News that Pharmac is to fund the HIV drug Truvada for an estimated 4000 at-risk New Zealanders has been widely welcomed by the LGBTQi community. But with the plan set to cost the taxpayer millions in subsidies, there’s got to be a better way, argues Act’s Stephen Berry.

As a gay man, HIV Aids has been in the background of my life. I don’t have it, and it’s not as dangerous as it was, but it still kills a million people every year globally and we all know someone whose life was cut short by the silent killer. Besides the disease itself, our persecutors have used it as a stick to beat us with for decades.

The anti-HIV PrEP drug, Truvada, is doubtless one of the wonder drugs of our time. It makes the virus undetectable in a carrier and virtually impossible to transmit. Someone without HIV can also take Truvada; after a 28 day course they can be over 99% resistant to infection. This is a breakthrough.

Before the last election campaign, slogans about eliminating HIV by 2025 sounded either fantastic or somewhat grim. Truvada makes it possible – if we can get past the $900 per month price tag.

I’ve never supported politicians overriding Pharmac. Partly for principled reasons, but also some self interest.  When the scientific merits of drug funding processes are replaced by a democratic one, smaller demographics like LGBT aren’t going to get a fair shake against people with heart conditions and cancer sufferers. Even if we could win the argument for Pharmac funding of PreP, there’s got to be a better way.

While campaigning for ACT last election (see, bust your prejudices) I heard from a guy who could import generic PrEP. He agreed it would be better to seek alternatives to a Truvada subsidy and I was keen to help, whatever tedious tomes of legislation would need to be tackled. I also learned the patent protecting the Truvada brand expired in June last year, so the legitimacy of generic PrEP versions were no longer an issue.

Even though generic PrEP has not been approved by Medsafe in New Zealand, that doesn’t mean it is banned. Researching the Medicines Act, I found there are processes in place already for GPs to prescribe unapproved medicines for import just as they have the discretion to prescribe medicines for treatment of conditions not intended by the manufacturer. That prescription can be posted to the generics manufacturer, in this case in Swaziland, and three months supply is posted back to New Zealand for $100 including postage and packaging. That’s the same level of protection from $900 monthly Truvada vs a $1-a-day generic import.

The main difficulty is when Medsafe and Customs intercept your medicine at the border. Up until now PrEP has been a bit of an unknown for most GPs. Many are happy to assist their patients in seeking out alternative medications and write a prescription, but fewer remain that way when Medsafe contact them for confirmation and questions. This results in even fewer GPs willing to prescribe.

Since the election, I’ve been investigating several avenues to help make generic PrEP more easily available in New Zealand on the proviso it will be safe for the user to take. Pharmaceutical companies charging over $10,000 a year for their product does appear obscene on the surface. However we also need to take into account the expensive regulatory processes involved in research that may discover nothing plus the incentive to develop world changing drugs just isn’t the same without financial reward.

The conclusion I eventually came to is the approval system we have in New Zealand is actually pretty reasonable. The Medicines Act contains simple to follow processes for manufacturers to obtain permission. The rules are fair but the frustration experienced by my friend at delays while his medicine was held at customs is totally understandable. I spent a lot of time researching improvements but eventually concluded that it’s reasonable for Medsafe to take some time to confirm medicines intercepted at the border are legitimate.

I wondered why generic PrEP was not already available in the country given the simple processes for this to take place. One GP I met said the situation is hopeless because two companies have already obtained approval to import cheap generic products, but weren’t doing so and I was wasting my time. An OIA request with the Ministry of Health confirmed that approval had occurred.

It would be easy to propose hosing in taxpayer money for PrEP before the increase in HIV infections reaches crisis levels again. This is the  tactic being employed by Labour, the Greens and special interest groups, but as I say, I support the existing Pharmac model.

So why are these approved companies not importing PrEP? In two words, regulatory uncertainty.

These two companies will have been aware that while they were obtaining permission to import their generic PrEP, Pharmac was also investigating a deal for Truvada. Such a deal would see them faced with a competitor who could undercut their very cheap product even further using taxpayer subsidies, having enormous impact on their business model. They’d be silly not to wait and see.

During the recent Pride Festival in February, Pharmac finally announced an agreement to supply Truvada branded PrEP to an estimated 4000 at-risk New Zealanders. I imagine we will not discover the price Pharmac managed to negotiate but I hope they got a great deal, because the pre-agreement price tag of $10,800 a year for 4000 people is considerable.

Following the announcement I had a look at the fine print for the criteria determining what at risk groups are eligible for Pharmac’s subsidy. The language that follows is a bit more adult-orientated than what I have used thus far:

You must either be an HIV negative gay man with a gay male partner who already has HIV OR:

You must be a HIV negative gay or transgender man who has casual receptive anal sex with other gay men, AND either

• Have had casual receptive anal sex within the last 3 months without using a condom OR

• Have been infected anally with gonorrhea/chlamydia OR

• Had syphilis OR

• Have used methamphetamine within the last three months

You can see that for many, using this criteria will actually make it more difficult to obtain PrEP than importing generic versions from overseas. That is due to the perverse incentive system Pharmac has created for gay men to become eligible. You can obtain subsidised Truvada by using a very dangerous, addictive and illegal drug or by having casual condomless sex with a gay man whose HIV status is unknown. If you’re responsible with your sexual health, you don’t get the subsidy.

Even when government organisations create new programmes for benevolent reasons, and they’re usually benevolent, the unwritten Law of Unintended Consequences also creates a regulatory framework that punishes personal responsibility and traps people into dependency. This is the first time I’ve ever come across a government programme requiring you first use methamphetamine to get their help.

There are cheaper generic medicines that have been approved for import and supply in New Zealand, potentially costing as little as $1 a day. They’d probably be here already were it not for the campaign by left-wing activist groups for a taxpayer-funded gold class option. After that long campaign, most gay men will not be eligible to obtain Truvada and must continue using the same cumbersome import system.

Pharmac only has a limited budget with which to negotiate purchasing expensive, life-saving pharmaceuticals. It can’t afford to fund everything and needs to make tough decisions on the merits of numerous products for cancer, Alzheimer’s, heart disease etc. I would argue that when we have so many other tools to fight the spread of HIV, perhaps this subsidy isn’t the best application of Pharmac’s scarce resources, especially when they’ve knocked out a much cheaper alternative for everyone in the process

Stephen Berry was Act’s spokesperson for Health and LGBT issues in the 2017 election.

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