Barriers to PrEP Uptake in Young U.K. Men Who Have Sex With Men

Participants

Interview participants were required to be between 18 and 24 years old, living in the United Kingdom, and identify as MSM. To ensure a comprehensive conversation about PrEP, participants were required to have some knowledge of PrEP. To guarantee participants met these criteria, a short pre-interview survey was administered to all participants asking whether they had some preexisting knowledge of the drug PrEP, what it does, and who should take it. Other than these inclusion requirements, no further sampling approaches were utilized, and individuals were invited to take part successively. In total, 10 YMSM were recruited through volunteer sampling, utilizing relevant gatekeepers (e.g., lesbian, gay, bisexual, and transgender [LGBT+] university societies). Age ranged from 18 to 22 years (M = 19.9, SD = 1.14). Additional demographic details can be seen in Table 1.

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Table 1

Demographic Characteristics of the Interview Participants

Pseudonym	Age	Sexuality	Race
AJ	20	Gay	White
Edward	20	Queer	White
Harry	21	Gay	White
Jonah	22	Gay	White
Kyle	19	Gay	White
Matt	20	Gay	Hispanic
Ned	18	Gay	Asian
Ryan	21	Gay	Asian
Sean	19	Gay	White
Theo	19	Bisexual	White

Note. Sexual and racial identities were classified by participants themselves.

Data Collection

Interview questions were formulated based on background reading, with a particular focus on contentious points from previous research. Feedback on the appropriateness of questions was sought from within the researchers’ networks, which included members of the YMSM community. Interview questions discussed various aspects of PrEP knowledge, perceptions, and misconceptions. Interviews were conducted over Microsoft Teams (M duration = 27 min; SD = 11 min). Recordings were uploaded to a secure institutional research drive. After the interview, participants were sent a debrief sheet further outlining the study as well as links to support and to the researchers’ contact details. Recordings were transcribed, and names were anonymized using pseudonyms for use in quoted extracts. In aiming to be more transparent and open about data adequacy (see Vasileiou et al., 2018), the decision to cease data collection and proceed to analysis was based on several factors: the researchers’ previous experience with similar projects, reflections on the more sensitive nature of our topic (i.e., increased recruiting challenges), project time constraints, the richness of interview data, and perceptions of data sufficiency. As such, the number of interviews conducted was considered appropriate when comparable recurring insights were observed by researchers in later interviews (Kelly, 2010) and when the data corpus was viewed as sufficient to warrant detailed understanding when considering the proposed analysis and research question (Braun et al., 2023). Ethical approval for this study was granted by the author’s institutional ethics committee (code: UG 20-088). The interview schedule used to guide data collection is available as supplementary material. Given the vulnerable nature of the participant group and associated ethical restraints, transcript data cannot be made available (see Prosser et al., 2022, for a detailed discussion of open data practices in qualitative research).

Analytic Approach

Data were analyzed utilizing reflexive thematic analysis (Braun & Clarke, 2019). Data were coded and assessed via a process of continual reflection, considering assumptions, and actively engaging with the data in an organic and evolving way, in order to provide an in-depth analysis of the perspectives given (Braun & Clarke, 2021). Coding took a primarily semantic approach, exploring specific surface meanings from participant accounts. This allowed focus on data specifically informing barriers to PrEP uptake, with the aim of identifying barriers consciously perceived to be blocking PrEP uptake. However, subconscious cognitive processes, such as state shame, ¹ can present unique barriers to PrEP uptake. Therefore, where necessary, a latent approach was also utilized, requiring a more interpretive take on the underlying meaning of some accounts, exploring concealed ideologies or assumptions that inform or produce the semantic content in the data (Byrne, 2022). Codes were assigned to meaningful units of data, and similar descriptors were collated to form candidate themes. These stages were conducted by the first author of this paper. No specific software was used for coding, with the researcher keeping detailed notes for their codes within the original transcript data. In collaboration with the second author, themes were reviewed by identifying reinforcers and contradictors within the data, to ensure that they were the most pertinent themes in relation to the research question. Analysis was data-driven (inductive), approaching the data without a preconceived framework in mind (Willig, 2022), since the research itself examines a unique subgroup of MSM. This was approached from a critical realist viewpoint, identifying responses as indicative of barriers to PrEP uptake that objectively exist within a participant’s environment but also reflecting how certain responses were treated as techniques utilized to construct participant realities that also pose barriers to PrEP uptake. This acknowledges that participant truths may be a product of the wider social world around them. An analysis log was kept during the coding and theme development process, noting candidate themes, subcategories, codes, and associated data extracts, allowing the researchers to reflect on and return to aspects of the data and analytic outcomes in line with the iterative process of reflexive thematic analysis. This log is available to view as Supplemental Material.

Reflections

Positions of both researchers and participants should be noted. This does not invalidate the research but simply provides context to interviews and analytic processes. Reflexivity is central to reflexive thematic analysis, acknowledging that knowledge is never free of researcher influence, both in terms of analysis and study design (Braun et al., 2023). Both researchers are MSM, which may impact the analytic claims made. The primary investigator, who was responsible for the study design and conducting interviews, was also a part of the YMSM community. Interviews were, therefore, formulated based on personal experiences of PrEP-perceptions within the U.K. YMSM community as well as existing research in this area. This permitted an interview more focused on the principal unique barriers to PrEP uptake specifically experienced by this community but is in no way an exhaustive account of all the barriers experienced by YMSM in the United Kingdom. In carrying out the interviews, a YMSM identity arguably may have elicited more open and honest responses from participants, as participants likely felt more comfortable talking to a member of their community (Knapik, 2006). From the participant’s perspective, it should be noted that one participant had a parent who was a sex therapist, one was a medic interested in queer health, and another involved in equality matters at their university. ² These participants were likely to have more knowledge about PrEP compared to most YMSM. However, this additionally allowed a more nuanced analysis of barriers from a range of YMSM living in the United Kingdom.

Perceived Necessity of PrEP

A key barrier to PrEP uptake for many participants was a perceived lack of necessity to take PrEP, attributable to three principal perceptions. First, participants often seemed to have a narrow conceptualization of PrEP and its benefits. Second, participants perceived other methods of protection as suitable enough to nullify PrEP consumption. Finally, certain participants did not view PrEP as necessary for them in their current lifestyle.

Starting with the narrow conceptualization of PrEP, many framed PrEP solely as a tool that reduces the risk of contracting HIV in individuals already having high-risk sex:

Pre-exposure prophylaxis. . . can be taken, if you’re kind of, worried that you’re, I guess involved in the kind of high-risk behaviors that means you’re more susceptible to catching HIV. So, it’s like a medication to take um yeah, I don’t know, um just as precautionary. . . and then high-risk in terms of sexual high-risk behaviors I guess yeah not using condoms. (Matt)

While correct, such statements unidirectionally limit the relationship between PrEP consumption and condomless sex. Participants viewed PrEP’s sole purpose as being a precautionary tool used to reduce the risk of HIV contraction during condomless sex. Very few participants expressed that PrEP can be a beneficiary tool that permits individuals to have condomless sex when they did not before. This perception is qualified by claims that PrEP use would not affect an individual’s frequency of condomless sex:

It should be used with condoms like you know contraception as well, well not contraception. You know having safe sex as well you can’t just use it on its own, but I mean I think to be honest it seems like a lot of the gay community probably see PrEP as an alternative. (Matt)

Therefore, certain participants did not perceive PrEP to have any unique benefits, compared to condoms, for example, thus reducing the perceived necessity to take PrEP. Furthermore, even when participants did view PrEP as permitting more condomless sex, the subjective benefits of this were also extremely restricted:

Therefore, I would move on to PrEP if I wanted to stop wearing a condom. I feel like that’s probably why I would start taking PrEP because otherwise I would be wearing a condom and then, I wouldn’t worry. (Harry)

While this participant does acknowledge that PrEP use would facilitate condomless sex, the benefits of this are restricted to not having to wear a condom. Participants in this study were unable to expand their conceptualization of the benefits of PrEP to include the emotional benefits of such an effective and convenient form of protection. This suggests that participants’ perceived necessity of PrEP was limited because they incorrectly believed that PrEP does not have any or many unique benefits, compared to other forms of protection.

It can, therefore, be maintained that the use of other forms of protection also reduces participants’ perceived necessity to take PrEP. The most popular contraception discussed among participants was a condom, as it was discerned as more universally effective than PrEP, since it could prevent the contraction of multiple sexually transmitted infections (STIs). However, considerations of HIV as a unique factor to consider in this regard were not considered:

I always just engaged in safe sex so it’s like, do I need this added preventative measure if I’m already sort of like I’m doing what I should be doing to make sure that both me and my partner are safe. (Jonah)

So maybe like the perception of me thinking that condoms are like more effective in the sense that it protects us from uh various diseases or like STIs. (Ned)

PrEP was, therefore, perceived as an added inconvenience that provides little extra protection when used in tandem with condoms or misperceived as a less effective HIV prevention method compared to condom use alone. Therefore, while individuals may view PrEP as unnecessary due to the perceived efficacy of condoms, for some individuals, this perceived lack of necessity may be based upon misinformation. Furthermore, in the absence of condoms, the utilization of other HIV risk-reduction strategies decreased the perceived necessity to take PrEP:

[Talking about unprotected sex] Uh. It depends who it’s with. If it’s someone that I know that’s definitely not got any STIs then I don’t care; just fine if it’s someone that is more like a hookup then, I dunno it’s a bit. The next day I’ll be a bit like ohhhh maybe I shouldn’t have done that. (AJ)

As this extract demonstrates, some participants appeared to utilize serosorting, the procedure of selecting sexual partners based on their HIV status, to prevent themselves from contracting HIV, and many of these participants only felt comfortable doing so when having sex with acquaintances or friends of friends. This risk-reduction tool was viewed to alleviate the need for PrEP, if one can confidently trust the health status of a sexual partner. In relation to this, STI testing was also referred to as a protection technique, in the absence of condoms:

[Referring to unprotected sex] normally like me now, I know that that’s risky behavior and it’s like almost like every single time you wake up in the morning you’re always like that was so stupid, but if I test every four weeks or whatever then everything’s fine (Matt)

What is suggested here does demonstrate good testing behavior; however, getting frequently tested is not itself an HIV prevention technique, as early detection of HIV does not lead to HIV eradication (McGarrity & Huebner, 2014). Therefore, individuals are apathetic to taking PrEP due to a range of different perceived HIV, and STI, prevention methods. However, the varying legitimacy of these techniques means that some reduce the perceived necessity of PrEP uptake in ways that put an individual’s sexual health at risk.

The use of alternative protection methods was not the only factor that altered YMSM’s perception of PrEP’s appropriateness in our sample, leading to a limited perceived necessity to take PrEP. There were also situational factors discussed that were seen to prevent the need for PrEP uptake, the most common being a monogamous relationship:

I would think that it’s not necessary, like if I was if I will be in a stable relationship for a long term then there probably and then cos if we get tested and stuff then we probably do not have the need to take PrEP, like it would just be an extra step every day or like having to go to get PrEP even if it’s free. (Ned)

At the time it was offered to me I was in a relationship; so, we were having unprotected sex, but it was only ever with each other, and we had been checked uh. (Kyle)

Participants often partook in informed serosorting, utilizing STI tests to ascertain their partner’s HIV status before engaging in unprotected sex with a romantic partner, thus reducing the perceived need to take PrEP. However, as noted by Kyle, there is a chance that infidelity from a partner could result in HIV transmission within a relationship. However, many participants in monogamous relationships did not seriously acknowledge the potentiality of infidelity and the associated increased risk of HIV infection. Therefore, while being in a monogamous relationship did limit the perceived appropriateness of PrEP, it may not reduce the risk of HIV contraction enough for this to be considered a justifiable barrier to PrEP uptake.

Therefore, the perception of PrEP’s benefits, the use of other contraceptive methods, and perceptions of PrEP as personally inappropriate all affect the perceived necessity of PrEP, thus acting as barriers to PrEP uptake. In considering a potential model to PrEP uptake, views on the necessity of PrEP in one’s lifestyle may constitute the first barrier to YMSM implementing PrEP use. However, regardless of the level of perceived necessity to take PrEP, many participants felt that they did not have the requisite knowledge to do so.

Knowledge About PrEP

Participants often lacked sufficient knowledge in several different areas relating to PrEP. This lack of knowledge often revolved around the characteristics of PrEP, the requirements to be eligible for PrEP, and the process of acquiring PrEP, all of which may reduce the likelihood of PrEP uptake for YMSM:

I don’t I don’t know where I would get it like um like I don’t know; is that the sort of stuff you can get like over the counter at Asda or you know, like the medical center in uni. And then on top of that the lack of knowing and not knowing who to ask is then like another issue. How do you how do you Google that like what do you type. (Sean)

I have the knowledge of it but then I didn’t know if I really needed it, like there wasn’t really advertisements or like actual people or like posters advertisements telling me that I probably need PrEP. (Ned)

These differing gaps in knowledge produce unique barriers to PrEP uptake. For example, not knowing what online information about PrEP is true and what is false may create false negative perceptions surrounding PrEP that could prevent uptake. Furthermore, not knowing what the criteria for PrEP are could cause an individual to avoid going to acquire PrEP out of fear of getting rejected. And not knowing how to get PrEP and who to ask to resolve this issue could also act as a sizable barrier to PrEP uptake.

An explanation for this relative lack of knowledge can be theorized from accounts of the specialized websites utilized as sources of PrEP information by those who did have knowledge about PrEP:

I think I’ve seen it on medical websites and also websites that talk about like news within like LGBT communities and things like that. (Theo)

A lot of the times it’s like you need to collect small pieces of information from like all these like different like sources and then like piece together, but there’s no like one coherent thing that’s like here’s all the information you need to know. (Ryan)

Participants spoke about having to actively acquire and assemble information about PrEP from medical and LGBT+-specific websites. The effort required to actively assemble information from several sources to gain appropriate levels of knowledge was seen to limit a full understanding of PrEP and associated factors. One further knowledge base discussed was sexual education classes at school, which could be used to provide all YMSM with knowledge on PrEP. However, many participants claimed that their school education insufficiently informed them about PrEP and other LGBT+ sexual issues, beyond use of condoms and STI testing:

In the same way that it’s sort of taught in schools like and like general safe sex stuff like use the condom use, go and get tested every so often, but there’s no I’ve never had anything about like oh you can try PrEP. Maybe like if that was implemented maybe it would raise more awareness and then, yeah, then it wouldn’t be like everyone’s burden to take it on themselves and be like PrEP what is it? (AJ)

I mean like because you don’t get taught about gay sex in sex ed, so it’s like if you went to a sexual health clinic how are you meant to ask like if a certain pain is normal. (Sean)

Participants alluded to the fact that the sexual health education received at school was very heteronormative, mainly focusing on protection methods utilized by heterosexuals. This lack of education not only leaves YMSM without proper knowledge of PrEP, but also stigmatizes gay sex as an inappropriate discussion topic within school sexual health settings. This itself could also act as a barrier to PrEP uptake, as it ingrains the idea that gay sex should not be spoken about in public settings, such as GP clinics. It may also unfairly place the burden of learning about how to protect oneself on YMSM themselves, resulting in insufficient levels of knowledge about PrEP.

Therefore, many YMSM appear to have an insufficient level of PrEP-specific knowledge, and this could be attributed to the sexual health education received at school, which many participants claimed to be heteronormative and insufficient. In further considering a model for PrEP uptake here, initial considerations of whether PrEP is necessary for one’s lifestyle are followed by a need for understanding how PrEP works and where it can be accessed. Consequently, this leads YMSM to reflect on how they feel about acquiring PrEP.

Perceived Comfort of Acquiring PrEP

For participants who perceive the acquisition of PrEP to be necessary and have the requisite knowledge to do so, there was still potential for PrEP uptake to be prevented by how comfortable participants felt discussing their sexual health in medical settings. Perceptions of comfort were often affected by YMSM’s concerns about potential negative reactions from healthcare professionals:

You’d like to always think that clinicians that you’re going to get are going to be very open and very um aware of LGBT health and that sort of thing but you never know, so I think yeah probably I’d go through with it up until the point that I actually am like in the waiting room, and I can imagine I’d be a bit nervous to actually meet the GP and kind of gage what they’re how comfortable they are about talking about you know LGBT health and PrEP. (Matt)

The institution itself, like you don’t want to go to like the NHS and like be completely like you know disregarded, so it depends on also like their working culture and how they treat the individual because if, if I had a bad experience, I’ll be more inclined to not do that again. (Ryan)

Within these extracts, the fear of being judged by medical professionals produced anxiety for YMSM. This fear of being judged may be a product of concerns surrounding the ingrained homophobia of clinicians, which may be perceived to be more prevalent in older clinicians, of which GPs are a large proportion. As stated by one individual, Ryan, if he were to feel judged within a clinical setting while trying to obtain PrEP, this may prevent him from visiting sexual health medical settings in the future, which could be particularly damaging if he ever experiences serious sexual health issues. Furthermore, even if individuals do not perceive that a clinician will have a negative reaction to conversations about gay sex, there are still anxieties that the clinician will not have the requisite knowledge to prescribe PrEP. This concern was mainly articulated by participants such as Matt, in relation to GPs. This concern is based on the perception that GPs are not taught to cater to gay sexual health issues and will, thus, create an uncomfortable environment during PrEP consultations. However, this was not a view shared by all:

I have experience with going and talking to doctors and you know talking to them about things that might be quite uncomfortable, um. So, yeah, in a way it would make it easier um and, in a way, obviously because I’m not like typical it might make it harder because places like Tavistock that’s what they do that’s their function whereas um in general you know the we are a smaller part of the population, so general STI places and GPs don’t have as much experience or anything. (Edward)

As a transgender man, Edward did not fear judgment within medical settings. This was due to the frequency with which he had experienced such conversations, specifically surrounding his gender identity, thus removing this barrier to PrEP uptake. However, he expressed significantly more concern that the GP would not have enough knowledge about PrEP to be able to confidently prescribe it to a transgender individual. Therefore, while these anxieties surrounding visiting a medical setting can affect all YMSM, it may affect certain subpopulations within this community significantly more.

Furthermore, even if an individual does not have any emotional concerns about obtaining PrEP from medical settings, their comfort can still be exacerbated by the inconvenience of having to visit said setting:

Accessibility is probably going to be my number one; like, I know it’s bad but if I can’t do it on like with the medical center here. I don’t really fancy traveling all the way down to town just to pick up a tablet that I probably won’t even you know put to good use ummm for a while um, so and like I don’t know it’s just a matter of laziness, I guess. (Sean)

At this point probably just convenience and access? It’s like is it the sort of thing that I need to go through a long process for? Or is it the sort of thing that I can just pop into like either my local clinic or like any other sort of health service and just be like, hey, I need PrEP; can I have some. (Jonah)

Linked to motivation, individuals seemed to perceive the inconvenience of visiting a medical setting to obtain PrEP to outweigh the benefit that PrEP uptake would confer. This is particularly a barrier for obtaining PrEP from an STI clinic, instead of a GP, as visiting an STI clinic generally requires more excursion or visiting an environment less familiar to the individual. Therefore, the perceived convenience of doing so can affect motivation to acquire PrEP and act as a barrier to PrEP uptake. Obtaining PrEP from a GP may circumvent this obstacle of inconvenience, in terms of both physical effort and, therefore, time required to obtain PrEP. Although, as previously mentioned, the GP presents unique obstacles that increase the perceived discomfort of obtaining PrEP from this medical setting. Participants were receptive to using video e-consultations as an alternative method of PrEP acquisition, due to the perceived low levels of discomfort:

We’ve been doing a lot of consultations with patients online, and it has, yeah, I think it does. I don’t know it can it can sometimes be less awkward because you aren’t face to face. Maybe, yeah, actually having the conversation like this might make it less awkward. Being like this makes it less hard for me cos you could you quickly you close the consultation online you’re kind of out of that space and environment you can just get on with your day. Whereas being in person with them and they say something awkward, and you just have to sort of sit there and then leave awkwardly it’s a lot more, intense. (Matt)

When asked, many participants expressed that being able to obtain PrEP online would alleviate much of the discomfort associated with obtaining PrEP and make the process more convenient. Matt specifically claimed that an online PrEP service would also allow individuals to exit more easily if the situation became awkward or anxiety-inducing. Therefore, the perceived comfort of obtaining PrEP from a medical setting acts as a significant barrier to PrEP uptake, due to feelings of anxiety and perceptions of inconvenience. Online methods of PrEP delivery were viewed positively as one way to help to alleviate this barrier. Taking the outlined themes into account, the perceived comfort of acquiring PrEP signifies the final barrier in our model of PrEP uptake. The model (shown in Figure 1) theorizes how our three identified barriers for PrEP uptake interact with each other to form a cascade. YMSM in the United Kingdom must first perceive PrEP to be necessary, have the requisite knowledge about it, and finally feel comfortable acquiring PrEP from a medical setting to eventually obtain PrEP. At each barrier, a proportion of YMSM will be prevented from taking PrEP, and therefore, the number of YMSM will decrease as one moves down the model cascade. However, each step does not occur independently, and certain steps may interact to reinforce barriers. Represented in pathway 1 not having the requisite knowledge about PrEP can impact how necessary individuals perceive PrEP to be. Represented in pathway 2 how inconvenient YMSM perceive acquiring PrEP to be could also potentially influence individuals to alter their thinking in terms of perceived necessity.

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Figure 1

A Cascade Model Showing How the Identified Barriers to PrEP Uptake May Interact

Limitations

When discussing applications of this study’s findings, it is important to acknowledge limitations. While this study benefitted from a diverse range of YMSM perspectives (including three non-White and one transgender individual), no Black YMSM were interviewed. Data collection was also influenced by geographical proximity, willingness to volunteer to take part, and the rigid timescale for this project. As such, our findings can only provide a snapshot of detail around PrEP uptake. Research suggests that Black YMSM are significantly less likely to take PrEP than their White counterparts and are also at an increased risk of HIV contraction (Hoyt et al., 2012). Future research needs to include perspectives from this high-risk community. To elicit in-depth conversations, this study required participants to already have some knowledge of PrEP, thus excluding a proportion of YMSM. For those YMSM unaware of PrEP, barriers may be more knowledge-based and less nuanced, as their lack of knowledge may make them less aware of some of the perceived issues associated with obtaining PrEP, such as the potential for judgment from a GP. As such, the sampling approach here only gathered perspectives from those who may have been more engaged in this domain. However, with widespread media coverage and increased funding, PrEP awareness will likely increase. Finally, while this qualitative study provided useful insights, the type of data obtained is not extensive enough to produce a concrete model. Our theoretical model must be quantitatively tested to assess whether removing these barriers increases PrEP uptake and whether the order in which these barriers are removed affects rates of increase. This could be done by examining whether certain vignettes or experimental stimuli aiming to tackle the perceived barriers will affect willingness to take PrEP (i.e., need, knowledge, and access).

Implications

Our findings provide useful insights into potential ways to disseminate information about and educate relevant groups about PrEP, for instance, being exposed to accounts from PrEP users around consumption and benefits beyond condom use only (e.g., further reduction in anxiety surrounding HIV contraction and increased partner intimacy). Furthermore, health information and education (e.g., in schools or via government programs) should consider justifications for PrEP being nonessential due to partner trust and disclosed sexual health status. Training could emphasize the importance of testing and protecting oneself and a partner should anything change (or be misjudged) during intimate relationships. In addition, education programs would do well to ensure they continue to increase awareness of what may count as at-risk behaviors. As noted earlier, making discussions around PrEP part of compulsory sex education in schools could eliminate health literacy barriers in the YMSM community and potentially help combat shame surrounding conversations about gay sex. Combating possible information inconsistencies across multiple sources supports the need for a central authority to manage key PrEP information (e.g., via national strategies). Such approaches would hopefully aid in relevant groups understanding where and how they can access help, support, and obtain a prescription. Comfort in knowing whether a healthcare provider was queer-friendly was discussed here and in previous findings. Programs that encourage acknowledgment of support in this regard, perhaps noted through membership to or completion of associated training, may help evidence appropriate knowledge and help reduce patient concerns.

To overcome the barriers illustrated in our model, we recommend the utilization of a dedicated online application for PrEP. This would ideally be nationally/centrally managed, since associated tests and prescriptions could be accessed by all and delivered uniformly, increasing efficiency and maintaining the quality of care (Zwaanswijk et al., 2011). This application could also facilitate e-consultation processes, potentially diminishing anxieties associated with acquiring PrEP discussed above. Research has already observed that access to at-home HIV testing kits increases the frequency of testing behavior (Katz et al., 2018), suggesting that at-home online PrEP consultations may similarly increase levels of PrEP uptake. The application could also provide useful data on PrEP use, with accurate and comprehensible information in one accessible platform. This may further help tackle certain myths or misinformation. Such an application could also benefit services such as the U.K. NHS financially, as patient information could be obtained via an online form, keeping consultations brief. Research by Now Healthcare Group (2019) suggests that utilizing telehealth applications throughout the NHS could save NHS England up to £7.5 billion annually.