Impact case study database

Prof Estcourt’s team’s research has impacted on HIV prevention policy and practice in some of the most vulnerable and marginalised groups in Scotland, the UK and the Republic of Ireland. It has also influenced pan-European prevention guidance. In Scotland, this has contributed to a 40% reduction in new diagnoses of HIV in MSM in the last two years (a cost saving of £320,000 per transmission) and provided PrEP for PWID in the context of an uncontrolled outbreak, in the first example of this worldwide.

The Deputy Chief Medical Officer for Scotland is “indebted to Professor Estcourt and the team for their contribution to the national HIV prevention agenda. They are highly regarded in Scottish Government in terms of the quality and importance of their work in the SH and BBV fields” (S1).

Impact on Scottish HIV Prevention Policy:

The Scottish Medicines Committee approved PrEP for people at highest risk of HIV in April 2017 based on the recommendations from Scottish Health Protection Network Working Group [S2]. The Group used data from GCU research [R1, R2] to:

1) provide its estimate of PrEP uptake in MSM at high risk of HIV (58.5%) (R1, S2/page 4/para3), leading to the Group’s recommendation for approval of PrEP and subsequently the estimate on which planning of national clinical PrEP services was based. Subsequently 1855 MSM were protected from acquiring HIV in the first year of roll out.(S3/page17/para3).

2) to determine risk-based eligibility criteria for PrEP. Evidence from [R2] suggesting that condomless anal intercourse with two or more previous partners in the last 12 months was a marker of HIV transmission risk, led to the Working Group recommending that this should be (S2/page4/para3) (and subsequently became, S3/page16/Fig 4.1) one of the eligibility criteria for PrEP. This enabled an additional 2776 MSM, a group at highest risk of HIV and poor sexual health, to be protected from acquiring HIV in the first two years of the PrEP programme (S4/page9/last para).

We improved understanding of HIV transmission in PWID which led to an expansion of targeted HIV testing and PrEP provision during an ongoing HIV outbreak.

Findings from our bio-behavioural and qualitative research [R3, R4] directly informed the public health response to the outbreak:

3) Enhanced testing initiatives were introduced in the “hotspot areas” identified in the research ahead of publication [R3] [S5,S6,S7]. which contributed to 112 PWID being diagnosed with HIV (2016-2019) and linked into effective HIV care. Dr McAuley provided evidence at Scottish Affairs Committee (2016-2019) inquiry on problematic drug use on 7 May 2019 [S5], which was referenced by the Scottish Government when endorsing plans for Scotland’s first safer drug consumption facility [S6]. Ahead of publication, the research also informed the business case for Scotland’s first Heroin Assisted Treatment (HAT) service which opened in November 2019 To date, 10 PWID have been successfully managed on HAT.

4) NHS Greater Glasgow & Clyde established a highly innovative PrEP service for PWID at high risk of HIV through sexual transmission, in identified “hotspot” areas [R3], [S7] Dr Smith’s qualitative study showed PWID would find PrEP acceptable if more widely offered [R4]. To date 37 PWID with concurrent sexual risk (largest cohort in Europe) have been protected from HIV by taking PrEP.

“… the research has undoubtedly had an impact on reducing the potential for onward transmission of the virus thus benefitting the health outcomes of the population most at risk (PWID). In addition, it is likely to have contributed to a major cost saving to the health board…” (S7, Chair of NHS Greater Glasgow & Clyde Outbreak Incident Management Team).

5) The minimum dataset for national reporting of Human Immunodeficiency Virus PrEP-related data has been incorporated into Public Health Scotland’s National Statistics reporting cycle (S8/page3/para1) [G3] helping policy and health planners to drive sustainable PrEP provision for the population.

6) Our national level epidemiological analysis [R6] has underpinned the decision to continue a Scottish national PrEP programme to reduce HIV transmission, widening PrEP eligibility criteria to include the two groups of MSM at very high risk of HIV [R6, S1]. As a result, an additional 1500 MSM are being offered protection from acquiring HIV per year.

“Our close links and joint working across research studies, policy and national strategies creates a unique partnership in which the views and needs of beneficiaries are central to the work from the very start” (S9, CEO HIV Scotland).

Impact on Republic of Ireland PrEP policy:

7) Estimates of PrEP uptake [R1], were used in the Republic of Ireland’s Health Protection Surveillance Report, on which the Irish National programme was based (S10/page7/3.4.3, page12/4.6, page14/5). 2289 people at high risk of HIV have benefitted from the Irish PrEP programme to November 2020.

Impact on Wider European PrEP guidance:

8) Prof Estcourt presented an early version of the minimum dataset at European Centres for Disease Control “PrEP in Europe”, workshops (2018 & 2020). It was so well received that it has been included in new European CDC PrEP Operational Guidance, (led by Prof Estcourt) as an example of a robust monitoring tool for country-level data reporting and European-harmonised reporting to monitor progress against HIV prevention goals [S11, Annex 3] [G5].