Emerging issues and their ethical implications – Pre Exposure Prophylaxis

Nurses will become increasingly involved in biomedical HIV prevention including the provision of pre-exposure prophylaxis (PrEP).  PrEP is the use of antiretroviral drugs taken by HIV-negative people to prevent HIV infection (http://endinghiv.org.au/nsw/stay-safe/prep/ see Section Biomedical HIV Prevention for more details).  PrEP is highly effective; however, as with any clinical innovation, its ethical implications need to be considered.

PrEP has provoked considerable controversy among bioethicists globally. Ethical debates around PrEP may concern justice – for example, Jay and Gostin (2012) argue that PrEP is very costly compared with alternatives, so questions of distributive justice are raised.[43] The high cost and regular monitoring required could exclude people on low incomes, unstable housing, drug dependence or mental health problems, exacerbating health inequalities[44] unless PrEP is properly subsidised to ensure equity of access.  There is widespread agreement among bioethicists that, in allocation of resources, any allocation scheme should be equitable[45] and yet, as Macklin points out, less than half of people with HIV in developing countries are receiving antiretroviral agents[46][47] let alone PrEP for those without HIV infection. Verguet at al. assert that PrEP is a high-cost intervention which will have maximum effect only in high-prevalence countries.[48]

A second ethical principle of relevance to PrEP is beneficence – there is a need to balance benefits and harms.  There is a strong ethical claim supporting the use of PrEP to prevent HIV infection.  However, this must be balanced with potential threats or harms.  In the case of PrEP, ethical questions may be raised about long-term safety, side-effects and the development of resistance.[49]

While not exhaustive, this discussion serves to emphasise the importance for nurses of exploring the ethical implications of new technologies and participating in ethical inquiry and debate in an informed way, as nurses worldwide are instrumental in the rolling out of treatments such as PrEP, in policy development around access, and in research. PrEP programs will only be optimally designed, implemented and evaluated with the inclusion of nurses’ informed ethical perspectives, alongside those of other health professionals, people with HIV themselves and those most at risk.