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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Let's seize our chance of a progressive alliance in Richmond - or we'll all be losers

Labour MPs have been brave to talk about standing aside. 

Earlier this week something quite remarkable happened. Three Labour MPs, from across the party’s political spectrum, came together to urge their party to consider not fielding a candidate in the Richmond Park by-election. In the face of a powerful central party machine, it was extremely brave of them to do what was, until very recently, almost unthinkable: suggest that people vote for a party that wasn’t their own.
Just after the piece from Lisa Nandy, Clive Lewis and Jonathan Reynolds was published, I headed down to the Richmond Park constituency to meet local Green members. It felt like a big moment – an opportunity to be part of something truly ground-breaking – and we had a healthy discussion about the options on the table. Rightly, the decision about whether to stand in elections is always down to local parties, and ultimately the sense from the local members present was that it would be difficult  not to field a candidate unless Labour did the same. Sadly, even as we spoke, the Labour party hierarchy was busily pouring cold water on the idea of working together to beat the Conservatives. The old politics dies hard - and it will not die unless and until all parties are prepared to balance local priorities with the bigger picture.
A pact of any kind would not simply be about some parties standing down or aside. It would be about us all, collectively, standing together and stepping forward in a united bid to be better than what is currently on offer. And it would be a chance to show that building trust now, not just banking it for the future, can cement a better deal for local residents. There could be reciprocal commitments for local elections, for example, creating further opportunities for progressive voices to come to the fore.
While we’ve been debating the merits of this progressive pact in public, the Conservatives and Ukip have, quietly, formed an alliance of their own around Zac Goldsmith. In this regressive alliance, the right is rallying around a candidate who voted to pull Britain out of Europe against the wishes of his constituency, a man who shocked many by running a divisive and nasty campaign to be mayor of London. There’s a sad irony in the fact it’s the voices of division that are proving so effective at advancing their shared goals, while proponents of co-operation cannot get off the starting line.
Leadership is as much about listening as anything else. What I heard on Wednesday was a local party that is passionate about talking to people and sharing what the Greens have to offer. They are proud members of our party for a reason – because they know we stand for something unique, and they have high hopes of winning local elections in the area.  No doubt the leaders of the other progressive parties are hearing the same.
Forming a progressive alliance would be the start of something big. At the core of any such agreement must be a commitment to electoral reform - and breaking open politics for good. No longer could parties choose to listen only to a handful of swing voters in key constituencies, to the exclusion of everyone else. Not many people enjoy talking about the voting system – for most, it’s boring – but as people increasingly clamour for more power in their hands, this could really have been a moment to seize.
Time is running out to select a genuine "unity" candidate through an open primary process. I admit that the most likely alternative - uniting behind a Liberal Democrat candidate in Richmond Park - doesn’t sit easily with me, especially after their role in the vindictive Coalition government.  But politics is about making difficult choices at the right moment, and this is one I wanted to actively explore, because the situation we’re in is just so dire. There is a difference between the Conservatives and the Lib Dems. Failing to realise that plays into the hands of Theresa May more than anyone else.
And, to be frank, I'm deeply worried. Just look at one very specific, very local issue and you’ll perhaps understand where I'm coming from. It’s the state of the NHS in Brighton and Hove – it’s a system that’s been so cut up by marketisation and so woefully underfunded that it’s at breaking point. Our hospital is in special measures, six GP surgeries have shut down and private firms have been operating ambulances without a license. Just imagine what that health service will look like in ten years, with a Conservative party still in charge after beating a divided left at another general election.
And then there is Brexit. We’re hurtling down a very dangerous road – which could see us out of the EU, with closed borders and an economy in tatters. It’s my belief that a vote for a non-Brexiteer in Richmond Park would be a hammer blow to Conservatives at a time when they’re trying to remould the country in their own image after a narrow win for the Leave side in the referendum.
The Green party will fight a passionate and organised campaign in Richmond Park – I was blown away by the commitment of members, and I know they’ll be hitting the ground running this weekend. On the ballot on 1 December there will only be one party saying no to new runways, rejecting nuclear weapons and nuclear power and proposing a radical overhaul of our politics and democracy. I’ll go to the constituency to campaign because we are a fundamentally unique party – saying things that others refuse to say – but I won’t pretend that I don’t wish we could have done things differently.

I believe that moments like this don’t come along very often – but they require the will of all parties involved to realise their potential. Ultimately, until other leaders of progressive parties face the electoral facts, we are all losers, no matter who wins in Richmond Park.


Caroline Lucas is the MP for Brighton Pavilion.