PrEP time: A large red ribbon hangs in Washington to mark World Aids Day. Photo: Flickr/Tim Evanson
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Why HIV prevention meds should be available on the NHS now

Pre-exposure HIV prophylaxis (PrEP) involves giving at-risk HIV-negative people a daily dose of HIV medication. Though controversial to some, it is proving highly effective in preventing infection and activists are calling for it to be rolled out immediately.

When I first meet Mario* he’s wearing a bullet-shaped pill holder on the buckle of his belt. He’s just come back from a check -up with his HIV doctor, and he shows me the three-months’ supply of pills he’s just collected from the sexual health clinic. “It’s important not to miss a dose. If I’m out at the weekend and have sex, I know I’ll always have the pills with me” he says, pointing to the pill holder at his waist.

The importance of taking HIV medication at the right time has been drummed into gay men with HIV for the past two decades. But Mario doesn’t have HIV.  He, like an increasing number of gay men, especially in the US, is taking a daily dose of Truvada (a one-pill combination of two HIV drugs more commonly used to treat HIV in those already infected), to prevent getting HIV.

Pre-exposure HIV prophylaxis – or PrEP – hit the headlines in 2010 when the findings of the international iPREX (Pre-exposure Prophylaxis Initiative) study were released. The study found that men taking a daily pill of Truvada almost halved their risk of getting HIV, compared with men in the trial who received a placebo pill. Men who took their pills regularly and consistently reduced that risk by over 90 per cent.

PrEP isn’t currently available on the NHS but over 500 gay men in England have been taking part in a PrEP study called PROUD.  Men in the trial were either prescribed PrEP immediately for two years, or randomised into a deferred arm that gave them PrEP in their second year of the trial. The early closure of the deferred arm last month, following interim data analysis by the trial’s Independent Data Monitoring Committee (with all men being offered PrEP by the end of this year), fast-tracked an emerging debate as to whether PrEP should be prescribed  on the NHS to those most at-risk of acquiring HIV.

The figures speak for themselves: when PrEP is used as prescribed it is highly effective at reducing HIV and, at a time when HIV diagnoses in the UK have never been higher, HIV activists are calling for PrEP to be made available on the NHS with immediate effect.

Yet, PrEP isn’t without controversy.  Just as when the contraceptive pill was introduced in the 1960s, concerns are being voiced that PrEP use will result in condoms being ditched all together, with a spiralling rate of other sexually transmitted infections. Last month, the actor Zachary Quinto voiced his concerns about the new medication, “I have heard too many stories of young people taking PrEP as an insurance policy against their tendency toward unprotected non-monogamous sex”. HIV prevention activists responded: isn’t that exactly how and by whom PrEP should be used?

I’ve spent the past three years interviewing and talking to dozens of gay men about their PrEP use or the circumstances in which they would consider taking PrEP. Contrary to some of the media reports, I’ve found that men are thoughtful, considered and resourceful in how they navigate sexual risk. It’s often complex, and PrEP makes it more so.  Yet, one thing is for sure: simply saying that PrEP will lead to men ditching condoms undermines the complexity of how men think about and negotiate sex and risk. For the men I’ve interviewed, PrEP offers more than protection against HIV: it reduces anxiety or stress when men don’t stick to the safer sex rules they’ve set themselves; it allows for intimacy and closeness between partners when one of them has HIV; and, especially for older men, it offers a potential way of addressing erectile dysfunction when men find it hard to stay hard or climax when they use condoms.

For Mario, the criticisms of PrEP are hard to fathom. “Ninety per cent of the sex I was having was unprotected anyway. I would get anxious after. Being on PrEP hasn’t had an impact on the type of sex I have because I rarely used condoms anyway. But it has had an impact on my anxiety levels and psychological well-being”.

His friend Daniel*, who is also taking PrEP, says it doesn’t mean he’s suddenly stopped using condoms. “I struggle between wanting to be safe and an impulse not to be. I recognise that I have a tendency to put myself in a position that’s marginally dangerous. With PrEP I can stop beating myself up when I occasionally don’t use condoms”.

As evidence around the world stacks up in favour of PrEP, the calls for it to be made available on the NHS will only increase. We now have compelling research on the effectiveness and acceptability of PrEP that didn’t exist even a year ago.  Now’s the time for thoughtful, well-researched and well-resourced action to be taken to make it available on the NHS.

Will Nutland is a Research Fellow at the London School of Hygiene and Tropical Medicine. His doctoral thesis explores the acceptability of PrEP in gay men in London.

* Names have been changed.

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The 2017 Budget will force Philip Hammond to confront the Brexit effect

Rising prices and lost markets are hard to ignore. 

With the Brexit process, Donald Trump and parliamentary by-election aftermath dominating the headlines, you’d be forgiven for missing the speculation we’d normally expect ahead of a Budget next week. Philip Hammond’s demeanour suggests it will be a very low-key affair, living up to his billing as the government’s chief accounting officer. Yet we desperately need a thorough analysis of this government’s economic strategy – and some focused work from those whose job it is to supposedly keep track of government policy.

It seems to me there are four key dynamics the Budget must address:

1. British spending power

The spending power of British consumers is about to be squeezed further. Consumers have propped up the economy since 2015, but higher taxes, suppressed earnings and price inflation are all likely to weigh heavily on this driver for growth from now on. Relatively higher commodity prices and the sterling effect is starting to filter into the high street – which means that the pound in the pocket doesn’t go as far as it used to. The dwindling level of household savings is a casualty of this situation. Real incomes are softer, with poorer returns on assets, and households are substituting with loans and overdrafts. The switch away from consumer-driven growth feels well and truly underway. How will the Chancellor counteract to this?

2. Lagging productivity

Productivity remains a stubborn challenge that government policy is failing to address. Since the 2008 financial crisis, the UK’s productivity performance has lagged Germany, France and the USA, whose employees now produce in an average four days as much as British workers take to produce in five. Perhaps years of uncertainty have seen companies choose to sit on cash rather than invest in new production process technology. Perhaps the dominance of services in our economy, a sector notorious hard in which to drive new efficiencies, explains the productivity lag. But ministers have singularly failed to assess and prioritise investment in those aspects of public services which can boost productivity. These could include easing congestion and aiding commuters; boosting mobile connectivity; targeting high skills; blasting away administrative bureaucracy; helping workers back to work if they’re ill.

3. Lost markets

The Prime Minister’s decision to give up trying to salvage single market membership means we enter the "Great Unknown" trade era unsure how long (if any) our transition will be. We must also remain uncertain whether new Free Trade Agreements (FTAs) are going to go anyway to make up for those lost markets.

New FTAs may get rid of tariffs. But historically they’ve never been much good at knocking down the other barriers for services exports – which explains why the analysis by the National Institute for Economic and Social Research recently projected a 61 per cent fall in services trade with the EU. Brexit will radically transform the likely composition of economic growth in the medium term. It’s true that in the near term, sterling depreciation is likely to bring trade back into balance as exports enjoy an adrenal currency competitive stimulus. But over the medium term, "balance" is likely to come not from new export market volume, but from a withering away of consumer spending power to buy imported goods. Beyond that, the structural imbalance will probably set in again.

4. Empty public wallets

There is a looming disaster facing Britain’s public finances. It’s bad enough that the financial crisis is now pushing the level of public sector debt beyond 90 per cent of our gross domestic product (GDP).  But a quick glance at the Office for Budget Responsibility’s January Fiscal Sustainability Report is enough to make your jaw drop. The debt mountain is projected to grow for the next 50 years. All else being equal, we could end up with an incredible 234 per cent of debt/GDP by 2066 – chiefly because of the ageing population and rising healthcare costs. This isn’t a viable or serviceable level of debt and we shouldn’t take any comfort from the fact that many other economies (Japan, USA) are facing a similar fate. The interest payable on that debt mountain would severely crowd out resources for vital public services. So while some many dream of splashing public spending around on nationalising this or that, of a "universal basic income" or social security giveaways, the cold truth is that we are going to be forced to make more hard decisions on spending now, find new revenues if we want to maintain service standards, and prioritise growth-inducing policies wherever possible.

We do need to foster a new economic model that promotes social mobility, environmental and fiscal sustainability, with long-termism at its heart. But we should be wary of those on the fringes of politics pretending they have either a magic money tree, or a have-cake-and-eat-it trading model once we leap into the tariff-infested waters of WTO rules.

We shouldn’t have to smash up a common sense, balanced approach in order for our country to succeed. A credible, centre-left economic model should combine sound stewardship of taxpayer resources with a fairness agenda that ensures the wealthiest contribute most and the polluter pays. A realistic stimulus should be prioritised in productivity-oriented infrastructure investment. And Britain should reach out and gather new trading alliances in Europe and beyond as a matter of urgency.

In short, the March Budget ought to provide an economic strategy for the long-term. Instead it feels like it will be a staging-post Budget from a distracted Government, going through the motions with an accountancy exercise to get through the 12 months ahead.

Chris Leslie MP was Shadow Chancellor in 2015 and chairs Labour’s PLP Treasury Committee

 

 

 

Chris Leslie is chair of Labour’s backbench Treasury Committee and was shadow Chancellor in 2015.