Ethics of pre-exposure prophylaxis in high-risk HIV patients

Abstract

Pre-exposure prophylaxis (PrEP) is the daily use of antiretrovirals to prevent human immunodeficiency virus (HIV) transmission in uninfected people at high risk of infection, including men who have sex with men and serodiscordant heterosexual couples. PrEP has the potential benefit of reducing the human population’s viral load, and unlike barrier protection, PrEP allows for individual control over HIV exposure. However, ethical concerns have been raised around this intervention’s risk of serious side effects. These side effect risks may not be justifiable given PrEP’s modest benefit and the existence of standard HIV prevention: condoms, counseling, and education. Critics of this preventative approach also worry that PrEP promotes unsafe sexual practices such as sex without barrier protection. However, this discussion is harmful to the underserviced at-risk groups targeted by PrEP, and prohibition of PrEP for this reason is unjustified in a society that allows women to access oral contraceptives despite the risk of adopting unsafe sexual practices. To ensure the safety of high-risk HIV groups, future clinical trials of PrEP should compare this intervention to the standard of prevention rather than placebo, and stigma mitigation strategies must be implemented at the policy level.