Why is HIV pre-exposure prophylaxis struggling to find a home in UK primary healthcare?

Since its introduction to the UK in 2017, HIV pre-exposure prophylaxis (PrEP) has revolutionised HIV prevention, offering near-complete protection against HIV acquisition when taken as prescribed^​1​. Real-world data have shown HIV acquisition risk reduction of more than 86%^​1​. Around 99% of PrEP users take a combination of oral tenofovir disoproxil and emtricitabine (TDF/FTC), while people with renal, bone or other contraindications take oral tenofovir alafenamide (TAF) in combination with FTC (Descovy; Gilead Sciences)^​2​. In 2024, cabotegravir (Apretude; ViiV Healthcare) — which is given as a two-monthly injection — was licensed, with other longer-acting agents in the pipeline^​3,4​. PrEP provision involves much more than one-off prescribing (see Figure)^​2​. Currently, PrEP provision is largely centralised to specialist sexual health services, with some outreach in other settings^​5–7​.

HIV transmission elimination depends on equitable, easy access to PrEP, but people of black and black Caribbean heritage (particularly females); trans women; and people living outside urban areas are underserved, experiencing barriers to attending sexual health services, potentially leading them not to perceive them as acceptable places to access PrEP^​8–11​. General practices and community pharmacies could overcome these barriers, particularly for underserved groups^{​12–15​}. However, despite enthusiasm at grassroots level, system-level barriers — such as drug cost disparity and service commissioning challenges — impede PrEP rollout in primary care^​16​.

Primary care PrEP pathways could mitigate barriers experienced by underserved groups. Encouragingly, UK-based research suggests high prospective acceptability for primary care PrEP pathways^​16,17​. However, these studies were, by design, hypothetical. When we looked at a real-world primary care PrEP pathway in France, the profile of users did not significantly differ from those already accessing PrEP through sexual health services^​18​. Further research is needed to better understand what the uptake of primary care PrEP pathways would be in the UK, particularly among underserved groups, and what accompanying interventions (e.g. awareness raising) might be needed to facilitate uptake.

Costs of delivering PrEP through primary care

Providing PrEP in primary care will likely have higher service costs than sexual health services, largely owing to the different drug costing mechanisms. Most sexual health services are within secondary care, sharing common medicine procurement and distribution routes, resulting in much lower drug costs for generic TDF/FTC PrEP than primary care can currently achieve. While injectable preparations are becoming available as branded formulations in both primary and secondary care^​3,4​, generic TDF/FTC PrEP is effective and relatively cheap, meaning that expensive, long-acting preparations are unlikely to be recommended as first line^​19​.

See Table for NHS Drug Tariff annual costs of medicines licensed for HIV PrEP compared with estimated secondary care costs^{​20–23​}.

The cost disparity could be addressed by modifying NHS Drug Tariff pricing through negotiations with pharmacy contractors. However, while possible, it would bring the tariff price below the list price, which is unlikely to be tolerated given the economic pressures already faced by community pharmacies^​24​. 

Alternatively, it may be fruitful to explore the transfer/sale of stock from secondary care supply chains; price controls on PrEP in primary care; homecare services; distributing pre-dispensed medication through community hubs; and negotiating PrEP provision as part of the global sum^​25​. While it is unlikely to achieve pricing parity with secondary care, these proposals could bring the cost of generic oral TDF/FTC to a more tolerable level, particularly if primary care pathways successfully reach underserved groups. 

Sexual health services have utilised multidisciplinary teams to provide PrEP more cost-efficiently over time. Nurses and non-registered healthcare support staff provide most clinically straightforward PrEP care, while more costly medical/nurse practitioner time is reserved for people with more complex needs. Integration with other workflows and wrap-around sexual healthcare (e.g. STI management during a PrEP appointment) provide further efficiencies. A similar approach in primary care could be challenging, particularly in community pharmacies where independent prescribing pharmacists would likely deliver most care, at least initially.  

Cost versus benefit

While financial considerations are important, the higher cost of primary care PrEP pathways could be justified to ensure equity of access and satisfy unmet need, in line with policy aims. The outreach PrEP service for people who inject drugs in Glasgow is an example of such an approach^​6​. This is particularly relevant as countries approach HIV transmission elimination, where targeted (and often more costly) interventions become increasingly justifiable. However, it is critical that primary care PrEP pathways do not simply end up offering existing PrEP users a more costly alternative to services they already access. 

Holistic PrEP care

National best practice firmly situates PrEP provision within wider, holistic sexual healthcare^​2​. It is therefore reasonable to assume that primary care PrEP pathways would also follow national best practice. This requires access to important workflows and resourcing. Although routinely available in general practice, community pharmacies often lack access to laboratory workflows, phlebotomy, clinical waste management, integrated IT systems, patient follow-up systems and referral pathways^​14,16​. In addition, mindful of the current pressures on general practice, the time (and resources) needed to provide holistic consultations similar to sexual health services would far exceed a typical 10-to-15-minute appointment. 

Emerging data also suggest a need for greater focus on PrEP retention — supporting people to remain on PrEP^​26​. Many patients stop PrEP within one year and people who have previously taken PrEP are at increased risk of acquiring HIV^​27,28​. Improving retention will likely mean active follow up of people who do not attend appointments and delivery of interventions aimed to avoid ‘PrEP fatigue’^​29​. Delivering holistic PrEP care could therefore be challenging to achieve with the conflicting demands and current set up of primary care. 

Modifying existing care pathways

As discussed, delivery of a full PrEP pathway within primary care would require significant system and environmental changes^​14,16​. However, integration between primary care and sexual health services with effective co-working could be the solution. 

An example of effective integration/co-working is the ‘Umbrella’ service in Birmingham and Solihull^​30​, which links sexual health clinics, community pharmacies and general practices. Some Umbrella pharmacies provide treatment for chlamydia, diagnosed through sexual health services, which could form the basis of similar pathways for PrEP. However, PrEP care is not limited to a single attendance, so any pathway will need to account for regular attendances. 

A network model could provide further benefits by maximising accessibility while retaining specialist oversight and easy routes to specialist sexual health services as needed. However, providing different elements of routine PrEP pathways in different settings risks fragmentation of care, which is unpopular with users and risks duplication of work, resulting in unnecessary costs. To avoid this, detailed PrEP pathways would need to be co-produced with service users and clinicians across the network, with careful delineation of the elements of care and where they are provided (e.g. blood tests, prescribing), costs and staffing, governance, responsibility for follow up and links back to sexual health services. 

Adapted online pathways, such as PrEP EmERGE^​31​ and the ePrEP Clinic^​32​, could synergise with primary care provision by facilitating elements of self-management through online postal self-sampling for STIs and HIV, potentially removing the need for phlebotomy in pharmacies and the use of asynchronous online consultations, potentially reducing healthcare professional time. 

Primary care PrEP pathways could theoretically help to expand PrEP access, making it more equitable, but further evidence is needed to establish if primary care pathways would reach patients that sexual health services are not reaching. Several structural barriers, including drug cost, impede largescale primary care PrEP pathway implementation. It is unlikely that primary care can achieve cost parity with sexual health services. 

While these challenges make it difficult to envisage oral PrEP delivery through primary care, there are important opportunities for effective co-working and integration that should be explored to take advantage of the potential that primary care offers in reaching HIV transmission elimination.