Written evidence submitted by the Terence Higgins Trust (PHA0019)

About Terrence Higgins Trust

Terrence Higgins Trust is the UK’s leading HIV and sexual health charity. We support people living with HIV and ensure their voices are heard, provide testing services for HIV and other sexually transmitted infections, and help the people using our services to achieve good sexual health.

Our vision is a world where people with HIV live healthy lives free from prejudice and discrimination, and good sexual health is a right and reality for all.

We were one of three organization that founded the HIV Commission, which in 2020 recommended that the HIV prevention pill PrEP be available in community pharmacies across England and other settings beyond sexual health services.[1]

Recommendation: The HIV-prevention medication PrEP is made available through community pharmacies, with clear financial accountability for its provision.
 

Intro

We believe that community pharmacies have the potential to support the expansion of access to HIV prevention tools – and in doing so, could be a critical component of ending new cases of HIV by 2030.

The Government’s Primary Care Recovery Plan recognises the potential that pharmacies have to accelerate and expand access to prescription medications, including for contraception and urinary tract infections.

As locations that already dispense emergency hormone contraception, we believe pharmacies are well placed to provide other sexual health care. The HIV prevention pill PrEP, which is currently only accessible through sexual health services, should be part of this expansion.  

This would serve three critical purposes:

1.      Improve access for people who want to take PrEP but currently face barriers to getting it.

2.      Increase uptake amongst people who are currently not seeking PrEP but could benefit from it, and ensure PrEP is accessible and acceptable for them.

3.      Relieve pressure on sexual health services and free up clinical time for more complex patients and outreach work.

Pharmacies have the potential to relieve pressure on secondary care and GPs services and to expand access to healthcare for patients if funded properly to do so. It is welcome that the Government’s ‘Pharmacy First’ ambition recognises this, but PrEP is currently missing from plans to make prescription medications more accessible to patients through pharmacies.

The HIV Action Plan

The Government’s HIV Action Plan committed that:

We will develop a plan for provision of PrEP in settings beyond sexual and reproductive health services.[2]

Terrence Higgins Trust welcomed this commitment, which followed a recommendation by the HIV Commission that:

There must be clear financial accountability and responsibility for PrEP provision beyond sexual health clinics (for example, in GP surgeries, maternity units, gender clinics and pharmacies). This should include promotion to improve awareness and uptake for all communities who will benefit from PrEP.[3]

However, there has been little progress on this commitment since the launch of the HIV Action Plan in 2021 and the Government’s annual report on progress against the HIV Action Plan does not mention the issue.

UKHSA and the University of Bristol are planning a pilot project delivering PrEP in pharmacies – in recognition that this could be a preferable route for groups currently less likely to access PrEP through sexual health services.[4]

PrEP Access

The Government’s commitment to develop a plan for PrEP provision beyond sexual health services was in recognition that PrEP access must be expanded.[5]

PrEP has been a key factor in driving down new HIV transmissions amongst gay, bisexual and men who have sex with men. However, there is no evidence of a fall in transmissions in the last two years for heterosexual men or women of any ethnicity. UKHSA data shows stark inequalities in whether someone with a PrEP need has their need identified in a clinical consultation and whether those who have their need identified go on to initiate PrEP.[6]

Heterosexual and bisexual women with a PrEP need are currently the group least likely to have their PrEP need identified in a clinical consultation and least likely to initiate PrEP. By ethnicity, Black African, Black Caribbean and Black ‘other’ people are the three groups least likely to have their PrEP need identified in the course of an HIV clinic appointment and to initiate PrEP if their need is identified.

Research by Terrence Higgins Trust and other HIV charities last year identified that even people proactively seeking PrEP are often struggling to get it. Nearly 60% of people trying to access PrEP had had to wait more than 12 weeks for it and sadly we are aware of people who have acquired HIV while waiting – new transmissions that were entirely preventable.[7]

Making PrEP available in Pharmacies

Pharmacies are an ideal additional location for expanding PrEP access. They are accessible to patients who may be less likely to be reached by secondary care services. Longer hours and weekend opening times are more suitable for people unable to attend services in the working day or who have childcare responsibilities.

Pharmacists already carry out Medicines Use Reviews for patients, so would be well-placed to counsel on PrEP and manage prescriptions, including as part of holistic assessment of other medications. They are well connected to other parts of the health service and can refer patients. There are services currently provided by pharmacies that act as a bridge between secondary and primary care that this would complement: sexual health prevention and treatment services, advice, Emergency Hormone Contraception, chlamydia screening, signposting and referral.

Upcoming clinical guidelines on PrEP from by British HIV Association and British Association for Sexual Health and HIV will suggest that PrEP provision be commissioned outside of specialist sexual health services, in community pharmacies, drug and alcohol services, primary care and in community settings. We also expect guidelines will change to recommend sexual health clinics dispense six rather than three-month PrEP prescriptions.

Making PrEP available in pharmacies would require the service to be commissioned. To prescribe PrEP, pharmacists would need to be able to:

• Access PrEP from NHS England without a prescription charge, in the way that sexual health clinics can
• Arrange initial HIV and renal testing, and then annual monitoring
• Refer patients who tested positive for HIV to local services
• Support or link in with local HIV promotion activities to increase knowledge and awareness of PrEP

The Government’s Primary Care Recovery Plan and ‘Pharmacy First’ ambition should provide an opportunity to take this forward. Representatives of pharmacists are themselves calling for PrEP to be available in their services. In December 2021, the Royal Pharmaceutical Society urged the Government to make PrEP available through community pharmacies as soon as possible.[8]

Sexual health services should remain a key route to accessing PrEP – and it is vitally important that they are properly resourced to relieve capacity issues and meet PrEP need. However, widening access to pharmacies would alleviate pressure and expand access. Especially in towns and rural areas, where pharmacies are often more accessible than sexual health services.

Unlocking the potential of pharmacies – which are often on the frontline of community health care – will be vital in tackling health inequalities, expanding PrEP access and ending new cases of HIV by 2030.