Doctors criticise London HIV drugs cost-cutting deal

Medical professionals and patient support groups have raised concerns after people with HIV in London have been asked to switch to taking different antiretroviral drugs, as part of cost-cutting measures.

In April, London HIV Consortium, which is responsible for the capital’s HIV services, was tasked with saving £8m over two years, having to manage growing patient numbers on a budget that has not increased in line with inflation.

London Specialised Commissioning Group (LSCG), which commissions the capital’s HIV treatment, negotiated terms with atazanavir manufacturer Bristol Myers Squibb to receive discounts for larger orders of the drug.

As a result, clinics have been given new “prescription messages” – recommending doctors ask certain HIV patients who take a life-saving protease inhibitor other than atazanavir to switch to atazanavir – with saving money given as the overriding justification.

But now HIV doctors and support groups have raised concerns that switching prescriptions creates “medical risks” and raises “ethical issues”.

‘Financial pressure’

LSCG HIV drugs commissioner Claire Foreman said: “It is not in anyone’s interest – not our patients nor the taxpayer – to treat fewer people with more expensive drugs.

“There are no financial incentives for clinics to switch patients.”

However, an HIV specialist at a London clinic, who wanted to remain anonymous, told the BBC: “Clinics are under financial pressure to contribute to the £8m savings.

“A confidential statement went out to doctors saying ‘there is a carrot and sticks approach to this. If you reach your targets each individual service will be set, there will be benefits for you this year, and clearly be benefits for you in next year’s budget’,” he added.

“Claire Foreman has back-pedalled on this.”

Ms Foreman denied this allegation, adding: “Doctors are taking a leading role to ensure patients can be treated despite the pressure on budgets.”

The clinician added it was “clearly evident” if doctors did not meet targets for patients switching to atazanavir.

“Doctors are under pressure from the LSCG to get patients to swap to cheaper prescriptions.

“I’m not sure if it was taken into account the pressure that would put clinicians under,” he added.

“Not only does that discomfort the patient, it’s costing us in terms of clinic visits.”

Ms Foreman said this was not the case, adding: “No HIV patient will be prescribed an incorrect medicine as a result of this process.”

The anonymous specialist went on to say: “It’s difficult to prescribe certain pills in London, that people outside London can get, due to financial pressure from doctors’ managers.”

Patient choice

LSCG said its prescription messages were in line with British HIV Association guidelines, but these were last updated in 2008 so did not consider drugs licensed since then.

More recent guidelines, including those of the European AIDS Clinical Society, recommend a range of drugs which are available through the NHS but are not suggested for prescription in LSCG’s messages.

However the specialist cited raltegravir as an example of an antiretroviral drug “that everyone wants access to, because it has few side-effects.

“But commissioners have stated it will only be used under certain circumstances.

“That’s entirely down to cost pressures. It would be easier to get outside London,” he said.

The specialist added: “The prescription messages stop putting patient choice at the centre of care in London.”

“This could potentially damage doctor-patient relationships.”

LSCG said: “All standard of care drugs licensed in the UK are available for use by HIV doctors.”

Dr Mike Youle, an HIV consultant at north London’s Royal Free Hospital, told the BBC about potential ethical and medical implications of switching patients’ prescription.

“When you’re talking about someone who has been stable on a drug for five years, I see no medical reason to change their prescription,” he said.

“There’s an ethical issue about switching people.”

But Prof Brian Gazzard, chairman of the drug purchasing group which advised the consortium, said: “All the doctor needs to do is note the reason the patient doesn’t want to switch.”

Meanwhile, African Health Policy Network chief Francis Kaikumba said: “Vulnerable African communities will be adversely affected as studies have shown African people are far less likely to question their health advisors.”

Ms Foreman said: “Clinicians and commissioners have been clear that any targeting would be unacceptable.”
Side effects

Addressing the medical implications, Dr Youle said: “Every time you change medication with HIV, you run two risks.”

“One is having a side-effect. Something might go wrong.

“The second is you might fail on the next drug. The virus might be resistant and you may put your health at risk.”

Prof Gazzard said: “Switching can involve side effects. If it does the patient will be told ‘we’ll switch you back’.”
Pills Switching HIV drugs can involve side effects

Dr Yusef Asad, from the National Aids Trust, highlighted emotional pressures patients might come under saying: “With HIV, daily adherence is vital. Concerns about their medication might undermine a patient’s willingness to adhere to treatment.”

Prof Gazzard said: “If stress is being introduced into that system it’s a problem between the doctor and patient, not the London Consortium.”

Meanwhile, Dr Youle asked: “What happens when the next tender goes out and a different drug becomes the cheapest?”

“You then have to say the drug you were originally on is cheaper and we’re going to move you back.”

Prof Gazzard said: “There will be a balance between the saving and the difficulties of switching people every two years.”

Some HIV support groups have said the deals between the LSCG and pharmaceutical companies were rushed through.

Robert Fieldhouse, editor of Baseline, a magazine for people living with HIV, said: “The consultation took place behind closed doors with the wider HIV community in the dark.”

But Ms Foreman said: “Commercially confidential processes mean specific prices of companies cannot be shared.”

Dr Asad said a wider debate should have been had before procurement.

“It would have been better to have a more open discussion earlier – asking ‘is it ok to switch stable patients simply on the basis of cost?’,” he said.

Meanwhile, with the government’s Health and Social Care Bill proposing to shake-up the way the NHS in England works, London’s HIV drugs procurement will be closely scrutinised to see how money savings could be implemented on a wider scale.