IN 2012, San Francisco-based biopharmaceutical giant Gilead Sciences launched Truvada as the first antiviral drug approved by the FDA as a means of pre-exposure prophylaxis (PrEP) for HIV prevention. A 2010 clinical trial that found that a daily prophylactic given to HIV-negative men who have sex with men was more than ninety percent effective at preventing HIV infection. Since then, health experts have hailed Truvada as an opportunity to prevent the transmission of the virus for around a million at-risk Americans.
Gilead’s initial launch of Truvada was quiet and cautious, and early adoption was slow. But in 2016 the company decided to roll out a more aggressive marketing campaign to promote wider adoption, which it did through print and digital ads and, later, through social media activation. Meanwhile, the LGBT press and organizations started to report widely on PrEP as a tool in the fight against HIV, and most were generally favorable to its widespread adoption. Last year, some 100,000 individuals went on Truvada to prevent HIV infection.
The ability to prevent HIV transmission through the use of PrEP has created a category of person defined as “at risk” for HIV infection and thus a candidate for this type of drug. But the question arises, how does a person come to be so categorized? PrEP, for all its technological and biomedical promise, opens a floodgate of questions about how individuals evaluate their risk of infection going forward.
The use of PrEP raises other interpersonal and ethical questions that have yet to be sorted out. All of the arguments in its favor assume that PrEP is completely effective in protecting the user and his partners from infection. But how can we be sure that we’re safe? What does it mean for community building if we’re all taking pills to protect ourselves from one another and calculating the risk potential of everyone we meet?
PrEP places epidemiological responsibility and therapeutic efficacy squarely on the shoulders of the individual, who must evaluate not only his own risk factors but also the efficacy of Truvada, whose manufacturer has a vested interest in promoting it. Are PrEP users responsible agents of self-care; are they being sold a product they don’t need (at considerable cost); are they being drawn into a public health trend that increasingly shifts responsibility to the individual? Government regulation yields to corporate “self-regulation,” as decisions are made and drugs filter through our bodies, forging us into pharmaceutical subjects. The manufacturers know that we have to swallow the idea of taking a daily prophylactic pill before taking action that will lead us to swallow the pill itself.
“Is PrEP right for you?” asks an ad for Truvada. Gilead’s new campaign means targeting at-risk populations by emblazoning these five words everywhere. But is there a right answer? Truvada offers a loose roster of risk factors (number of partners, preferred position in anal sex, etc.), but are most people equipped to think about risk in this way, to assess the probability of future actions, evaluate the effectiveness of prophylactic measures, and perform the necessary calculations? Many forces are aligned (corporate interest, pro-sex messages, risk avoidance) in favor of defining oneself as “at risk,” so there’s a feeling of being coerced. And when we frame PrEP as necessary and inevitable for rational sexual conduct, does this create an ethic of care that implies universal inclusion of everyone judged to be at risk? Now, with prescriptions running at $1,300 per year, new questions arise about who can afford to take PrEP and who should pay for it.
Where, then, do we find ourselves? At a minimum, PrEP puts a tool of empowerment into the hands of those who are vulnerable to sexual agression. But Truvada shifts a lot of personal responsibility to those who may also be vulnerable to persuasion. The safeguarding of public health, once the purview of government, has become increasingly atomized as people are forced to make their own decisions about whether to take a purely prophylactic drug like Truvada. PrEP is not an inoculation against HIV but a strategy for managing risk. The search for a vaccine seems an ever more distant hope. What remains morally urgent and necessary is for everyone to do their part to combat the spread of HIV; what’s needed is a clearer set of standards to guide individual decision-making and a social support system for those considering this course of action.
Rajat D. Singh is a cultural writer and critic based in New York City.
