SNP's HIV policy is a political pill that's hard to swallow

SNP's HIV policy is a political pill that's hard to swallow

by Jonathan Stanley
article from Monday 10, April, 2017

A LONG TIME AGO in a valley far away lived a GP. He treated people who were ill. He was funded by an NHS that gave him money to treat his patients using evidence that showed a health gain for spending the money that was better value than using the money for other treatments.

That was back in the day, but now NHS Scotland just died because the Scottish Government has approved prophylaxis for HIV ("prep") for men who have unprotected sex with men.

Overexaggeration? Not at all. This single funding decision has driven a coach and horses through the notion we treat people who are unwell or those who are becoming unwell where early intervention prevents deterioration. Worse, it does so when condoms are a cheaper and more effective means of prevention and also massively cut other infections. When the alternative is cheaper and better we call that "dominance" in health economic parlance. Condoms dominate prep, and no evidence of cost effectiveness has been presented for condoms plus prep, largely because condoms alone are so effective. Pretending prep is additional to condom use is dishonest, and worse, makes the economics of the funding proposal look even poorer, given fewer infections would be prevented if it were merely additive.

We have now taken the decision to give medicine to people who are perfectly healthy yet voluntarily expose themselves to high risk. 

Will crash helmets be free? Food? Clothing? Gas?  This decision matters because it undermines the concept of treatment free at the point of need because there isn't a clinical need here; just a political one.

The decision has been made because of pester power, by politicians feart of being blaming for refusing to save we so often hear. Suddenly incidental personal risk has been collectivised. Worse we have decided the health gain is not an objective one but one of semantics.

The treatment of HIV is daily antiretroviral drugs. Prophylaxis is, wait for it, daily antiretroviral drugs. 

How therefore is there clinical gain when HIV can be suppressed with treatment and sufferers lead essentially normal lives with vastly improved life expectancy. What is this health gain for which we are all expected to pay? I genuinely do not know.

Having spent decades encouraging safe sex the prep decision effectively makes this an issue only for low risk people. Women and straight men carry on with condoms; men who have sex with men have something they prefer. Of course prep does nothing to prevent other sexually transmitted diseases and many studies in the US have shown that these skyrocket when prep becomes widespread as risky sexual behaviour follows. 

The NHS faces huge challenges and we have to decide what it is there for. The Scottish Medicines Consortium works with the NHS to ratio resources so that the greatest health gain is made for the least cost. We either buy this idea or we don't or we choose to give preference to population groups for political expediency rather than health gains funded by solidarity.

This is not good. People campaign for funding using raw emotion when they know full well they otherwise would not get a look in. This undermines solidarity as patients will rightly claim they are being shortchanged and placed behind others for the sake of votes. 

Socialised healthcare has pros and cons, politicised healthcare however quickly becomes a racket and breeds resentment. If we are given to funding interventions of people who are perfectly healthy but through their own behaviour risk illness we open up a very expensive can of worms even before drug resistance is considered... and yes, this has been reported in the US already. 

This funding decision for prep was political. That is not an achievement. It is a worryingly casual dereliction of the fundamentals that underlie tax-funded healthcare free at the point of need to suit the needs of a subgroup who consciously undermine their own health and that of others. 

What is progressive about this?


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