{"id":899,"date":"2013-09-02T20:14:48","date_gmt":"2013-09-02T20:14:48","guid":{"rendered":"https:\/\/blogs.bmj.com\/sti\/?p=899"},"modified":"2013-09-02T20:14:48","modified_gmt":"2013-09-02T20:14:48","slug":"the-ethics-of-prep","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/sti\/2013\/09\/02\/the-ethics-of-prep\/","title":{"rendered":"The ethics of PrEP"},"content":{"rendered":"

A recent article in the US journal JAIDS, Sugarman & Mayer <\/i>(S&M),<\/i> provides a handy outline of the ethical issues around pre-exposure prophylaxis (PrEP) for HIV infection (Sugarman & Mayer<\/a>).\u00a0 The subject is very topical in the US, now that the Food and Drinks Administration have taken a step ahead of the rest of the world in approving Truvada (tenofovir-emtricitabine) for daily use as PrEP (16\/07\/12). The real-life impact is as yet unclear (US Truvada roll-out<\/a>); but the US National Institute of Allergy and Infectious Diseases (NIAID) is currently partnering with local public health departments to set up demonstration projects (US Truvada PrEP demonstration projects<\/a>). The world will be watching.<\/p>\n

One area of issues revolves around \u201cwell-being\u201d and has two major aspects.\u00a0 The first\u00a0concerns the possible development of drug resistance that could compromise future treatment options, in the individual and the wider community, either as a result of erratic adherence (the oral table needs to be taken daily, and is known to have adverse side-effects), or as the result of continued use of the drug after the individual becomes infected with HIV. The second concerns the possibility that PrEP could increase sexual risk behaviours (\u201crisk compensation\u201d) that might overwhelm the capability of PrEP to prevent infection.\u00a0 A second area of concern, that S&M label \u201cjustice\u201d, involves the degree of prioritization accorded to PrEP, as against management and prevention through ARV, where resources are scarce.\u00a0 Some have argued that ARV should take priority; others (more counter-intuitively perhaps) have made a case for privileging prevention over treatment.\u00a0 A third and final bundle of issues revolves around the impact of PrEP availability on future trials, both of PrEP itself and other forms of prevention.\u00a0 These relate to the correct \u201cstandard of prevention\u201d for study participants, and the inevitable tension, aggravated by the availability of PrEP, between assuring the well-being of participants and answering the research question.\u00a0 S&M cite HVTN 505 as an instance of the need for adaptive trial design. \u00a0For an excellent chalk-face account of the impact of ethical issues on research gaols (though in relation to preventative ARV, rather than PrEP): see Cohen and Sugarman STI blogs 11\/07\/12<\/a>.<\/p>\n

Concerns around drug resistance and risk compensation seem not to have been borne out by the US experience to date – though it is early days (US Truvada PrEP demonstration projects<\/a>).\u00a0 Europe has not yet followed the US example in licensing Truvada for PrEP.\u00a0 Studies indicate the acceptability of PrEP to MSM in London (Aghaizu & Nardone <\/a>2013) and Australia (Holt & De Wit<\/a> 2012).\u00a0 Attempts to model the probable impact of PrEP interventions in a range of settings have reached varied conclusions. Mukandavire and Vickerman<\/a> (2013), without reference to specific context, conclude that a scale-up of condom use is in most circumstances likely to be more effective than PrEP, but that PrEP could have a specific application in the case of female sex workers; Verguet & Walsh<\/a> (2012) see a future for PrEP in sub-Saharan countries with high HIV prevalence and without circumcision practice, such as S. Africa; Ying & Barnabas<\/a> (2013), for the same setting, see targeted PrEP as a cost-effective addition to ARV).<\/p>\n","protected":false},"excerpt":{"rendered":"

A recent article in the US journal JAIDS, Sugarman & Mayer (S&M), provides a handy outline of the ethical issues around pre-exposure prophylaxis (PrEP) for HIV infection (Sugarman & Mayer).\u00a0 The subject is very topical in the US, now that the Food and Drinks Administration have taken a step ahead of the rest of the […]<\/p>\n

Read More…<\/a><\/p>\n","protected":false},"author":152,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2794,2380],"tags":[],"class_list":["post-899","post","type-post","status-publish","format-standard","hentry","category-ethics","category-pre-exposure-prophylaxis"],"yoast_head":"\nThe ethics of PrEP - Sexually Transmitted Infections<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/sti\/2013\/09\/02\/the-ethics-of-prep\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"The ethics of PrEP - Sexually Transmitted Infections\" \/>\n<meta property=\"og:description\" content=\"A recent article in the US journal JAIDS, Sugarman & Mayer (S&M), provides a handy outline of the ethical issues around pre-exposure prophylaxis (PrEP) for HIV infection (Sugarman & Mayer).\u00a0 The subject is very topical in the US, now that the Food and Drinks Administration have taken a step ahead of the rest of the [...]Read More...\" \/>\n<meta property=\"og:url\" content=\"https:\/\/blogs.bmj.com\/sti\/2013\/09\/02\/the-ethics-of-prep\/\" \/>\n<meta property=\"og:site_name\" content=\"Sexually Transmitted Infections\" \/>\n<meta property=\"article:published_time\" content=\"2013-09-02T20:14:48+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"3 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/sti\\\/2013\\\/09\\\/02\\\/the-ethics-of-prep\\\/#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/sti\\\/2013\\\/09\\\/02\\\/the-ethics-of-prep\\\/\"},\"author\":{\"name\":\"\",\"@id\":\"\"},\"headline\":\"The ethics of PrEP\",\"datePublished\":\"2013-09-02T20:14:48+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/sti\\\/2013\\\/09\\\/02\\\/the-ethics-of-prep\\\/\"},\"wordCount\":526,\"publisher\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/sti\\\/#organization\"},\"articleSection\":[\"Ethics\",\"pre-exposure prophylaxis\"],\"inLanguage\":\"en-US\"},{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/sti\\\/2013\\\/09\\\/02\\\/the-ethics-of-prep\\\/\",\"url\":\"https:\\\/\\\/blogs.bmj.com\\\/sti\\\/2013\\\/09\\\/02\\\/the-ethics-of-prep\\\/\",\"name\":\"The ethics of PrEP - 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