“Welcome to a country where we do have a full NHS-delivered programme for PrEP, with no upper limit,” began Dr Rak Nandwani of NHS Glasgow and Clyde as he outlined Scotland’s experience to the joint conference of the British HIV Association (BHIVA) and British Association for Sexual Health and HIV (BASHH) in Edinburgh yesterday.
In the first eight months of the programme, since last July, 1295 people have been prescribed pre-exposure propylaxis (PrEP). Of these, 1254 are gay, bisexual or other men who have sex with men (MSM) and ten are women. (Data on the gender and sexuality of the last 31 participants are missing.)
One in eight MSM who have attended sexual health clinics since July have been prescribed PrEP.
Demand has greatly exceeded expectations – policy makers had anticipated that 1000 people would be prescribed PrEP in the first year of a programme. While leaflets to explain PrEP have been developed and there has been some work to build understanding of PrEP among GPs and healthcare professionals outside of sexual health, there haven’t been any major campaigns to raise awareness of PrEP. A lack of targeted campaigns does run the risk of limiting PrEP provision to communities where there is already some knowledge and awareness of PrEP.
In terms of age, 40% of PrEP users are in their teens or twenties, 29% are in their thirties, and 30% are over the age of 40. PrEP has been provided in 11 of the 14 Scottish health boards.
In line with UK guidelines, gay men can take PrEP either with daily dosing or event-based dosing. Daily dosing has been chosen by 82%, event-based dosing by 14% and 3% have switched between the two.
The availability of PrEP has brought new people into contact with sexual health services. Of 1780 people who said that PrEP was the reason they had attended, 18% had no previous record on the electronic patient record and 27% were attending for the first time in over two years. Attracting these people is welcome, but it has created an extra workload and reduced capacity for other groups of patients.
A poster from Dr Rachel Drayton of Cardiff Royal Infirmary outlined the roll-out in Wales over the same period of time – 386 people have been prescribed PrEP (the expectation was for 500 people in the first year). Again, almost all are MSM, most often living in the south east of the country. Daily dosing has been chosen by 94%.
Just under one in five PrEP users are over the age of 45 and kidney problems have been a greater issue than had been anticipated, based on the experience of previous studies which recruited a younger population. Among 261 potential PrEP users, 11 did not start PrEP for kidney reasons, 18 who did start PrEP have needed extra monitoring and specialist clinical support and 3 have stopped taking PrEP because of kidney issues.
When PrEP users are older, have pre-existing health conditions or are taking others medications, PrEP can be more complex to manage for clinicians. This has also been an issue in Scotland and has implications for how sexual health clinics organise their PrEP services. Training nurses to provide most aspects of PrEP (including prescriptions under a Patient Group Direction) will allow more people to be seen, but senior doctors need to be available for medically complex cases.