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Preparing for PrEP; the cost of delaying universal access in England
  1. Sally Jewsbury,
  2. Anna Garner,
  3. Michael Redmond,
  4. Cara Saxon,
  5. Siew Yan Teo,
  6. Chris James Ward,
  7. Orla McQuillan
  1. The Northen Contraceptive Sexual Health and HIV Service, Manchester University NHS Foundation Trust, Manchester, UK
  1. Correspondence to Dr Sally Jewsbury, The Northen Contraceptive Sexual Health and HIV Service, Manchester University NHS Foundation Trust, Manchester M13 9WL, UK; sally.jewsbury{at}


Objectives Pre-exposure prophylaxis (PrEP) is not commissioned within National Health Service (NHS) England. Individuals can access it privately online or by enrolment into a clinical trial. We established a list of individuals not enrolled in trials, awaiting PrEP. In response to the observation that patients awaiting PrEP trials were being referred with newly diagnosed HIV, we aimed to measure attendance, incident HIV, STI acquisition and missed opportunities for prevention.

Methods The search was conducted for patients on the list from November 2017 to November 2019. We examined the electronic clinical records of those on the list and extracted demographic information, STI and HIV diagnoses. In addition, for those diagnosed with HIV, we reviewed risk factors including chemsex and prior postexposure prophylaxis.

Results There were 1073 patients on list, and 520 (48.6%) were still awaiting recruitment in a PrEP trial. Eight (0.75%) had an enrolment appointment booked while 200 (18.64%) had been contacted and deemed ineligible according to PrEP trial criteria. 45 (32.15%) had not responded to contact. We identified 15 new HIV infections in patients awaiting PrEP. Of these, 9/15 (60.00%) did not meet eligibility criteria at point of contact, though had been eligible at first referral.

Conclusion It is unacceptable that 15 patients acquired HIV while waiting. The individual lifetime cost of treating HIV is estimated at £360 800(1). This equals £5 412 000 for these 15 infections notwithstanding the psychological and physical burden. We advocate the immediate role out of universal PrEP for those who need it on the NHS. While this decision is delayed, harm is coming to those waiting. Wider provision of PrEP may encourage increased attendance, but must consider additional resources to accommodate added visits. We are relieved that at the point of final submission (21 March 2020) NHS England have recently announced funding of PrEP for eligible patients from, further details are pending.

  • HIV
  • prep
  • prevention
  • policy

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  • Handling editor Jason J Ong

  • Twitter @sallyjewsbury

  • Contributors This paper was conceived by SJ, CW and OM. All authors contributed to data collection. SJ wrote the first draft of the article, with further contributions from CS, SYT, CW and OM. MR conducted the data searches and SJ conducted the descriptive analysis. All authors provided intellectual content, reviewed successive drafts and approved the final version of the article.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.