Scotland Leads the Way? Free PrEP Provision and its Limitations.

PrEP (pre-exposure prophylaxis) has been available through the Scottish National Health Service since July 2017. PrEP is a very successful HIV-preventing medication and it is around 90% effective when taken regularly. Despite Scotland being one of the first countries in the UK and internationally to offer PrEP through a publicly funded health service, it has still a long way to go regarding distribution. 

The main issue is that of accessibility to PrEP, as not all men who have sex with men (MSM) can access sexual health clinics. Additionally, people who inject drugs (PWID) are not seen as being ‘high risk’ and thus are not eligible to obtain PrEP unless they have an additional risk of HIV acquisition by sexual routes. However, unlike in other parts of the UK, Scotland has seen an increase in HIV cases among PWID since 2015. In Glasgow, the prevalence of HIV among PWID has increased from 1% pre-2015 to 11% in 2018 (Estcourt et al., 2021). This poses a great risk to these individuals who are already more likely to be in precarious situations like homelessness, unemployment and general ill-health. On the other hand, the Scottish health programme has been relatively successful in attracting a group of MSM who are able to attend sexual health clinics regularly for PrEP. However, many men from less tolerant households struggle with attending sexual health clinics if they still live at home, which is the case for many young MSM. Due to this, it would be beneficial to allow GPs to provide PrEP, although more investigation on how to implement this would be required.  

Furthermore, awareness and stigma surrounding HIV are also an obstacle to achieving 90% adherence or attending a sexual health clinic. A HIV-negative MSM explained that : 

“If I was on those medications for a year and if I went home...or anything like that I’d find it very difficult to be able to take my medications or I would find it a bit of a barrier that if my family knew about it they’d investigate why are you on these pills. And again that would probably put some doubt in their head and then they’d prob- ably then think the worst—that I was HIV positive” (Young, Flower and McDaid, 2014).  

The presence of roommates can pose a problem to PrEP adherence due to limited privacy. There is still a lot of mystery when it comes to PrEP, especially among non-MSM as many are unaware that such a drug exists. Additionally, the stigma surrounding HIV and the suggestion of promiscuity in those who take PrEP makes it hard for some people to take their medication. There have to be wider campaigns that teach both high-risk and low-risk individuals about the existence of PrEP, for instance, educating them on how PrEP works and its benefits at the same time as teaching them of the prevalence of HIV among MSM and PWID groups would reduce the stigma and fear of contraction present in MSM communities.  

Finally, I will explore Waverley Care's 'Culturally Sensitive HIV Testing and Treatment' program, introduced in June 2023, as a key initiative to address these challenges and anticipate related concerns. The project focuses on delivering culturally sensitive healthcare for the prescription of PrEP for those in minority and ethnic communities through videos and training (Ledin, 2023). This initiative reduces the gap between healthcare workers and the general public. One cannot be forced to take medication for the rest of their life, even one as life changing as PrEP, and this has to be reflected in healthcare practices and goals. We must aim to increase PrEP distribution, but this will not be possible through a ‘top-down’ approach, it can however, be achieved through communication, awareness, and empathy to everyone, regardless of if they choose to take PrEP or not.