This Monday marks two years of the implementation of PrEP in the pharmaceutical service of the National Health System (SNS). The pill that prevents the transmission of HIV became from that moment on a right for the population at risk, one that met a series of requirements set by Health. In 2019, entities that work on prevention estimated that some 17,000 people could benefit from this measure. 24 months and a pandemic in between later, 8,951 have accessed this treatment, according to data from the ministry.
When a new benefit is introduced in the SNS, the autonomous communities are responsible for implementing it. This has meant that the pre-exposure prophylaxis pill or PrEP, a treatment that prevents HIV infection among people who have sex without a condom, has reached the territories unevenly. "From the National Plan on AIDS (PNS) the implementation that has been carried out in all the autonomous communities and cities is valued very positively. However, the date and the number of designated centers has been very variable," says the Director of the Plan, Julia del Amo.
Although most communities began to implement it between the end of 2019 and the beginning of 2020, others such as the Canary Islands, the Balearic Islands or Asturias did not begin to do so until this summer. Currently, it is already underway in all of them and for Del Amo, the difficulties have been "those of any system in which you have to make a designation of prescribing centers, staff them and dedicate time to the care of subsidiary people All this at a time when health priorities were focused on the COVID-19 pandemic. "
Users who want to access the pill have to meet a series of requirements set by Health. They must be men who have sex with men - HSH, the term used in science to refer to this population - and transsexual people over 18 years of age who meet two of the following criteria in the last year - some are impossible to verify by the health personnel -: having had more than 10 different sexual partners, having practiced anal sex without a condom, having required post-exposure prophylaxis (a pill taken in the hours after having a risky sexual relationship to avoid contagion) or have had at least one bacterial STI. Also, for sex workers who do not use a condom regularly.
According to the data managed by Health, provided by 11 autonomous communities through the SIPrEP platform, in which information on epidemiological data can be shared and managed, there are 131 prescribing centers. 93% of users are men who have sex with men, 0.9% are trans women and 0.3% are women in prostitution. In addition, 81.3% of the people who have used the drug are Spanish, 45% have university studies and 53% have jobs.
By communities, the number of people served is very uneven. It is important to note, however, that valid comparisons cannot be made because HIV is an epidemic that occurs mainly in large cities, where a large part of the population at risk is concentrated. In the Valencian Community, PrEP has been dispensed to 804 people in 23 centers; in Galicia there have been 136 treatments; in Murcia, 95; in Asturias, 21 people in two STI units and one infectious unit; in Andalusia, 623 users in 17 centers; and in Extremadura it is prescribed in eight health centers, which have treated 28 people. In Castilla y León, the Sacyl Hospital Pharmacy services have dispensed the drug to 34 people and in Aragon there have been 45 treatments in five hospitals. All this, according to the latest data provided by the health ministries. The rest of the communities, except Madrid, whose data will be developed in the following paragraphs, have not provided the information requested by this wording.
Of the nearly 9,000 users, 2,000 are being served at Barcelona CheckPoint, a community center that already had experience in managing and monitoring PrEP. "Already before 2019 we were conducting important studies such as Discover and the implementation study promoted by the PNS. In addition, we had a risk reduction program in which we offered free controls to all those people who bought PrEP on their own. approved [en el SNS], we offered all those people to go to the public health system ", explains its director Ferrán Pujol.
Catalonia is the community where this pill has been dispensed the most, which is prescribed in 19 public hospitals, although unevenly. "We are a more accessible community center, with appointments that are not as cumbersome as hospital ones," says Pujol, who denounces a lack of resources and a large healthcare burden. Because the implantation of PrEP does not consist simply of giving a pill to people at risk of contracting HIV, but must be followed up continuously to control and treat the transmission of other sexually transmitted infections, which this drug does not prevent.
"The units are with a very important healthcare burden, but the additional provisions are null. In Catalonia the drug and the analyzes are financed, but not the personnel. We survive thanks to private funds," Pujol denounces. At Barcelona CheckPoint they have a waiting list of almost 1,000 people, which means that they can only accept new users "to the extent that someone leaves," he explains.
In the Community of Madrid the situation worries the experts consulted. There it is only dispensed at the Sandoval Health Center, a reference in attention to STIs. Only one center, of the 131 throughout Spain, in the region that has led the lists of new HIV infections from 2007 to 2018. In 2019 it has registered a lower number of infections, but experts indicate that these data are underrepresented by the saturation of epidemiological records in 2020. The council itself recognizes that "the waiting list for the dispensing of PrEP is a reality due to the great demand it suffers for its high level of specialization and for being the only one in Madrid in such dispensing , aggravated by the pandemic, at which time attention to people who were already being treated and urgent cases was prioritized. "
Until July 28, 2021, more than 1,800 users had been attended, which had generated 15,000 queries. "To alleviate the waiting list, the Hospital Clínico San Carlos has incorporated a Pharmacy technician in the center and the agendas have been reorganized, optimized the times in consultation and in the check-ups with the support of other health professionals (doctors and nurses) in relationship with adherence to treatment ", they point out from the counseling department. As of today, the waiting list for first consultations is 1,424 people. Some of these users report waits of up to six months. "One of the main problems is that Sandoval is totally saturated, because it is the only one that dispenses, while other centers have the will to do so, while the Community says no," laments the secretary general of the State Coordinator for HIV and AIDS ( CESIDA), Ramón Espacio.
Two weeks ago, the Madrid Minister of Health Enrique Ruiz Escudero advanced that the Community is studying the possibility of extending the dispensing to all the hospitals in the system. "We applaud it, but we want it to become a reality. There is demand and in a community like Madrid that cannot be allowed," says Espacio. For Pujol, "six or seven months of waiting lists translate into new infections that could have been avoided." And, although the data concerns the volume of the population at risk and the number of new cases in Madrid, this is not the usual trend in other communities with less population and more centers where it is dispensed. For example, the ministries of Valencia, Murcia, Extremadura and Castilla y León indicate that there are no unattended requests. In Asturias you have to wait around a month and a half and in Andalusia they are not aware of this data.
These two experts disagree, in part, in the assessment of these first two years since the incursion of PrEP in the SNS. Espacio considers that "it has gone relatively well" and that "it is progressing adequately", although it emphasizes that it is necessary "to reduce the waiting lists". Pujol is more critical: "I think that the implementation has not been as fast as we would have liked. I have the feeling that there has not been much interest. The pandemic has had an influence, of course, but the moment and the opportunity is not being seized."
Last week, at a CESIDA event, the Minister of Health, Carolina Darias, pledged to improve implementation in the autonomous communities, in order, accompanied by other measures, to achieve her department's goal of eradicating the HIV pandemic in Spain. by 2030. "The Ministry of Health is betting on PrEP as a combined prevention measure, working on expanding the criteria for the indication of PrEP, improving information on PrEP for the population that needs it, and improving epidemiological data about starting and following people on PrEP, "explains Del Amo. In addition, with the SIPrEP, the ministry will be able to produce an annual report on the situation of the drug in Spain without the need for estimates to take the necessary measures to improve. "Likewise, informative and training meetings are being held with the Autonomous Communities about PrEP to resolve any doubts that may arise," adds the director of the PNS.
Different entities that work on HIV care in various communities have pointed out another important problem when it comes to accessing treatment: ignorance on the part of primary care health professionals. "There is a lot of ignorance and, in some cases, there is a certain delay due to this. Direct referral and training to the health person is necessary," says Espacio. This is also noted in drug access routes. According to Health data, only 13% were referred from Primary Care. A figure very far from the 23% who did it from an STI center or the 38% who came of their own accord.
The spokesman for the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), Dr. Juan González, explains that to notice a decrease in HIV transmission, it is necessary that between 80 and 90% of the population at risk be in treatment . "If we do not reach that percentage, it will slow down, but cutting transmission through that route will not be possible if that barrier is not overcome," he says. Because the objective is that PrEP, administered to a large part of that population at risk, also protects those who do not take it, by reducing the chances of infection thanks to the protection of the other person.
This reduction has been quickly noticed in cities such as London, San Francisco or in France, but experts believe that in Spain it will take a little longer. "There has been a massive implementation there and they have seen an impact in two or three years. We, at the speed at which we are implementing it, it may take another two years at least to perceive it. If then we do not see a significant impact, it means that the implementation has not been adequate, "explains González.
However, valid epidemiological data are not yet available to assess whether PrEP has had an effect on HIV transmission. On the one hand, because they are collected a year late. In 2021, those for 2020 will be offered, but epidemiological registration systems have also been overwhelmed, so there will be a long diagnostic delay in the last two years. On the other hand, because the pandemic will make it difficult to discern whether a decrease in incidence is due to the pill or to restrictive measures caused by the coronavirus.
"We have not yet been able to measure the impact that the start of PrEP has on the incidence of new HIV infections in Spain. However, the fact that these almost 9,000 people at high risk of HIV infection are on PrEP, that is, that they are carrying out an effective prevention that drastically reduces the possibility of infection, is something very positive ", summarizes Del Amo.