about the roll-out of PrEP would need to tackle some serious ethical questions
about who gets access to the drugs, researchers from the CDC and the University of Oxford said in The Lancet in July
PrEP raises important ethical questions:
- What are the
obligations of governments and industry to provide such prophylaxis?
- How should resources
be distributed between research, treatment, counselling, testing, primary
prevention, PrEP and PEP?
- Who should have
priority for prophylaxis?
authors acknowledge that HIV-related stigma poses particular challenges, since
this can affect decision making. For example, one argument against provision of
PrEP for groups such as sex workers, drug users and men who have sex with men
“is based on the idea that providing prophylaxis expresses approval for
high-risk behaviours”, analogous to arguments used against needle exchanges or
condom provision to teenagers.
far, several studies of potential interventions to reduce HIV transmission have
not led to an increase in unsafe sexual behaviours, although that issue needs
to be evaluated in the studies of PrEP, the authors advocate.
go further in rejecting this argument. “First, public-health policy should aim
for prevention of ill-health rather than judgments of individual’s morality.
Second, we do not believe that provision of prophylaxis condones risky
behaviour; but rather, it acknowledges the reality of the epidemic.”
issue is the perception that people choosing risky behaviours should be at
lower priority for prevention than those whose risk is not affected by their
behaviour”, say the authors, citing as an example those infected via vertical
authors ask, “even if personal responsibility for infection was considered in
setting public-health priorities, how does one ascribe the degree of
point to two examples: ill-health in a smoker who was brought up in an
environment in which smoking was encouraged; and the social and economic
pressures on female sex workers in resource-poor countries.
no method of ascribing personal responsibility for disease is reliable or
valid. We therefore believe that neither judgments about morality, nor responsibility
for risky behaviours should play a part in decision making about [PrEP].
Instead, public-health decisions should be based on relevant factors such as
cost-effectiveness and clinical need.”
efficacy studies of PrEP underway, one concern is that such programmes, if
found effective, may be too expensive for the areas that have the greatest
need, and many prevention programmes, of which PrEP would be part, are already
the severity of the HIV epidemic and the potential benefits of pre-exposure
prophylaxis should lead us to begin planning for implementation as soon as
possible,” the authors urge:
- Which settings would
- What level of
efficacy would warrant widespread use?
- Which populations
would benefit most?
authors propose that “in regions with HIV epidemics in specific groups,
targeting of such groups (e.g., sex workers, partners of people known to have
HIV, and those attending sexual-health clinics) is probably the best strategy.
in areas with generalised epidemics, as is seen in some African countries,
potential populations could include most sexually active adults.
the procedures for access and dispensing remains a challenge. PrEP should never
be sold over the counter: the potential for misuse (for treatment as well as
prevention) and resultant widespread HIV resistance is just too great.
PEP has shown us that some people
seeking it have come across discriminatory attitudes from healthcare staff.
Would the stigmatisation of marginalised, high-risk communities lead to PrEP
being denied to the very people who need it most? These power inequalities and
a comprehensive training programme for probable providers would have to be
addressed in advance of any move to make PrEP widely available, regardless of