PrEPosterous?

The ethics of state-funded pre-exposure prophylaxis for men who have sex with men at high risk of human immunodeficiency virus

Abstract

The debate over state-funded provision of PrEP for HIV prevention in the UK has intensified in recent years due to the establishment of the PrEP Impact Trial and a legal challenge to the NHS’ decision not to commission the drug. This thesis explores the ethical and economic issues associated with the provision of PrEP.

I begin with an appraisal of an existing economic analysis of PrEP, highlighting its shortcomings and detailing the sensitivity analyses required for a more useful future analysis.

Three key ethical issues are then explored: adherence, risk compensation, and effective targeting. They are considered in the context of principlism and the importance of autonomy relative to other values. A broadly utilitarian approach is also taken in balancing benefits and harms, accounting for the impact these issues might have on the wider community and population.

Policy implications form the conclusion, providing a suggested way forward. First and foremost, I demonstrate a clear need for further research and economic analysis, noting the arguably hurried nature of PrEP provision. I also argue for daily PrEP to become the default method of dosing, with event-based PrEP kept as a reserve to be sparingly used at the discretion of doctors when clearly appropriate. With PrEP as the appropriate default now, a defence of long-acting injectable PrEP as the default is provided in anticipation of its introduction. Finally, I call for additional efforts to minimise the prevalence of risk compensation and prevention optimism; potential methods are highlighted, such as counselling and SMS reminders.

The overarching conclusion of this thesis is that the introduction of PrEP has been rushed, and there are several unanswered questions. In order to provide PrEP in the most useful and ethical way with minimal unwanted side effects these questions must be answered.

Date of Award	23 Jun 2020
Original language	English
Awarding Institution	The University of Bristol
Supervisor	Jonathan C S Ives (Supervisor) & Jeff Round (Supervisor)