Towards an Integration of PrEP into a Safe Sex Ethics Framework for Men Who Have Sex with Men

Procedural fairness in benefit package design: inclusion of pre-exposure prophylaxis of HIV in Universal Coverage Scheme in Thailand

Since 2002, Thailand's Universal Coverage Scheme (UCS) has adopted a comprehensive benefits package with few exclusions. A positive-list approach has gradually been applied, with pre-exposure prophylaxis (PrEP) of HIV recently being included. Disagreements resulting from competing values and diverging interests necessitate an emphasis on procedural fairness when making any decisions. This qualitative study analyses agenda setting, policy formulation and early implementation of PrEP from a procedural fairness lens. Literature reviews and in-depth interviews with 13 key stakeholders involved in PrEP policy processes were conducted. Civil society organizations (CSOs) and academia piloted PrEP service models and co-produced evidence on programmatic feasibility and outcomes. Through a broad stakeholder representation process, the Department of Disease Control proposed PrEP for inclusion in UCS benefits package in 2017. PrEP was shown to be cost-effective and affordable through rigorous health technology assessment, peer review, use of up-to-date evidence and safe-guards against conflicts of interest. In 2021, Thailand's National Health Security Board decided to include PrEP as a prevention and promotion package, free of charge, for the populations at risk. Favourable conditions for procedural fairness were created by Thailand's legislative provisions that enable responsive governance, notably inclusiveness, transparency, safeguarding public interest and accountable budget allocations; longstanding institutional capacity to generate local evidence; and implementation capacity for realisation of procedural fairness criteria. Multiple stakeholders including CSOs, academia and the government deliberated in the policy process through working groups and sub-committees. However, a key lesson from Thailand's deliberative process concerns a possible 'over interpretation' of conflicts of interest, intended to promote impartial decision-making, which inadvertently limited the voices of key populations represented in the decision processes. Finally, this case study underscores the value of examining the full policy cycle when assessing procedural fairness, since some stages of the process may be more amenable to certain procedural criteria than others.

Clinician imaginaries of HIV PrEP users in and beyond the gay community in Australia

Through the development and implementation of HIV pre-exposure prophylaxis (PrEP), the characteristics of PrEP users have been configured in a range of ways. Drawing on the concept of 'imaginaries', we consider how clinicians imagine PrEP users and related communities. We conducted 28 semi-structured interviews in 2019-2020 with PrEP-providing clinicians based in New South Wales and Western Australia. Participants included general practitioners, sexual health nurses and sexual health doctors. We inductively developed three themes through a reflexive thematic analysis: 'PrEP users as 99% gay men/MSM', 'The informed and connected PrEP user', and 'Condom users in the PrEP era'. Participants imagined PrEP users primarily as gay men, and so we focused on how gay community was imagined in relation to PrEP users. Users were imagined as supporting one another to use PrEP effectively, but some were imagined as threatening norms of condom use amongst gay community. Analysing clinician imaginaries of PrEP users reveals insight into how clinicians speculate about and engage with changing community norms related to condom use and accessing PrEP. These imaginaries reveal ongoing tensions about who is believed to be best suited to PrEP, and PrEP's impact on norms of conduct in imagined biosocial communities like gay men.

Pathopolitics: Pathologies and Biopolitics of PrEP

This paper unveils the pathologies that are produced and sustained by the pharmaceutical industry, specifically by Gilead Sciences, Inc. Broadly defined, pathopolitics is the politics of treating and/or reproducing pathologies. This paper examines pathopolitics in the context of PrEP, or pre-exposure prophylaxis, an antiretroviral medicine that prevents HIV transmission. Although Gilead promises to prevent a pathology through PrEP, it reproduces social and biological pathologies by exposing certain people to higher risks of infections and diseases, thus epitomizing the operating logic of the pharmaceutical industry: that life is protected only insofar as it offers surplus economic and social value. This essay raises three fundamental sets of questions: (1) What are the techniques and mechanics of pathopolitics? (2) How does the pharmaceutical industry produce and exploit surplus value? (3) What is the nature of the relationship between the pharmaceutical citizenship and pathopolitics?

Demedicalizing the Ethics of PrEP as HIV Prevention: The Social Effects on MSM

In order to demedicalize the ethics of pre-exposure prophylaxis (PrEP) as HIV prevention, I consider the social effects on men who have sex with men (MSM). The Centers for Disease Control and Prevention (CDC) considers MSM to be the highest risk group for contracting HIV in the USA. The ethics of using PrEP as HIV prevention among MSM, however, has both a medical dimension and a social dimension. While the medical dimension of the ethics of PrEP includes concerns about side effects, drug resistance and distribution, the social dimension of the ethics of PrEP includes concerns about stigmatization, sexual and romantic relationships and sexual freedom. The medical concerns of the ethics of PrEP may take precedence over the social concerns, but there is a growing body of literature that already addresses the medical concerns. Much less attention has been given to the social concerns of the ethics of PrEP, and in this article, I aim to fill this gap in the literature. Therefore, I focus on the often-overlooked social dimension of the ethics of PrEP to help understand the connection between the risks, relationships and communities of MSM using PrEP as HIV prevention.