- Category: HIV Prevention
- Published on Tuesday, 27 December 2016 00:00
- Written by Gus Cairns
The clinic at 56 Dean Street in Soho, central London, the largest sexual health clinic in the U.K., saw an unprecedented 40% drop in new HIV diagnoses this year. Another clinic, the Mortimer Market Centre a mile away from Dean Street, has seen an even bigger 50% fall.
A December 22 press release from the Chelsea and Westminster Hospital, which runs Dean Street, said that in the period between January and November 2016, the clinic diagnosed 373 new HIV infections. In the same period in 2015, they diagnosed 626 -- a fall of 40.4%.
The Dean Street clinic accounts for 1 in 9 HIV diagnoses in the U.K. and 1 in 2 diagnoses among men who have sex with men in London.
The fall in diagnoses appears to be real. Dean Street has carried out approximately the same number of HIV tests (in the region of 6250-7500 per month) from January 2015 until now, so this is not due to fewer tests being done.
The drop also does not appear to be due to declines in risk behavior or to the clinic attracting more people at lower risk of HIV. Sheena McCormack, principal investigator of the PROUD study, who works at Dean Street, told Aidsmap, "The decline has been quite significant. Last year we were seeing between 40 and 60 diagnoses every month. This year it has been more like 25 to 40."
“We wondered if the increased publicity about PrEP had resulted in more people coming along who were at lower risk," she added. "But if this was the case you’d expect to see fewer other sexually transmitted infections (STIs) too, and they have not declined."
Alan McOwan, Dean Street’s lead clinician, confirmed this. "Syphilis cases have essentially flat-lined this year," he told Aidsmap. "We saw just over 1000 cases in 2015 at Dean Street and the same number this year."
This appears, then, to be a genuine decrease in HIV infections in a population of men who have sex with men at very high risk for HIV. Is this due to improved testing and treatment -- or is it at least partly due to pre-exposure prophylaxis or PrEP?
"I think it must be at least partly due to PrEP, as we instituted a policy of immediate treatment on diagnosis back in 2012," McCormack commented. "As a result, 50% of the gay men we diagnose are now themselves in early infection, as incidence assays show, and have less time to pass on HIV. But we didn’t see anything like this happening in 2012."
McOwan said one practice change Dean Street has made in the last year may have contributed. "In July we instituted the San Francisco model, which means that people walk out of the clinic with their first prescription of antiretroviral therapy (ART) the day they are diagnosed, and now 75% of our HIV-positive clients start treatment at their first HIV appointment." However, he added, "this started too recently to explain the fact that the drop in infections started a year ago."
It therefore looks very possible that PrEP may have been a significant contributor to the drop in diagnoses, despite the fact that it is still not generally available in the U.K.
On October 19 last year, the website iwantPrEPnow.co.uk, which informs people about how to buy cheap generic tenofovir/emtricitabine for PrEP online, referred its first user to Dean Street in an arrangement whereby the clinic offered HIV and kidney monitoring tests for PrEP buyers. They also offered to test drug levels to see if people were buying genuine drugs; some results from this scheme were presented last month at the Glasgow HIV conference). This arrangement opened formally this past February.
McCormack commented: "In February we only had about 100 PrEP buyers coming to us. By June we were able to report at the British Association for Sexual Health and HIV conference that we had about 400 people in the scheme. We now have about 500 regular attenders. We also have about 75 people attending Dean Street still in the PROUD study out of the 350 or so still remaining."
McOwan gave Aidsmap a slightly lower estimate of about 350 regular generic PrEP users attending Dean Street, but speculated that other people who attend for STIs might be buying PrEP but not telling the clinic.
"The important thing is whether awareness and usage of PrEP is reaching the right people," he commented. "We now have saturation coverage of it in the clinic: we did a series of YouTube videos of consultants and health advisors talking about PrEP which now play in rotation with other videos on clinic screens. If the 'nodal' gay men who have a lot of partners and who would previously been at the center of a cluster of infections are now not becoming infected, they are not passing it on to anyone else."
Greg Owen, who runs Iwantprepnow.co.uk, said that his site currently gets about 10,000 unique visitors a month. This was translating into about 500-600 personal consultations which had ended up with a referral to Dean Street or one of the other London clinics with similar arrangements. He said, "Although this is a complete finger-in-the-air estimate, I think about 1800-2000 people are regularly accessing PrEP by buying it online in the U.K."
Owen said that the publicity about PrEP this year, including NHS England’s refusal to provide it in March, and the subsequent successful court action against this decision by the National AIDS Trust, had definitely increased awareness of PrEP among gay men in the U.K.
"Up to July this year, we were averaging about 6000 unique visitors a month," he said. "In August, we had 12,000, and half of those were on the day that the High Court ruled that the NHS had the power to fund PrEP."
"I think we’ve had good luck, in a way," Owen added. "The way that the story has developed in the U.K. means that it could not have been better designed to catch the attention of the people that most clearly would be targeted by a PrEP awareness campaign anyway."
Another London Clinic Sees Even Bigger Fall
Dean Street is not the only London clinic that has seen a fall in HIV diagnoses this year. Ian Williams of Mortimer Market Centre confirmed that his clinic had also seen a fall, and the clinic at St. Thomas’s Hospital has seen at least a stabilization in new diagnoses.
The day after Dean Street's announcement, Mortimer Market Centre, a mile away from Dean Street (part of the Central and North West London Health Trust), announced that its raw data show a more than 50% drop in HIV diagnoses from January to September 2016 when compared with the same period in 2015. This is despite more HIV tests being performed and a comparable rate of bacterial STI diagnoses.
Mags Portman, GUM lead at Mortimer Market, said, "We made a decision to actively support those buying PrEP online early in 2016. This approach has been embraced by all staff from nurses to health advisors to doctors. We ensure that our patients at higher risk of HIV are fully informed about the use of PrEP and have access to safe monitoring alongside good sexual health advice and regular STI screening."
"We remain vigilant for a potential rise in STIs, which has been reported elsewhere, but so far the rate of bacterial STIs in our clinics are comparable to the same time-point last year," Portman continued. "This is very encouraging. Given that the lion's share of HIV is transmitted by people who are recently infected themselves, and who are often untested, we are convinced that PrEP is responsible for the large decreases in new diagnoses being seen."
Implications for Access
One interesting question this fall in diagnoses brings up is whether it will cause changes to the proposed implementation study of PrEP in England, which aims to enroll a minimum of 10,000 people to start PrEP in the next 3 years.
McCormack commented, "These figures may be telling us that targeting PrEP at those most likely to acquire and pass on HIV may have a more dramatic effect than computer models showed -- as some of us suspected."
"This implies that the implementation study could also have a more dramatic effect. If so, this raises questions about whether it really needs to continue for 3 years and whether PrEP should be made generally available sooner," she continued. "This in turn will be dependent on getting it off the ground as soon as possible -- and that depends on 2 things: firstly, that the bureaucracy of running it as a study does not in itself consume too much of the cost, and secondly, that they manage to negotiate a really good price with drug suppliers."
I Want PrEP Now. www.iwantprepnow.co.uk