Cultural Conundrums: The Ethics of Epidemiology and the Problems of Population in Implementing Pre‐Exposure Prophylaxis

Abstract

The impending implementation of pre-exposure prophylaxis (PrEP) has prompted complicated bioethical and public health ethics concerns regarding the moral distribution of antiretroviral medications (ARVs) to ostensibly healthy populations as a form of HIV prevention when millions of HIV-positive people still lack access to ARVs globally. This manuscript argues that these questions are, in part, concerns over the ethics of epidemiological science and knowledge production practices. Questions of distribution, and their attendant cost-benefit calculations, will rely on a number of presupposed, and therefore, normatively cultural assumptions within the science of epidemiology specifically regarding the ability of epidemiological surveillance to produce accurate maps of HIV throughout national populations. Specifically, ethical questions around PrEP will focus on who should receive ARVs given the fact that global demand will far exceed supply. Given that sexual transmission is one of the main modes of HIV transmission, these questions of “who” are inextricably linked to knowledge about sex, gender and sexuality. As a result, the ethics of epidemiology, and how the epidemiology of HIV in particular conceives, classifies and constructs sexual populations will become a critical point of reflection and contestation for bioethicists, health activists, physicians, nurses, and researchers in the medical humanities and biomedicine. This paper examines how cultural conundrums within the fields of bio- and public health ethics are directly implicated within the ethics of PrEP, by analyzing the problems of population inaugurated by the construction of the men who have sex with men (MSM) epidemiological category in the specific national context of South Africa.

Robust Vaginal Colonization of Macaques with a Novel Vaginally Disintegrating Tablet Containing a Live Biotherapeutic Product to Prevent HIV Infection in Women

“…Although drug resistance was rare in the IPrEx study [ 47 ], concerns remain over the use of front-line antiviral drugs as microbicides because of the potential for development of viral resistance. In addition, there are ethical concerns regarding the circulation of antiretroviral drugs (ARVs) to healthy individuals when many HIV-positive individuals lack access to primary treatment with ARVs [ 48 ]. The novel vaginal formulation described in this paper, has the potential to provide women with a non-antiretroviral approach to prevent HIV-1 infection by enhancing the protective properties of the vaginal microbiome.…”

Our Village Is Watching: Sociocultural and Attitudinal Factors Related to HIV Sexual Risk Behaviors among Black South African Men Who Have Sex with Men

“…Disjuncture exists between political mandates and legislative oversight (Oswin, 2007;L. Rispel, 2009;Sember, 2009), societal and community attitudes of same sex behavior among men (Smith, Tapsoba, Peshu, Sanders, & Jaffe, 2009), the social stigma and discrimination associated with hiv transmission through same sex behavior among men (Cloete, Simbayi, Kalichman, Strebel, & Henda, 2008), and cultural beliefs about masculinity (Fiereck, 2015b;Isaacs & McKendrick, 1992;Y. M. Sikweyiya, Jewkes, & Dunkle, 2014).…”

“It’s behaviors, not identity”: Attitudes and beliefs related to HIV risk and pre-exposure prophylaxis among transgender women in the Southeastern United States

“…This study found stigma related to promiscuity and medical mistrust to be associated with lack of interest in PrEP [ 21 ]. However, this analysis did not specifically address the unique perspectives and barriers faced by the transgender community since it combined data for MSM and TGW [ 22 ]. Qualitative data from San Francisco, CA suggest that integration of the unique needs and characteristics of the transgender community into PrEP promotion strategies is essential to improving PrEP uptake in this population [ 15 ].…”