Friday 3 June 2016

Why the NHS should not fund PreP

PreP stands for Preventive Exposure Prophylaxis. It is medication that prevents the infection of HIV with a 85% probability for those who may be exposed to high risk with infected partners. PreP is therefore an important armour in the arsenal against the spread of HIV amongst gay men. NICE, the body in England that reviews the effectiveness and economic benefits of medication for the NHS has recently recommended not to prescribe PreP on the NHS and NHS England has declined to do so. Its analysis of costs and benefits suggests that its costs simply outweigh the benefits. This calculation may change soon and there has been a significant outcry from AIDS campaign groups such as Terrence Higgins about the decision. They have branded NHS England 'irresponsible' and 'shameful'. But lets look at this in a bit more detail.

Personal responsibility or a matter for the NHS?
Foto: Science Library BBC

PreP is not medication for people who have contracted HIV but it is a preventive substance for those who are at high risk to contract the disease because they engage in unprotected sex. The groups that typically come to mind that may benefit from this medication are sex workers and people in the porn industry. However, both industries have extremely by now low infection rates. In fact, the porn industry is highly (self-) regulated now and has only seen few (less than 40 compared to more than 400 in the previous year) infections in the last four years. Porn stars (gay or straight) need to undergo regular tests and prove their HIV status to be allowed to work.

So, PreP is not a medication for people who professionally may put themselves at risk. S, who is it for? In essence, it is for a group of gay men who deliberately decide to have unprotected sex. This is crucial in the argument for or against public funding of PreP as there is in fact a simple and cost-effective means to prevent HIV contraction, it's called the condom. However, at the moment, some men decide not to use a condom which exposes them to a higher risk of contracting the disease. At present, many of them self-fund PreP (at about £400 per month).

The argument for publicly funding PreP through the NHS is thus an argument about whether or not to spread (or socialise) risk. One may argue that we do this all the time. We are all exposed to the possibility to have an accident in our lives, say to break a leg when cleaning the gutter on the house. Emergency care is provided free at the point of use in the UK and the costs are borne by everyone through taxation that funds the NHS. The critical difference between an accident and risky sexual activities however lies in the role of agency. In the case of the latter, some men deliberately expose themselves to risks even though they do not need to. Terrence Higgins and others argue that society should pick up the tab for this. I disagree.

So what's the rationale behind their case for public funding of PreP? It appears that they mainly employ a public health argument: to prevent the disease from spreading, those men who decide to have unprotected sex have a right to draw on public funding to reduce the risks. This seems to me to reduce those men to mere recipients of public assistance, when in fact they are actually the agents and initiators of the risks they want others to mitigate for them. The interpretative framework that is often invoked here is that of human rights. It is, so the argument goes, their human right to be free from risk. But human rights are the sort of set of rights that are easily invoked only once active agency is discounted. It has a patronising undertone. Men who decide to have unprotected sex are not like those who have no choice, say women within an abusive marriage who are coerced to have unprotected sex with their unfaithful husband. Gay men do have a choice. They simply decide not to exercise it to the benefit of their health.

My suspicion is that the NHS will eventually fund PreP for everyone. Mainly because the cost-benefit argument that NICE bases its decision on is relatively weak in the face of moral pressure and fake indignation from organisations such as Terrence Higgins. What we really need is a debate about the limits of mutual beneficence and the obligations we ourselves have to maintain our own health.

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