Pre-exposure prophylaxis (PrEP) has been and continues to be an intervention that causes controversy and debate between stakeholders involved in providing or advocating for it, and within communities in need of it. (Cairns et al 2016)
PrEP is a highly effective, daily, orally-consumed, preventative HIV medication. A UK open-label randomised control trial of 544 HIV-negative men who have sex with men (MSM) found that 0 participants who took PrEP contracted the virus (McCormack et al 2016). PrEP was first approved by the FDA in 2012, and its use has become more widespread in the US, UK and Australia since then (Cairns 2016). As a result of PrEP’s widespread usage, a 71% decline in new HIV infections has been recorded among gay and bisexual men in the UK since 2014. Despite evidence of its efficacy, PrEP’s availability has been limited. The National Health Service announced on March 15 that they would make PrEP available for high-risk groups. Until this intervention, PrEP’s availability had become a question of means – rather than access — since PrEP was a demand-driven intervention. This was because instead of getting PrEP based on risk assessment conducted by medical professionals, MSM would have to self-assess risk factors to access PrEP. Before the NHS’s intervention, they had to either join an open-label trial or buy PrEP privately. Under Article 25 of the Universal Declaration of Human Rights (UDHR), everyone has the right to a standard of living adequate for health and well-being, including medical care. Under Article 27, everyone has the right to share in scientific advancements and its benefits. In this piece, I will argue that challenges to the availability of PrEP are culturally constructed within the context of MSM, informed by perceptions of sexuality, HIV stigma and their intersections. I will analyse this through the lens of medical anthropology surrounding pharmaceuticals and their culture.
The first concept I want to discuss is that of Pharmakon which is typically used to understand pharmaceuticals both as remedy and poison. Throughout the process of approving a drug, a balance between its biomedical benefits and consequences needs to be struck – how will this drug affect the population if it is made fully available? PrEP, like most drugs, underwent this approval process. Then why was PrEP’s availability (via the NHS on doctors’ recommendation) challenged so exhaustively and treated differently than other preventive medications, especially considering its already widespread use and proven efficacy/safety? The answer lies with the dual purpose of drugs – its physical impact and symbolic meaning (Persson 2004; Geest 1996). Persson discusses HIV and highly active antiretroviral therapy (HAART), a cocktail of drugs that maintains immune system function of those with HIV, using Pharmakon to understand the social implications resulting from the physical side effects of the drug. For HAART, the ‘poison’ or side effects are visible, characterised by fat redistribution (lipodystrophy). However, Persson analyses this ‘poison’ as having more than just physical consequences, arguing that HAART embodies “cultural ideas about self and body, about illness and health, efficacy and responsibility” (Persson 2004; Nichter and Vuckovic 1994). The appearance of HAART patients created a pharmaceutical identity based on fear and stigma surrounding HIV within the LGBT community (Geest 1996; Calabrese 2015; Spieldenner 2016). In PrEP’s case, the cultural perception of users has not embodied any pharmaceutical or biomedical side effects or ‘poison’. Contrarily, the cultural perception of MSM as sexually promiscuous and irresponsible is seen as the ‘poison’ of PrEP (Race 2016). The rate of success for PrEP is dependent on three factors: uptake, adherence, and sexual practices (Grant et al 2014; McCormack et al 2016). Therefore, challenges against the initial availability of PrEP were determined by the interaction between how the patient demographic is perceived to behave and the biomedical requirements for PrEP’s efficacy (Cairns 2016).
“Michael Weinstein, President, AIDS Healthcare Foundation, has called the pill a ‘party drug’ and those who lived through the early days of the AIDS pandemic have raised concerns that PrEP undermines traditional advocacy messages about condom use” (Belluz, J. 2014). Condom migration is the theory that widespread PrEP use will reduce condom use among MSM, thus increasing contraction rates of other sexually-transmitted diseases (STDs) and ultimately inflating other public health issues. McCormack’s PROUD study tested for incidence of other STDs and found no increase before and after the study, meaning PrEP did not visibly influence sexual behaviours such as condom use. Furthermore, a mathematical model of HIV interventions for MSM concluded that an increase in condom-less sex and new partners to 50% or more would not negate the effects of PrEP implementation on public health (Punyacharoensin et al 2016). Although a shift in sexual behaviour is hard to measure, this study provides mathematical evidence that even if the theory of condom migration is accurate, PrEP would still reduce HIV infection rates in MSM.
Kane Race (2016) discusses the emergence of PrEP as a “reluctant object” due to “its punitive association with unbridled sex”. He frames this reluctance as a symptom of larger issues of HIV policy, behavioural and clinical research and how they are shaped by attempts to manage or otherwise avoid the presumptive/negative perception of gay sex. The HIV crisis of the 80s was characterised by endemic homophobia associated with HIV and its connection with gay sex and death, an association that still exists today. PrEP intersects this narrative as “pharmaceutically mediated viral suppression makes it possible to dislodge gay desires for sex without condoms from their cultural associations with wilful self-destruction” (Race 2016). This analysis can help inform why PrEP availability has been so meticulously challenged. It indicates a complex intersection between PrEP as a pharmaceutical, HIV as a virus and perceived responsibilities of MSM. “PrEP is said to have the potential to erode gay men’s sexual responsibility by enabling ‘‘unprotected’’ sex with multiple partners or, rather, reducing the anxiety that would formerly have prevented it.” (Cairns 2016)
Assessing the forces that challenge PrEP’s availability is incredibly complex. One of these include the perceived responsibility of MSM in relation to HIV contraction. Among gay men, HIV contraction is understood as a result of irresponsibility and it is their personal duty to prevent it through risk reduction. This is exemplified by PrEP’s access as it stood before the latest NHS intervention. As a demand-driven drug, MSM are required to assess their own risk and request PrEP accordingly. This is indicative of how MSM’s responsibilities are perceived by healthcare providers. On the one hand, PrEP could erode sexual responsibilities such as condom use, on the other, it could provide people with agency over their health. PrEP, unlike condoms, does not rely on the partners involved. Therefore, PrEP is more than just a daily medicine – it is a tool for agency over one’s health (Persson 2004). In sum, the limitation of PrEP access/availability as a result of perceived responsibility transfers responsibility surrounding HIV from condom use to pharmaceutical adherence. This begs the question of what the roll out of PrEP would have looked like if HIV was a ‘straighter’ epidemic in Western countries with sufficient healthcare capacity. Challenging the availability of PrEP based on the perception of bodies and sexual behaviours of MSM is indicative of a deeply ingrained, systematic homophobia.
In conclusion, understanding how cultural concerns challenge PrEP’s availability involves complex analysis of MSM, HIV and PrEP. PrEP has become a reluctant object as a result of the stereotyped and stigmatised sexual behaviours associated with MSM. Sex, HIV and MSM have had strong cultural connotations for decades and the implementation of PrEP has the ability to redistribute responsibilities and give rise to increased agency over health in relation to HIV. In addition to reducing anxieties associated to sex and HIV for MSM, PrEP may reformulate how the bodies of these men are perceived both within and outside of the LGBT community. In light of this, challenges against PrEP have been disproportionately overemphasised. An overemphasis which must be addressed in order to tackle health injustices for MSM.
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