street Clinic, the Camberwell Sexual Health Centre and the Barts Sexual Health Centre, are in the process of agreeing the services they can offer.
A position statement from the British HIV Association and the British Association for Sexual Health and HIV states that clinicians need to know how to respond to patients who are seeking PrEP or purchasing it online.
With increasing numbers of people importing tablets for PrEP, there are clearly risks that the medication will occasionally be used in a way which harms a user’s health (for example, after seroconverting to HIV or by somebody with impaired kidney function). The clinical support that is now being offered reduces those risks although it’s unlikely that everyone who needs it will seek it out.
Moreover leaving PrEP to those who can afford it is likely to deepen health inequalities and limit the number of people using PrEP – meaning that it is unlikely to have a significant impact on the rate of new HIV infections. However a large NHS PrEP programme, in combination with other improvements to prevention, could result in significantly fewer HIV infections in gay men.