In a delegated Officer Key Decision, Jason Strelitz, Corporate Director for Adults, Health and Communities, approved the acceptance of £572,000 in grant funding from the Elton John AIDS Foundation (EJAF) to expand access to Pre-Exposure Prophylaxis (PrEP) in North East London (NEL). Newham Shared Service will act as the lead local authority, responsible for procuring services, project management, coordination, and monitoring on behalf of all NEL local authorities. This initiative, known as Expanding PrEP Access through Novel Delivery in North East London (ExPAND - NEL), aims to reduce HIV diagnoses and health inequities by increasing PrEP awareness and uptake, particularly among under-represented groups.

Expanding PrEP Access through Novel Delivery in North East London (ExPAND - NEL)

Jason Strelitz, Corporate Director for Adults, Health and Communities, approved the acceptance of £572,000 in grant funding from the Elton John AIDS Foundation (EJAF) on behalf of all North East London Local Authorities to expand access to Pre-Exposure Prophylaxis (PrEP). Newham Shared Service will act as the leading Local Authority with responsibilities for the procurement of services to deliver six workstreams outlined inthe proposal, pilot project management, coordination, and monitoring on behalf of all NEL Local Authorities.

The ExPAND-NEL programme aims to increase PrEP awareness and uptake, particularly within under-represented groups at risk of acquiring HIV.

Expanding PrEP access through Novel Delivery in North East London (ExPAND-NEL) will reduce HIV diagnoses and health inequities by increasing PrEP awareness and uptake, particularly within under-represented groups at risk of acquiring HIV.

The programme intends to extend PrEP awareness-raising, initiation, and continuation beyond specialist sexual and reproductive health (SRH) clinics, making it accessible to residents who do not currently access PrEP via specialist services but could access it via other physical or digital settings.

The ExPAND-NEL programme has several aims:

• Increase awareness through grassroots engagement and non-specialist health staff.
• Provide cost-effective PrEP via a digital platform integrated with STI testing.
• Facilitate PrEP initiation and continuation in non-specialist settings, including primary and secondary care, and community locations.
• Provide enhanced support for those with lower PrEP awareness and social barriers, and pathways for those with complex needs.
• Reach up to 3,100 people, increasing PrEP coverage by 60%.
• Establish a scalable model to influence PrEP delivery elsewhere.

To achieve these aims, ExPAND-NEL will:

• Engage under-represented groups through targeted community outreach.
• Train non-specialist health staff to discuss and refer patients for PrEP.
• Establish a direct-to-consumer online PrEP service (DPrEP).
• Deliver PrEP in non-specialist settings using existing infrastructure.
• Strengthen specialist SRH clinics to handle complex cases and interface with the DTC pathway.

The report notes that the North East London (NEL) area has a high proportion of groups at risk for HIV, and that while HIV incidence declined between 2018 and 2021, it remains one of the highest in London and England. The report also notes that the number of new diagnoses increased sharply in 2022, and that national data shows a further substantial increase in 2023.

The report states that in NEL, as elsewhere in London, the incidence of HIV is higher among gay, bisexual, and other men who have sex with men (GBMSM), particularly young GBMSM, Black ethnic groups, those born abroad, and particular at-risk groups such as sex workers. It links high HIV prevalence in NEL to the large and growing LGBTQ+ population, high migration levels, large Black African and Caribbean communities, relatively large groups of people who engage in high-risk sexual behaviours, and injecting drug use.

The report notes that PrEP is currently available free of charge to eligible individuals through specialist Sexual and Reproductive Health (SRH) services, but that increases in PrEP uptake in NEL have not been equitable across at-risk groups. It states that rates of new diagnosis among other at-risk groups have increased recently, and that the increase in HIV infections in recent years in London has been steepest among GBMSM aged under 35, heterosexuals aged 35-54, people of Black or 'other' ethnicity, and heterosexuals born abroad.

The report identifies several reasons why the PrEP needs of some underserved groups may not be fully met by specialist clinics, including a lack of awareness of sexual practices that put them at risk of HIV, stigma attached to sexual health clinics, a lack of understanding that SRH services can provide preventive care and health promotion, and limited capacity of SRH clinics.

The ExPAND-NEL pilot aims to tackle these barriers to enable increased uptake and utilisation of PrEP across NEL, particularly within underserved groups.

The report states that the ExPAND-NEL pilot programme aligns well with strategic priorities within the 'Fairer Newham' Corporate Plan (2022-26), including Priority 1: A healthier Newham and ageing well, and Priority 6: Supporting our young people. It also aligns with Newham’s Health and Wellbeing Strategy, 50 steps to a Healthier Newham (2024-27), which promises to increase PrEP uptake and HIV screening among priority groups.

Alternative options considered and rejected included not accepting the funds, and for each NEL Local Authority to procure, manage and coordinate the programme directly. The option of not accepting the funds was rejected due to the missed opportunity to reduce new HIV diagnoses, the continuation of inequity in PrEP access and uptake, and the strategic alignment and policy influence of the ExPAND-NEL programme. The option of each NEL Local Authority procuring, managing and coordinating the programme directly was rejected because Newham hosts the NEL Sexual Health Shared Service Commissioning Service, which has established governance structures and experience in managing complex multistakeholder programmes, and because Newham can leverage existing procurement routes to ensure rapid contracting and implementation of the programme.

The report details several financial, legal, and equalities implications of the decision. It states that the funding will be form a specific grant, administered by Newham, across NEL local authorities, and that all spend and grant income will be allocated to specific unique budget codes. It also states that the Council has a statutory duty to take such steps as it considers appropriate for improving the health of the people in its area, and that the recommendations in the report are in keeping with this duty. Finally, it states that the ExPAND-NEL project aims to address health inequities by increasing PrEP awareness and uptake among underserved groups in North East London.

The report includes a consultation sheet indicating that the Director of [INSERT TITLE] and the Lead Member [insert title] have been consulted and have agreed with the decision.

The report includes an appendix with a joint proposal to the EJAF, which provides further details about the ExPAND-NEL project. The proposal includes a project description, background information, key strengths of the model and experience, a description of the ExPAND-PrEP pilot, a commissioning approach, information about partnerships, a monitoring and evaluation plan, a sustainability/exit strategy, a project management plan, a project risk and mitigation plan, and a budget.

The report identifies several delivery partners for the ExPAND-NEL project, including LB Newham, NEL Local Authorities, The Love Tank, Positive East, All East service at Barts Health, All East service and other East London SRH Clinics (Homerton, BHRUT), and SHARE. It also identifies several collaboration and dissemination partners, including Mona Hayat, Director of the London Sexual Health Programme; Charlotte Pomery, Chief Officer for Participation and Place at the NEL NHS Integrated Care Board (ICB); Professor Kevin Fenton, Regional Director at the Office for Health Improvement and Disparities (London); Dr Sue Mann, NHS National Clinical Director for women’s health; Dr Janet Barter, President of the Faculty of Sexual and Reproductive Healthcare; Professor Jane Anderson, Chair of London Fast-Track Cities; Helen Corkin, Sexual Health Lead - London at the UK Health Security Agency; and Marc Thompson, Lead Commissioner of the London HIV Prevention Programme.

The report includes a detailed budget for the ExPAND-NEL project, which includes funding for a DPrEP provider, The Love Tank, Positive East, SHARE, LB Newham, Barts Health / All East, Homerton UHFT, and BHRUT.

The report identifies several risks to the success of the project, including delays with establishing the DTC service, delays or issues with recruitment to new roles, lengthy procurement or legal timelines, delays or issues with integrating systems or pathways, DPrEP diverting significant volumes of PrEP activity from NEL SHRS, costs becoming unsustainable for LAs if PrEP demand increases, non-specialist staff not actively delivering PrEP, low uptake of the new pathway or access not improved to groups most at need, high rates of PrEP cessation or continuation not properly managed, and lessons from the pilot not being taken on by other areas. It also identifies a lack of data or poor quality data as a risk. The report includes a mitigation plan for each of these risks.