Dr Will Nutland Explains the History of PrEP in England


Will Nutland, DrPH, is cofounder of PrEPster, an honorary assistant professor at the London School of Hygiene and Tropical Medicine, and an activist.

Will Nutland, DrPH, is cofounder of PrEPster, an honorary assistant professor at the London School of Hygiene and Tropical Medicine, and an activist. PrEPster, based in England, was established in October 2015 to educate communities in England about pre-exposure prophylaxis (PrEP) and how to access it, and to advocate for political progress in establishing the availability of PrEP in England and beyond.


Can you discuss the history of PrEP availability in England?

For England, PrEP has been available for free through our fantastic National Health Service for just over a year, about 18 months. Prior to that, PrEP was available through a clinical trial called the Impact trial that made PrEP available for free in England to 25,000 of us. I was one of the participants on that trial. Prior to the trials starting, there was another small-scale trial of 550 gay and bisexual men that finished in 2014. And for those people who were unsuccessful in being able to get PrEP through the PROUD trial, and then in between the PROUD trial finishing and the IMPACT trial starting, the vast majority of us who were sourcing PrEP at that time were buying generic PrEP online from generic pharmacies.

One of the things that PrEPster did, alongside some of our colleagues, was to do pill testing on the generic PrEP that we were buying online. There's been lots of scary stories about whether it's safe to buy PrEP online or any drug online. Are we buying the real things? Are we going to get ripped off? And so we worked with some great clinical colleagues to do 2 things: One of them is PrEPster did secret shopper pill testing. We bought the pills and then we had them lab tested. And prior to that, a set of our colleagues based in sexual health clinics actually drew the blood from those of us who were taking those PrEP drugs, to determine whether we had the correct levels of drug in our body from the pills that we were taking.

So PrEP has been kind of available both on trials through our National Health Service and through those of us who were buying generic PrEP online for about 10 years. We estimate there are around 45,000 to 50,000 people in the UK right now who are either currently taking PrEP or have taken PrEP.

But as with other parts of the world, we know that lots of people stopped using PrEP or changed how they use PrEP because of COVID. Lots of people stopped having sex or had sex differently. Right now in England, if you want to access PrEP, you can go to one of our many National Health Service sexual health clinics. Almost every sexual health clinic in the UK now provides PrEP for free. I want to reiterate, we have a free National Health Service, something that we are all immensely proud of. I mean, it does have its problems, but it's also a brilliant system.

So you can go into your sexual health service. Most people will leave their initial PrEP assessment with at least 1 bottle of PrEP in their hands so they can start PrEP immediately. You will also be given an HIV test, a kidney function test, and a full screening for sexually transmitted infections [STIs]. Lots of clinics now have moved to a system whereby once you've had that first test, your follow-up clinic appointments every 3 months might be a phone assessment; you will be sent your HIV and your STI testing kits through the post, you'll do them at home, and then you'll get your results back; and then your PrEP will be will be sent to you through the mail.

The perverse thing about living through this awful situation with COVID is it's actually forced some more rapid change into how sexual health services and access to PrEP happens. Most of the people in the UK who use PrEP are gay and bisexual men. We've got a lot more work to do, as I know is the case in many other parts of the world, to increase PrEP awareness to some of the other groups of people who could benefit from it and to make sure that PrEP is available within those settings that those people ordinarily use.

For example, we know Black African women, who are one of the groups who are disproportionately impacted by HIV across Europe, are much less likely to seek their sexual health care from a sexual health clinic. Instead, they're much more likely to seek that care from their family doctors or their GP, or general practitioners, as we call them here. And yet, right now, PrEP is not widely available from GP centers or our primary care providers. We're hoping that's going to change.

We're also hoping that we can look at ways that PrEP can be available from pharmacies, from chemists’ shops—not necessarily all of them, but some that would be able to offer a specialist service, making PrEP much more available from a high street setting rather than from sexual health services that right now often have long waiting lists, long waiting times, and many of them are not providing in-person appointments because of issues around COVID.

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