The executive director of the NZ AIDS Foundation responds to claims that Pharmac funding of a brand-name HIV drug is a waste of taxpayer money.

Last week Stephen Berry wrote an op-ed column for The Spinoff entitled “Pharmac’s anti-HIV drug subsidy is an own goal for LGBT”, regarding the recent funding of the HIV prevention drug PrEP.

Mr Berry makes several points that are worthy of discussion and we would like the opportunity to address some of them. His key argument is that Pharmac are paying too much for PrEP sold under the Truvada brand, and could instead be paying significantly less for a generic version.

He is correct – generics usually are cheaper than name-brand drugs. And as we can see from the recent proposal to change the funded brand for HIV treatments tenofovir and entecavir to generic versions, Pharmac has no problem with funding generics and frequently does so once patents expire. Typically we see a list price drop by at least 90% when generics become available.

Only one of several patents on Truvada in New Zealand expired last year – others are due to expire soon. When all patents have expired, Pharmac could enter a negotiation process with Gilead, the makers of Truvada, and other companies that make generic versions of PrEP. We may end up with a generic version or we may keep access to Truvada – the availability of generics often helps Pharmac negotiate lower prices with the original company, even without switching.

But Pharmac is also entitled to fund a treatment or prevention even while patents are in place. It’s not required to wait for generics before funding something. The decision to fund PrEP now is consistent with previous decisions to fund tools that safeguard Kiwis’ sexual and reproductive health, such as condoms, contraceptive pills and HPV vaccination.

We also know that 2016 had the highest number of new HIV transmissions in New Zealand ever. We’re already at a crisis point. Pharmac made the decision to fund PrEP with this information, but also based on a clear cost-benefit analysis. Research commissioned by NZAF has shown that a single HIV infection can cost the health system up to $1,000,000 over the course of a person’s lifetime if they are diagnosed in their 20s. Funding PrEP for those at significant risk of acquiring HIV, even at the $800 per month price tag, is cheaper for the health system than to not fund it.

So while Mr Berry says PrEP is “set to cost the taxpayer millions”, he is not taking into account the millions saved by funding it – not to mention the countless people who will avoid contracting HIV.

Mr Berry also says he’s “never supported politicians overriding Pharmac”, implying that Pharmac, an organisation independent of the government, did not act independently in making the decision to fund Truvada.

This is false, and the implication that the Labour government pressured Pharmac to fast-track funding is incorrect. In fact, NZAF worked with Pharmac throughout 2017 to prepare an application for PrEP’s funding – long before the election.

In an interview with RNZ earlier this year, Pharmac’s chief executive Sarah Fitt said the application “went through our normal process where we got clinical advice.”

“It got a high priority recommendation for the high-risk group, from our clinical advisors so we took it through our normal process.”

Mr Berry writes that the generic version of PrEP “would probably be here already were it not for the campaign by left-wing activist groups for a taxpayer-funded gold class option.”

NZAF’s campaign to have PrEP funded was independent of Gilead, the company who produces Truvada. We wanted access for people at risk of HIV to a drug proven to prevent HIV. We didn’t care which brand we got, and we had no desire for a “gold class option”, primarily because it doesn’t exist. Generics have been proven to be just as effective as name-brand drugs, and so there was no specific medication/brand that we asked for in our application. If a “gold class option” did exist – one that was proven to be more effective at preventing HIV – then we absolutely would have campaigned for that.

Before the funding, we were (and continue to be) working hard to promote access to generic versions of PrEP and to help at-risk people learn how to import generic versions from overseas – including through a coupon scheme where people on low incomes can get a three-month supply of generic PrEP for free.

Mr Berry then asserts that “… for many, using [PHARMAC’s] criteria will actually make it more difficult to obtain PrEP than importing generic versions from overseas”, and that “if you’re responsible with your sexual health, you don’t get the subsidy”.

The first implication here is that people who don’t use condoms consistently are irresponsible, which is a sweeping generalisation and on the whole very unhelpful. There are many reasons that individuals struggle to use condoms consistently, particularly in the most vulnerable and marginalised groups of the LGBTQ community. Instead of shaming, we need to help people find ways to overcome these barriers, or else to provide alternate solutions.

The second implication is that people who consistently use condoms for anal sex will not be eligible for Pharmac funded PrEP.

This is a correct assessment of the criteria – and it’s because as a general rule, people who consistently use condoms for anal sex do not need PrEP.

Condoms are extremely effective at preventing HIV transmission, and for people who are using them every time they have anal sex, there is no need to for them to also be taking PrEP. This is why Pharmac’s criteria exist, resulting in the most effective use of taxpayer money.

Mr Berry says he “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”.

NZAF agrees that there are other tools to prevent HIV transmission – including condoms and Undetectable Viral Load. Unfortunately, despite over 30 years of consistent condom promotion and high rates of condom use among gay and bisexual men in New Zealand, we’re still seeing a rise in the number of new transmissions. In this context, Pharmac should be congratulated for making a funding decision that supports a combination approach to HIV prevention. Such an approach is already resulting in declines in HIV incidence in jurisdictions we often compare ourselves to overseas – and there is no reason why the same can’t happen here.

Something needs to change – and if an effective, affordable option exists, then it should be made available. Pharmac-funded PrEP is a fantastic, milestone step in the right direction to Ending HIV.

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