Doctors flagrantly broke rules for prescribing a safe-sex drug during 2021 Covid-19 lockdowns.
A bottle of "PrEP" ( Pre-Exposure Prophylaxis) used to prevent HIV. Photo: 123rf
Pre-exposure prophylaxis, better known as PrEP, can reduce the risk of being infected with HIV by 99 percent. It is funded for some people in three month supplies, but among Pharmac's requirements is that the patient must have had unprotected receptive anal intercourse with a casual partner in the previous three months.
Pharmac received advice 18 months ago to change the prescription requirements but are yet to do so.
There were concerns Aucklanders faced restricted access to the drug last year after spending more than three consecutive months in lockdown restrictions, meaning users wouldn't have been eligible for a renewal.
However, some patients and doctors lie to access the drug. Multiple health professionals have spoken to RNZ, including two Auckland-based general practitioners who say over lockdown they did not check whether patients legitimately met the rules. Men who have sex with men (MSM) without a condom, and transgender people, are considered high risk by Pharmac.
Speaking anonymously, Dr A thought Pharmac's rules amounted to requiring a "slut confession" from patients -who are required to detail their sexual history - and said they would "tick whatever box was required" to help patients wanting PrEP.
"It's like going to a doctor and saying: 'Hey, yeah, I need to confess I'm a slut, please give me the pills'," Dr A said. "I just think it's a bit of a roadblock really."
Similarly, Dr B said the rules, which require a special authority form to be completed, were "not really relevant" and "out of date".
Dr A disregarded the special authority because "it takes time" and they had "better things to talk about" with patients, like "making sure that they're safe [in their sexual practices] ... and also making sure that we're also screening for all the other things as well".
Funded users of the drug have to be tested for HIV, syphilis and undergo a full STI screening every three months when they renew their prescription.
On the other hand, Dr B did not know any medical professionals that followed PrEP prescription rules so was not concerned about the possible risk users of the drug could have been exposed to after lockdown.
Figures provided to RNZ through the Official Information Act show funded PrEP prescriptions, nationwide, dropped during Auckland's lockdown.
It is not known why people stopped taking the drug but there were 1945 people who received a funded prescription in July 2021 (the immediate month before lockdown) and only 1630 in October 2021 - when the July cohort would have needed to renew their supply.
Count of reimbursements by Pharmac for funded PrEP prescriptions. Photo: Supplied / Pharmac
Similarly, there were 1603 funded prescriptions in September 2021 and then 1929 in December 2021 (the immediate month after Covid-19 restrictions eased) when the September group would need new supply.
Dr A said there was "always a reason they're asking for PrEP and if they ask for it, they get it".
They were concerned about patients who had stopped taking the drug and had since "dropped off the list" because they had broken the routine of taking a PrEP pill daily.
Dr A said it would be "disappointing" if doctors were sticking to the rules, which could encourage MSM into riskier behaviour to access the drug.
There is a special authority waiver Pharmac has for doctors to prescribe PrEP to patients that meet "the spirit of the criteria but are unable to meet the technical requirements". It can take up to five days to be approved.
However, both Dr A and Dr B had never heard of the waiver until asked about it for this story and said they could not see why general practitioners would bother because they already knew their way around the special authority form and did not want to have to deal with more paperwork.
Another Auckland-based doctor, who previously spoke to RNZ about PrEP access concerns, "didn't know it was possible" either.
"It obviously wasn't communicated widely or well," they said. "Why would you bother with it?"
This all comes while Pharmac continues to look at changing the eligibility requirements for funded PrEP; the main change would mean people could be prescribed the drug based on their future risk of unprotected receptive sex, as opposed to their past behaviour.
The changes were endorsed by the drug-buying agency's Anti-Infective Subcommittee in September 2020.
HIV peer support organisation Body Positive's executive director Mark Fisher said "it just needs to happen" because it was "a really minor change".
Body Positive excecutive director Mark Fisher says there shouldn't be barriers to accessing PrEP. Photo: Supplied
He said barriers to accessing PrEP needed to be removed. "If people have the courage to ask for PrEP, there's a reason that they've got to that point and if we put barriers in then they won't come back and access it."
Pharmac's chief medical officer Dr David Hughes cancelled an interview with RNZ five minutes before it was due to start and a statement was given instead, with a media staff member saying the interview could not be rescheduled in a timely manner.
He said Pharmac relied on medical professionals to use their "best judgement when assessing who will be eligible for any medicine" when prescribing PrEP.
The furthest he went was mentioning that Pharmac does commission audits of special authorities "from time to time".
Looking at the relationship between PrEP and lockdowns, Dr Hughes said there appeared to be an association between the two but there were many possibilities that could be behind it.
He pointed out funded prescriptions of PrEP more than halved in the first month of New Zealand's first Covid-19 lockdown in 2020.
Prescription rates, shown in a graph provided to RNZ, then took about three months to return to "the preceding growth trajectory".
Despite being 18 months since Pharmac's Anti-Infective Subcommittee endorsed changes to PrEP prescription criteria, Dr Hughes said an internal review of the implications of widened access should be completed soon.
He said Pharmac understood the desire for easier PrEP access, but it had to be managed within a fixed budget.