If NHS England ever comes to be dismantled it won’t be because a heartless Tory government has decided that, for reasons of neoliberal ideology, it ought to be replaced by private insurance schemes. It will be because the unreasonable and limitless demands placed on it by those who claim to be its friends have inflated its budget to a level that public funds can simply no longer sustain.
That moment was brought a little closer last week by a victory in the High Court for the National Aids Trust (NAT). The trust had argued that the NHS should fund, at £400 per month a time, a group of drugs known as PrEP, or Pre-exposure Prophylaxis. These were developed as pills for treating HIV infection but have more recently been found to lower the incidence of HIV infection when taken on a regular basis by HIV-negative gay men.
Pro-PrEP campaigners like to compare the drug to the contraceptive pill, which is available by NHS prescription. But if the contraceptive pill was costing the NHS £400 a month a time (rather than the actual cost of £10 a year) it would certainly never have been doled out for free – it would have broken the NHS long ago. As for condoms, most people are quite happy to buy their own. It would be bizarre if PrEP were available for free while people are willing to pay for a much-more effective method of preventing the spread of HIV.
The High Court ruling does not compel the NHS to prescribe the drugs to those who want it, only to say that the NHS may choose to pay for it. But such is the pressure from HIV charities that it is a fair guess that the NHS, if it doesn’t roll over and give in, will face another court case to try to force it to pay for the drugs. If PrEP does become available on the NHS, thereby establishing the principle that the health service is there to provide anything which can protect against risks associated with lifestyle, there really is no limit to the potential demands on the taxpayer. It would be hard then to argue that the NHS should not also pay for cycle helmets, free beer to wean heavy drinkers off spirits, safety nets for bungee-jumpers and anything else which could conceivably help to save lives. In fact, I wouldn’t be surprised if the cost-benefit of these three were higher than for prescribing PrEP. There is little to be gained from reducing the per-occasion transmission risk of HIV if, by encouraging risky behaviour, you are greatly increasing the occasions on which transmission could occur. Handing out free PrEP will inevitably legitimise a lifestyle of having unprotected sex with multiple partners and thereby lead to an increase in people doing it. Besides, PrEP only protects against HIV. The fact that unprotected sex spreads other diseases doesn’t seem to enter the arguments of the NAT. Campaigners like to cite a Lancet study in which 243 gay men who admitted to having unprotected anal sex with multiple partners were prescribed PrEP. After 12 months three of them were diagnosed with HIV, compared with 20 in a similar-sized control group who were not prescribed PrEP immediately. If that is a triumph, it has to be set against higher rates of other sexually-transmitted diseases — a remarkable 57 per cent among those taking PrEP compared with 50 per cent who were not taking it. Among the PrEP-takers, 39 per cent had gonorrhoea, 30 per cent chlamydia and 11 per cent syphilis. Any disinterested person reading those figures would come to one very firm conclusion: that having unprotected anal sex with multiple partners is extremely hazardous. If there is a role for public health authorities, it shouldn’t lie in handing out expensive pills in the hope of reducing one sort of sexually-transmitted disease at the expense of increasing others. It should lie in strongly discouraging promiscuity and unprotected sex altogether. That was once government policy. Back in the 1980s the message was pretty uncompromising, with scary TV ads involving gravestones, swirling mist and the slogan ‘don’t die of ignorance’. The Aids campaign then took the same approach as anti-smoking campaigns. Like or loathe all those pictures of diseased lungs and throat cancers, you can’t deny they have helped bring down levels of smoking, from 51 per cent of men in 1974 to 20 per cent now. What the government didn’t do with smoking was say: people are going to smoke whatever we do, so why don’t we get the NHS to hand out low-tar fags for free, in the hope that it will persuade smokers to give up high-tar fags. Yet that is analogous to what the NAT is proposing in the case of HIV. It assumes that no-one can possibly be expected to refrain, for reasons of protecting their own health, from something they enjoy doing and that therefore the best we can hope to do is follow a rather feeble harm reduction strategy. It isn’t working. As the NAT admits on its website the number of new HIV infections is still rising, from 2,423 in 2004 to 3,360 in 2014. Aids may no longer be a death sentence but it remains a serious, life-impeding disease which causes a lot of misery and is treated at vast taxpayers’ expense. That infection rates are increasing when it is so easily avoidable – ie by the simple expedient of not having unprotected sex with multiple partners – is a scandal. So why did the strategy change from the rather brutal, hectoring TV ads of the 1980s to the point of invisibility now? If there is a government safe-sex campaign any more I can’t say I have noticed it. Neither had an 18-year-old girl whom I recently heard say she had sat through sex education classes without HIV once being addressed. Maybe she wasn’t paying attention, but either way the message – if there is a message – clearly isn’t getting through. It isn’t hard to guess why public health campaigns against sexually-transmitted diseases seemed to disappear. With HIV/Aids, the entire issue became wrapped up with gay rights. The anti-Aids campaign was accused of stigmatising gay people and so was toned down and then pretty much dropped altogether. As it happens, I think covering cigarette packets with lurid pictures of cancers is over-the-top. The last thing I would want to see is bus stops plastered with colourful images of genital warts and HIV-related conditions. But in between the two starkly-opposed approaches to smoking and HIV surely lies a happy medium where the public are given the facts and left to make up their own minds, and where it is assumed that yes, people do have some will-power and aren’t just the helpless prisoners of their own urges. I don’t begrudge anyone HIV/Aids treatment on the NHS, but handing out free supplies of PrEP and telling people to go out and enjoy themselves is no strategy for reducing the misery of HIV.
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