Should governments subsidize a drug for healthy people?
When a conservative Christian journalist writes a story about a highly-praised AIDS drug headlined “Killing Grandma for Gay sex” and an AIDS activist describes it as a “profit-driven sex toy for rich Westerners”, you know that you’ve uncovered an ethical controversy.
This month the UK’s National Institute for Health and Care Excellence (NICE) issued a published an evidence summary on the use of Truvada, a lucrative Gilead drug for HIV pre-exposure prophylaxis (PrEP). In a number of other countries, Truvada has already been rolled out as a way of keeping gay men safe from infection with HIV. If taken every day, it prevents infection – a kind of pharmaceutical condom.
The controversy in the UK is not so much over whether it works, but whether it should be government funded. “There is little doubt that Truvada is effective in reducing HIV acquisition in high-risk people who are HIV-negative,” says the NICE advice.. “However, issues relating to uptake, adherence, sexual behaviour, drug resistance, safety, prioritisation for prophylaxis and cost-effectiveness are also important to consider, especially at a population level.
In August, the High Court ruled that the UK’s National Health Service had to supply Truvada because children with cystic fibrosis, amputees and blood cancer victims could be disadvantaged. It would cost the NHS up to £20 million a year. Outraged critics said that the money would be better spent on treatments for sick people rather than healthy people engaging in risky behavior.
On a public health level, there are concerns about whether the men could commit to taking the drug regularly. It might also lead them to neglect condom use and to expose themselves to other sexually-transmitted diseases like syphilis. Kevin Fenton, the former chief of HIV/AIDS for the Centers for Disease Control and Prevention, said a few years ago: “Some studies suggest that even a small increase in risk behavior due to a false sense of security about the pills’ effectiveness could actually increase HIV infections, an outcome we cannot afford.”
On an ethical level, there are fears that it would promote promiscuity. Dr Peter Saunders, of the UK Christian Medical Fellowship, told the Daily Mail: “This is a strategy fraught with dangers. Making Prep freely available to already promiscuous homosexuals could well encourage more sexual risk taking and more sexually transmitted disease as a result. The best way of preventing HIV infections is by avoiding the high-risk sexual behaviours that lead to it. Those who rely on it for protection against HIV are effectively playing Russian roulette.”
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