Article Text

Download PDFPDF
Putting the NHS England on trial: uncertainty-as-power, evidence and the controversy of PrEP in England
  1. Maurice Nagington1,
  2. Tony Sandset2
  1. 1 School of Health Sciences, Faculty of Medicine Biology and Health, University of Manchester, Manchester, United Kingdom
  2. 2 Institute for Interdisciplinary Health Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway
  1. Correspondence to Dr Maurice Nagington, Health Sciences, Faculty of Medicine Biology and Health, University of Manchester, Manchester M13 9PL, UK; maurice.nagington{at}


Pre-exposure prophylaxis (PrEP) (Truvada) is a medication which if taken correctly is almost entirely effective in preventing HIV infection. In regions and countries where it has been widely taken up, HIV seroconversion rates have significantly decreased. Alongside testing and treatment, it offers the very real prospect of ending HIV infections. However, in England, commissioning it has (and still is) a controversial process, where NHS England has repeatedly raised supposed ‘uncertainties’, first legal and then scientific. The same has not happened in Scotland, where PrEP was commissioned to anyone who needed it in April 2017. This article presents a close reading of the IMPACT trial protocol, which we conclude cannot answer the questions it sets out to answer. We then suggest that the uncertainties the trial claims to address are in fact a tool of power which is deployed to strategically ration healthcare; introduce uncertainty about commissioning PrEP; and shift the boundary between individual responsibilities and state responsibilities for public health and HIV prevention. We conclude that all the above constitute an unethical use of clinical trial rhetoric, systematically discriminate against minority and vulnerable groups, and ration healthcare for those who most need it. As such, we call on all academics, clinicians and activists to resist further unethical misuses of clinical trial rhetoric.

  • sexual medicine
  • public health
  • health policy
  • medical ethics/bioethics

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Twitter @NagingtonUoM, @@TweetingTony

  • Contributors Both authors have contributed to the original ideas of this article. No one else has provided any significant input.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.