On the NHS
Decisions on health policy are made separately in England, Wales, Scotland and Northern Ireland. The NHS in each country has taken a different approach to PrEP. People living in England who meet the eligibility criteria can access PrEP from some sexual health clinics by taking part in the IMPACT trial. The trial is providing PrEP to 10,000 people over three years. Each participating sexual health clinic is allocated a limited number of places, some of which are reserved for women, heterosexual men and trans people (i.e. everyone except MSM). In and , PrEP is available at sexual health Wales Scotland clinics. In Northern Ireland, there is no NHS provision of PrEP.
Online
Several online pharmacies based overseas sell generic PrEP medications. It is legal to buy and import PrEP to the UK, as long as it is for personal use.
In order to show that the drugs are only for personal use, individuals are advised to buy no more than three months' worth (usually up to 3 bottles of 30 pills) at once. The website iwantprepnow.co.uk lists a number of online pharmacies that have been checked and verified. Checks have been made to ensure that the sites are reliable and that the PrEP they are selling is genuine.
People who buy their own PrEP drugs are strongly recommended to get clinical advice and support, for example from an NHS sexual health clinic, in order to take PrEP safely.
Should i consider taking PrEP?
You are be the best person to decide whether PrEP works for you considering your sexual behavior . PrEP is unique in that it is an HIV prevention option that can be completely private, and is individually-controlled.
This is confidential and the only other person that you may consider alerting you are taking PrEP is your doctor.
Here are stories from people and PrEP that may help you understand your need or you may found relevant.
PrEP Impact Trial
We know from previous studies that PrEP can effectively reduce the risk of HIV infection. Several countries have implemented PrEP programmes to provide the drug to individuals at high risk of HIV. To plan a PrEP programme in England, NHS England and Local Authorities need to know how many people need PrEP, how many will want to take it and for how long. In order to find this out, we are conducting this research. This study does not involve a placebo, so everyone who is enrolled in the trial will have access to PrEP.
The PrEP Impact trial will answer three important questions:
1. How many people attending sexual health clinics need PrEP?
2. How many of these start PrEP?
3. How long do they need PrEP for?
10,000 people will be recruited to the trial over three years. HIV negative people attending sexual health clinics in England will have their risk of acquiring HIV checked by the clinic staff. If the clinic staff consider an individual meet the eligibility criteria for the trial and a are consider to be at high risk, they will offered PrEP . We will measure how many attendees at sexual health clinics meet eligibility criteria for PrEP, how many of these take up the offer of PrEP and how long they use PrEP for.
There won’t be any additional tests other than those already recommended routinely for the safe delivery of PrEP, including tests for STIs, hepatitis, HIV and monitoring of kidney function. Information about attendances and test results will be collected through the existing information system that sexual health clinics currently use to report to Public Health England.
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For further information about what is involved in taking part in the trial please read the current version of the participant information sheet.
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If you choose to participate you will need to read this information thoroughly. The clinic staff at your local participating clinic will guide you through the process of confirming that you would like to participate.
If you have any questions, please get in touch with your local participating clinic
This trial has been approved by the London-Hampstead Research Ethics Committee.
How to take PrEP
For people whose HIV risk is through vaginal sex or injecting drug use, PrEP needs to be taken daily. For people whose risk is through anal sex, there are two additional options: four-days-a-week and on-demand dosing.
DAILY DOSING This involves taking PrEP once a day, every day, on an ongoing basis. Most PrEP studies were based on daily dosing, so there is more scientific evidence for daily dosing than other approaches. Daily dosing has been tested in relation to anal sex, vaginal sex (with cisgender people) and injecting drug use. Many international guidelines recommend daily dosing as the only way to take PrEP.
FOUR DAYS A WEEK Studies suggest that for people whose HIV risk is through anal sex, taking PrEP four days a week is highly effective (see question 19). This hasn't been tested in the most rigorous kind of study (a randomised controlled trial), but the experience so far suggests that this approach is effective. Some people may decide to take just four doses a week, out of concern about cost or side-effects. In this case, it is best to take PrEP on alternate days, for example on Tuesdays, Thursdays, Saturdays and Sundays. Due to differences in drug absorption in different parts of the body, this is unlikely to work when the HIV risk is through vaginal sex or injecting drug use.
ON-DEMAND DOSING This approach, also known as 'event-driven' or 'event based' dosing, involves taking PrEP just before and after having sex. The French IPERGAY study showed that on-demand dosing is very effective in preventing transmission through anal sex. The on-demand IPERGAY regimen involves taking a double dose of PrEP (two pills) from 2-24 hours before anticipated sex, and then, if sex happens, additional pills 24 hours and 48 hours after the double dose. In the event of sex on several days in a row, one pill should be taken each day until 48 hours after the last sexual intercourse. Most European guidelines support on-demand dosing for people whose HIV risk is through anal sex. There is more information on its effectiveness in question 13. The UK guide to PrEP, published by HIV i-Base, gives practical examples of how this regimen can be used. Due to differences in drug absorption in different parts of the body, on-demand dosing is not recommended for people whose HIV risk is through vaginal sex or injecting drug use.
How PrEP works
The research to answer this question comes from lab studies which show how long it takes for a maximum concentration or 'steady state' of drug to be reached in blood, vaginal tissues and rectal tissues. Drugs vary in how long they take to achieve this concentration in different parts of the body. For example, there are differences between the two drugs contained in PrEP, tenofovir and emtricitabine, although both are probably needed for PrEP to be effective. The research is complex but incomplete (see the next question for more details). After reviewing it, the authors of [draft] BHIVA guidelines make the following recommendations for practical advice to give to PrEP users. There are different recommendations for people whose risk is through anal or vaginal sex.
For people whose risk of HIV is through anal sex, whatever dosing schedule they use: Starting: PrEP can be started with a double dose (two pills) taken 2–24 hours before sex. Stopping: PrEP should be continued daily until 48 hours after the last sexual risk. Re-starting: If PrEP has been stopped and it is less than 7 days since the last dose then PrEP can be restarted with a single dose. If it has been more than 7 days, take a double dose.
For people whose risk of HIV is through vaginal sex or frontal sex: Starting: PrEP should be started as a daily regimen of one pill a day, 7 days ahead of the likely sexual risk. If it is not possible to take PrEP for a full 7 days before a likely sexual risk, starting with a double dose (two pills) might provide some extra protection, but this is unproven.
Condoms and other prevention strategies could also be used during the first few days of PrEP use. Stopping: PrEP should be continued daily until 7 days after the last sexual risk. Re-starting: The same guidance as for starting.
People who are at risk through injecting drug use (slamming) as well as sexual risk need to know that PrEP takes longer to achieve protective concentrations in the blood than in tissues. Taking PrEP for 7 days before and 7 days after is recommended.
Adherence in order for PrEP to work
By testing participants' blood for the presence of PrEP drugs, researchers have attempted to estimate the number of PrEP doses they have actually taken. They have then looked at the number of HIV infections in people with different levels of adherence. The useful studies which have taken this approach have all been with MSM, where the HIV risk is through anal sex.
Nonetheless, for people whose risk is through anal sex, it may be reassuring to know that four or more doses a week appears to be highly effective. Due to differences in drug absorption in different body tissues, it is thought that higher levels of adherence are required when the HIV risk is through vaginal sex – probably six or seven doses a week.