On Tuesday 2nd August a High Court judge ordered the NHS to provide daily pills to 10,000 gay men who don’t have HIV but are at high risk of being infected through unprotected sex. It will cost taxpayers in England £400 a patient, about £20 million a year.
The drug, Truvada, pre-exposure prophylaxis, known as PrEP (Prep) is given to high-risk groups, mainly young promiscuous men. It’s currently used in the US, Canada, Australia and France to help protect the most at-risk gay men. Alex Craddock who runs a website called, ‘I Want Prep Now,’ told Channel 4 News that he currently orders a generic version of Prep online from India at £45 a month.
NHS England which funds drugs for cure, rather than prevention, had refused to prescribe Prep. It argued that because it is a preventative medicine, it should be funded by local councils. It also stated that spending on Prep might mean they couldn’t afford other treatments; such as drugs for children with cystic fibrosis, stem cell transplants for a rare blood cancer, and prosthetic knees for amputees. They were challenged by the National Aids Trust charity and the High Court ruled there was nothing to stop the NHS from paying.
Studies have shown Prep reduces the risk of getting HIV from sex by more than 90 per cent when used consistently. Among people who inject drugs, it reduces the risk by more than 70 per cent when used regularly. Those figures are what is achievable with responsible use and many of those most at risk are unlikely to take the pills regularly. The authoritative Cochrane Review was less reassuring. Results from four trials which compared the drug versus a placebo showed a reduction in the risk of acquiring HIV infection by about 51 per cent.
There is evidence of a dramatic fall in condom use among men taking the drug, leaving them exposed to other infections. A recent French study found that condom use declined to just 24 per cent among men taking Prep. There is a chance that the HIV virus may evolve to become resistant to Prep resulting in a much deadlier strain. Michael Weinstein, president of the AIDS Healthcare Foundation in the US, voiced concern ‘about the potential for overall spread of the virus as well as other sexually transmitted diseases for which Prep offers no protection.’ In February, doctors reported the case of a 43-year-old gay Canadian man who tested positive despite taking Prep for two years.
Dr. Peter Saunders, Chief Executive of the Christian Medical Fellowship. said the free use of Prep is, ‘fraught with dangers.’ His concern was not medical but ethical, although couched in the same terms. He believes that making Prep freely available to already promiscuous homosexuals could encourage more sexual risk-taking and more sexually transmitted disease as a result. Any effect on decreasing HIV transmission rates could be cancelled out by rising levels of promiscuity. His blog cites studies showing gay man having an average of twelve coital acts per week with an average of twenty one sexual partners in the previous 30 days.
James Mildred, of the Christian Action Research and Education charity, said: ‘We have really serious concerns about the NHS spending tens of millions on a drug that we believe could facilitate more risky sexual lifestyles. Given the risks of increased promiscuity associated with Prep, this would be an expensive and potentially irresponsible action.’
But who seriously cares about the views of anyone who puts, ‘Christian’ in their professional title and what is it to do with anyone else if gay men choose to be sexually active without condoms? The judge in the High Court clearly saw gay men as victims who must have expensive protection provided by the State. In the words of Mike Freer, MP for Finchley and Chairman of the all-party group on HIV, ‘Health care is not about making the right choices. NHS England should be graceful in defeat.’
His view on individual choices being irrelevant was echoed by Deborah Gold, Chief Executive of the National Aids Trust. ‘Practising safe-sex is a conscious decision like taking the Pill,’ she said on the Today programme. ‘But using protection might depend on someone else, or the situation that night.’
Meaning, it seems, I am not going to spoil my pleasure or risk offending my partner by insisting that they put on a condom.’ An attitude ruinous to the lives of millions of women and children in Africa, if not in the developed world.
In the West, the principle is the thing, and gay rights are now enshrined in law, almost a new religion, a shibboleth as strong as anti-racism. So strong that the free pleasure taken by gay men apparently trumps all other priorities in the health service. Of course there are selfish reasons to worry about this.
Reaching sixty, a strange number of people I know seem to have trouble with their joints. Hip Hop dancing becomes mainly hop as the ball and sockets grind away preventing free movement and sound sleep at night. Skiing also goes off a cliff as the knee hinges stiffen. Middle age is often the time of a first cancer scare and friends begin to die. I am not yet at the age when all around me are seeking cataract ops, getting their hearing tested, or being asked by their doctor to name the Prime Minister but it’s obvious what the future holds; after the age of forty there is a creeping certainty about the what is to come although you thought it would never happen.
But it’s a scary and unpalatable rather than selfish to hear how NHS drugs have to be rationed for all groups.
‘There isn’t a bottomless pit to spend on the NHS,’ said Philip Davies, Tory MP for Shipley when he heard about the Prep ruling. ‘The fact that we’re depriving cancer patients of crucial drugs at the expense of other treatments is something we’ve got to look at,’ he said. ‘You’ve got to wonder what reaction you’d get if you looked a cancer patient in the eye to explain you haven’t been able to fund their treatment because you’ve prioritised other treatments.’
NHS England said the ruling would delay a decision about funding for thirteen other treatments, including for children with cystic fibrosis, prosthetic knees and implants for deafness. There is already rationing for cataracts, at a mere £800 an eye, and of course the continuing bitter wrangle over cancer drugs.
Britain risks missing out on a new era of cancer drugs, which are increasingly expensive. NICE, the National Institute for Health and Care Excellence, takes a robust cost-based approach before it approves even life-saving drugs, such as Nivolumab, which was considered the most significant breakthrough for treating skin and lung cancer in the last twenty years. It was one of the first of the new immunotherapy treatments, which harness the body’s own immune system and teach it to attack tumours. But when results were published to great acclaim last summer, NICE decided that at £63,200 a year it was not ‘cost-effective use of NHS resources.’
The drug, made by US firm Bristol-Myers Squibb, is available to lung and skin cancer patients in the US and Germany.
Last November the life extending drug Kadcyla was withheld from new breast cancer sufferers. NICE will make a final decision on the drug in February 2017. It only gave women an extra six months, but for a mother with young children that time was better than nothing.
The Organisation for Economic Co-operation and Development report compares key health records from its thirty four member countries and found that women with breast cancer were more likely to reach the five-year survival point in almost all countries other than Britain, with only the Czech Republic, Poland and Ireland trailing behind. Only the Czech Republic, Poland and Denmark had worse rates for surviving bowel cancer than Britain, while cervical cancer rates were worse in only Ireland and Poland.
So it was strange to hear the swift legal decision to prioritise young gay men who have made a ‘life-style choice,’ or rather death-style choice to simply not buy a packet of rubbers.
Since the 1960s the Left has pointed out that a high crime rate is the price we pay for freedom; it seems that it is also about paying through the nose and other parts of the anatomy for people to behave with destructive irresponsibility.
The NHS is unique, envied and now used by people the world over, but we also know that since its creation along with the welfare state, something has gone badly wrong with British social attitudes. In the NHS there are countless missed appointments, delayed hospital discharges through inadequacies in social care, inappropriate pharmacy, including drugs doled out for people living abroad through fraudulent prescriptions, and sold abroad illegally by chemists, and no serious attempt is ever made to control fraud or waste. In fact, trying to control it is considered by many to be immoral, in case it discriminates against victims.
The great divide between British society before and after the Beveridge Report of 1942 which founded the Welfare State, was surely the eradication of the concept of the ‘deserving and undeserving poor.’ The poorest people particularly seem to hate this kind of egalitarianism, with tabloids relishing tales of men living on benefits after fathering twenty children. But everyone is deserving now, and gradually all blame attached to one’s own circumstances have been eroded. This avoids the harshness of the worst kind of Victorian utilitarianism, which saw poverty as a sign of moral weakness, but it has led to an enfeebled, infantilised culture, at least in England, where the work ethic and self-reliance have drastically waned.
Notions espoused with revolutionary joy forty years ago have not turned out so well for many people; abandonment of the concept of chastity before marriage has led to the mass easy exploitation of vulnerable English girls largely abandoned by their parents. Millions of children now suffer from being fatherless. Step-parents, domestic chaos, unhappy children, more children in care are all accepted now as the norm, unquestioned until the bill comes in and we all have to pay. But now the very grown up question is looming – how long can we afford it?
As it seems our money for endless welfare and health spending is running out we have to decide realistically what really matters in the NHS. After the war its creation was about delivering a new, fairer, compassionate society, based on a cohesive population of about forty million, now it holds a lurid mirror up to us, showing not the future, but what we have become; greedy, unfair and unhealthy.
In the light of this ruling about gay men, we need a fearless public debate to establish priorities. I suspect most will choose fair rationing and high standards of clinical care above all else. But they might also start looking at the outdated beliefs underlying the causes of all the waste and unfairness in the system.
NICE, which is often not nice at all, will publish its evidence on Prep this autumn. With a sad irony they have also just sent out a completely unrelated press release saying; ‘Increased condom use can tackle STIs.’
They are right, but don’t say it too loudly or you will annoy a lot of gay men and their right-thinking friends.
(Image: eGuide Travel)
