A lot has changed since the early days of HIV/AIDS. In the
not so good old days an HIV infection pretty much constituted the end of the
road for those infected. Most infected people died of one or another infection
a healthy immune system would have been able to cope with. The public health
messaging at the time was unequivocal: protect yourself and others by using
condoms every time you have sex with someone whose HIV status is unknown to
you. The ethical rationale for this was predicated on ideas such as Dan
Beauchamp’s. He wrote, ‘public health should advocate a counter-ethics for protecting the public’s health, one articulated
in a different tradition of justice and one designed to give the highest
priority to minimizing death and disability.’[1]
Libertarians such as the gay philosopher Richard D. Mohr didn’t buy into this
story, questioning even whether the idea of ‘public health’ was intelligible to
begin with.[2] He
wasn’t the only critic of public health promotion campaigns. Patricia
Illingworth warned more than two decades ago that AIDS health promotion campaigns could be
hazardous to our autonomy.[3] She
argued, persuasively to my mind, that many health promotion campaigns are
manipulative and so they undermine autonomous decision-making by competent
adults.
I cannot help but wonder whether we have come full-circle on
this issue. Today we have medicines available that effectively control HIV.
AIDS is so rendered a chronic manageable illness. These medicines have a truly
remarkable side-effect. They are capable of rendering people with HIV infection, who take them, non-infectious for all practical intent and purposes.[4] Indeed,
medication has come on the market offering something called pre-exposure
prophylaxis. The idea here is basically that perfectly healthy people with a
fairly high risk of contracting HIV take this medication to prevent the virus
from taking hold in case they get exposed to it.
There are all sorts of ethical issues that arise in the
context of the proposition that healthy people should take drugs to prevent a
future infection that might never happen to them in the first place, at a cost
of thousands of dollars per year per non-patient. Still, epidemiological
modeling suggests that this strategy could end the HIV pandemic in a generation
or two. You can see why: If infected people take drugs that render
them non-infectious and everyone at high risk for contracting the virus took
the same class of drugs as a prophylactic against an infection, eventually new
infections would decrease very significantly. In the absence of a preventive
vaccine this might be our best shot at beating the virus.
The courts have not quite caught up with this new reality.
HIV infected individuals with undetectable viral load, who have unsafe sex
without telling their partners, still risk prosecution in many countries. But
what about the public health promotion industrial complex’s response? Has it
modified its campaigning on the issue? It turns out, the strongest condemnation
of pre-exposure prophylaxis came from public health promotion people. They were
primarily concerned that people in groups at high risk for HIV infection might
take the medication and engage in unsafe sex.
There is a mindset at work that we might be
better off threatening people with HIV sufficiently to scare them into having
safe sex. Telling them the truth and risking that some might decide to take
drugs efficiently protecting them against HIV in order to engage in unsafe sex
doesn’t seem an option. Why would otherwise sensible people hold such views? Well, they are
concerned that a rise in unsafe sex could lead to people acquiring other
sexually transmissible illnesses.[5]
Even if that was true, surely any health care system ought to strive toward reducing the number of people with a serious infection such as HIV even if that meant accepting a higher number of people with mostly treatable infections such as syphilis, gonorrhea and the like. Bizarrely the suggestion has also been made that if gay men stopped using condoms courtesy of the risk-reduction the pre-exposure prophylaxis affords them, they would eventually be as sloppy with the medication itself. It goes without saying that there is zero evidence to support this contention. As to the increased risk-taking alluded to a moment ago, available research suggests that pre-exposure prophylaxis goes hand-in-hand with only a slight increase in the likelihood of reduced condom use .[6]
Even if that was true, surely any health care system ought to strive toward reducing the number of people with a serious infection such as HIV even if that meant accepting a higher number of people with mostly treatable infections such as syphilis, gonorrhea and the like. Bizarrely the suggestion has also been made that if gay men stopped using condoms courtesy of the risk-reduction the pre-exposure prophylaxis affords them, they would eventually be as sloppy with the medication itself. It goes without saying that there is zero evidence to support this contention. As to the increased risk-taking alluded to a moment ago, available research suggests that pre-exposure prophylaxis goes hand-in-hand with only a slight increase in the likelihood of reduced condom use .[6]
There’s also the usual rhetoric of ‘reckless’ behavior,
which ignores that a decision to have unsafe sex can be a carefully considered
choice. It is not that safe sex is a cost neutral activity. Surely there is a
reason for why most people do not use condoms consistently.[7] Patricia
Illingworth wrote an illuminating monograph defending the right of gay men and
others to make such choices.[8]
It seems Illingworth and Mohr had a point when they warned
about the capacity of public health promotion activities to harm individual
autonomy. To campaign against HIV pre-exposure prophylaxis in order to ensure
that gay men don’t make safe sex related choices health promotion people
disagree with seems ethically deeply problematic. Their task would surely be to
persuade potentially risk taking people not do do so by outlining what risks,
other than HIV, they would run if they did what they are contemplating doing. To
use the threat of an HIV infection as a means to achieve other objectives,
namely to reduce the incidence of other sexually transmitted illnesses, is a
non-starter.
UDO SCHUKLENK
[1] As
quoted in Patricia Illingworth. 1990. AIDS
and the Good Society. London: Routledge, p. 48.
[2]
Richard D. Mohr. 1987. AIDS, Gays and State Coercion. Bioethics 1(1): 35-50.
[3]
Patricia Illingworth. 1991. Warning: AIDS Health Promotion Programs May Be
Hazardous to Your Autonomy. In: Christine Overall and William P. Zion. (eds). Perspectives on AIDS: Ethical and Social
Issues. Toronto: Oxford University Press, pp. 138-154.
[4]
Gus Cairns. 2014. No-one with
an undetectable viral load, gay or heterosexual, transmits HIV in first two
years of PARTNER study. March 04. http://www.aidsmap.com/No-one-with-an-undetectable-viral-load-gay-or-heterosexual-transmits-HIV-in-first-two-years-of-PARTNER-study/page/2832748
[accessed March 05, 2014]
[5]
For a bioethical version of this concern see Richard M. Weinmeyer. 2014.
Truvada no substitute for responsible sex. February 14 .Bioethics Forum http://www.thehastingscenter.org/Bioethicsforum/Post.aspx?id=6777&blogid=140
[Accessed March 04, 2014]
[6] Martin Holt, Dean A. Murphy, Denton Callander et al. 2012. Willingness to use HIV pre-exposure prophylaxis and the likelihood of decreased condom use are both associated with unprotected anal intercourse and the perceived likelihood of becoming HIV positive among Australian gay and bisexual men. Sexually Transmitted Infections 88: 258-263.
[6] Martin Holt, Dean A. Murphy, Denton Callander et al. 2012. Willingness to use HIV pre-exposure prophylaxis and the likelihood of decreased condom use are both associated with unprotected anal intercourse and the perceived likelihood of becoming HIV positive among Australian gay and bisexual men. Sexually Transmitted Infections 88: 258-263.
[7] L.A.
Scott-Sheldon, K.L. Marsh, B.T. Johnson and D.E.
Glasford. 2006. Condoms + pleasure = safer sex? A missing addend in the safer
sex message. AIDS Care 18:750-4
[8]
Patricia Illingworth. 1990. AIDS and the
Good Society. London: Routledge
