Some years ago, the biggest problem in global health seemed to be the lack of resources available to combat the multiple scourges ravaging the world’s poor and sick. Today, thanks to a recent extraordinary and unprecedented rise in public and private giving, more money is being directed toward pressing heath challenges than ever before. But because the efforts this money is paying for are largely uncoordinated and directed mostly at specific high-profile diseases — rather than at public health in general — there is a grave danger that the current age of generosity could not only fall short of expectations but actually make things worse on the ground.
Why?
Tackling the developing world’s diseases has become a key feature of many nations. Some see stopping the spread of HIV, and other major killers as a moral duty and all these have been followed by desperations and many studies and research undertaken to help address the situation. One such study that have been undertaken is the ground braking HIV Pre-exposure prophylaxis or simple PreP.
What is Prep?
Pre-exposure prophylaxis (PrEP) for HIV negative people unarguably has the potential to stop transmission on a scale that could play a significant role in ending the HIV epidemic. But in another way it is a quite different moment. Rather than a single, self-evidently justified demand PrEP creates a complicated set of ethical, legal, public policy and practical challenges. Many of these relate to gender, equity and rights. Cheryl Overs in her submission to health System global argues that for people living with HIV the preventive value of ARV medication is a side effect of lifesaving treatment whereas PrEP is taken by well people. In medical ethics it is accepted that the safety level required of medication for treatment differs from that for prevention. The issue is simple, if a drug that might cause damage in the long term saves the lives of patients it is ethical to approve it as treatment but not ethical to provide it to people who are not ill. Despite many studies that suggest that PrEP will, or will not, have harmful side effects, the fact are we don’t know what might emerge in millions of PrEP users over decades, Overs argues that Medical history is littered with such scenarios.
Useful, independent research and rich discussions about PrEP and women in various settings do not seem to be occurring. If insightful guidelines about who should, and should not, be prescribed PrEP are being developed this is not an open process. Nor are plans for the anti-discrimination measures or public health messages that will be needed if PrEP is to fulfill its potential. So far we are only seeing grand claims about ‘saving millions of lives’ of people classified as being at risk. These are based on, sex workers and men who have sex with other men.
It is certainly true that many of those most in need of access to PrEP live precarious lives but that precarity is driven by discrimination, sex work, and homosexuality that form a powerful barrier to any form of health care or preventative measure. The tension between public health and human rights on one hand, and punitive legal environments on the other, has been well documented in relation to HIV. In Botswana there has recently been such a case that had to be settled in a Court of law by allowing high risk population group to merely register a society. In many other countries law has not kept up with developments in HIV so that the work of public health authorities and services to ‘key populations’ continues to be impeded by policy that reflects irrational fear and stigma. Criminalization of HIV, sex work, adultery, abortion and the potential for civil legal actions remain a reasonable fear that drives barrier to the regular testing that must accompany PrEP.
One of WHO’s building blocks of the health system is ‘medical products and technologies’. Yet the example of PrEP demonstrates that the existence of an efficacious medication is only the starting point for the complex array of ethical and practical decisions that need to be made to improve health outcomes. And these decisions are molded by, and imbued with, questions of power, gender, and marginality. In the case of HIV sexuality, legal status, and poverty are particularly profound intersecting issues.
All too often we are lacking vital social science research that demonstrates ÔÇô not that particular medication works ÔÇô but the situations under which the introduction of a new technology can bring positive benefits, the unanticipated consequences of change, the beliefs and the preferences of particular ‘beneficiaries’ of interventions, and the motivation of those who seek to intervenes, Overs argued in her submission to Health System Global. Research and Development undertaken by some researchers and scholars coming from social science discipline / background into health policy and health systems is often met with so much skepticism and sometimes just lack of understanding mostly driven by traditionalist old school sterile thinkers who are na├»ve and rigid.
Recent discussions about universal health coverage and its relation to human rights have highlighted that health policy change is not purely a technical, quick fix, driven by costing data alone. Rather there are political and public policy questions at play which are profoundly influenced by national and global health initiatives and the power and agency of citizens to demand their entitlements. As discussions about PrEP move forward ÔÇô and significant progress is being made quite rapidly ÔÇô there is an urgent need for public policy analysts, activists, health systems researchers and public health agencies to use their skills to ensure that due consideration is given to the health and human rights of women. Unless that happens the epidemic ending potential of ARV based HIV prevention will not be realized.
*Thabo Lucas Seleke is a Researcher in Health Policy and Health Systems Strengthening
