Each year human immunodeficiency virus (HIV) infects about 50,000 people in the United States, and more than two million worldwide. Reducing the number of infections with this virus, which causes AIDS, is a high priority for public health officials. Some strategies to reach this goal, however, raise significant moral concerns.
These concerns arise when experts seek to reduce infection rates by assuming that men and women lack the freedom to change their sexual behaviors or exercise self control, when they fail to acknowledge that self-restraint is possible and morally required, especially in the face of life-threatening disease.
One strategy for trying to control the pandemic includes “pre-exposure prophylaxis,” or PrEP, which involves an uninfected person taking a daily dose of the drug Truvada, an anti-retroviral medication. When someone takes the Truvada pill each day, and is later exposed to HIV through sex or injectable drug use, it can reduce the likelihood that the virus will establish a permanent infection by more than 92 percent. While the drug can have side effects, it is generally well-tolerated.
Many activists in the gay movement have argued that PrEP should be widely available and promoted, though other activists strongly disagree. AIDS Healthcare Foundation (AHF) founder Michael Weinstein has stressed, for example, that there are likely to be compliance issues. When someone is required to take a regimen of drugs every day in order to be protected, he argues, it is reasonable to expect that some will fail to do so. A 2014 article in The Advocate, a gay news outlet, notes that,
“When asked why so few people have started PrEP, experts give plenty of reasons — cost, worries about long-term effects, and lack of awareness about the regimen itself among both doctors and patients are chief among them. But one top reason is the stigma of using PrEP. Weinstein’s name and the name of his organization, AHF, have become synonymous with the stigma surrounding PrEP use. In an April Associated Press article, Weinstein declared that PrEP is ‘a party drug,’ giving license to gay and bisexual men to have casual, anonymous sex. He’s called it a ‘public health disaster in the making,’ as his oft-repeated argument is that the most at-risk people will not adhere to taking a pill each day.”
These compliance concerns have led some researchers and clinicians to look into the possibility of one-time “disco dosing,” where an individual would take the medication, in a high dose, prior to each anticipated “risky weekend.”
There are other problems with PrEP as well. Some researchers have noted that once people start on the drug, their risk compensation changes, meaning they engage in more sex with "non-primary partners." Even if PrEP reduces rates of HIV infection, as studies have suggested, the incidence of other sexually transmitted diseases (STDs) may rise due to risk-compensation behaviors. PrEP can provide a false sense of security and encourage the lowering of inhibitions.
These kinds of approaches directed towards certain “at-risk populations” clearly raise concerns about sanctioning or supporting immoral behaviors. Medical professionals have raised objections of conscience when it comes to prescribing PrEP to HIV-negative men who indicate they are, or will be, sexually active with other men. They may raise similar objections to providing prescriptions for “disco dosing.” Writing such prescriptions means cooperating in, or facilitating, the evil actions of others.
Is pre-exposure prophylaxis always illicit? Not necessarily. For example, if a medical professional were to prescribe Truvada to the wife of a man who was infected through pre- or extramarital sexual activity, it would be for the purposes of protecting the wife from infection during marital relations, and would not involve the problem of promoting or facilitating unethical sexual behaviors.
STDs constitute a serious danger in an age where sexual behaviors are becoming ever more indiscriminate. STD outbreaks and pandemics often have their origins in unchaste behaviors and morally disordered forms of sexuality. The Centers for Disease Control notes that “men who have sex with men (MSM) remain the group most heavily affected by HIV in the United States. CDC estimates that MSM represent approximately 4 percent of the male population in the United States but male-to-male sex accounted for more than three- fourths (78 percent) of new HIV infections among men and nearly two-thirds (63 percent) of all new infections in 2010.” We should not be supporting or facilitating behaviors involving multiple sexual partners. These sexual practices, in the final analysis, are not only immoral in themselves, but also reckless and clearly contributory to the spread of STDs.
Reprinted with permission. Rev. Tadeusz Pacholczyk, Ph.D. earned his doctorate in neuroscience from Yale and did post-doctoral work at Harvard. He is a priest of the diocese of Fall River, MA, and serves as the Director of Education at The National Catholic Bioethics Center in Philadelphia (see www.ncbcenter.org).