Nurses are 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 (see PrEP for Prevention and Biomedical prevention add link section of this resource).
As with any clinical innovation, the ethical implications of PrEP are important to consider. When first introduced, PrEP provoked controversy among bioethicists globally. Ethical debates around PrEP may concern justice. For example, Jay and Gostin (2012) argued that PrEP is very costly compared with alternatives, raising the ethical issue of distributive justice (40). They pointed out that the high cost and regular monitoring required could exclude people on low incomes, unstable housing, drug dependence or mental health problems, exacerbating health inequalities (40) unless PrEP is properly subsidised to ensure equity of access. In Australia, this is less of a concern due to PrEP’s listing on the Pharmaceutical Benefits Scheme (PBS), but in many countries the cost is prohibitive, and availability is inequitable.
Bioethicists argue that, in resource allocation, any scheme should be equitable (41) yet, as Macklin pointed out, not all people with HIV in developing countries receive antiretroviral agents, let alone PrEP for those without HIV infection (41). The proportion of people globally on treatment now is much higher (approaching 76%) (43) than when this issue was raised. Still, Verguet et al. assert that PrEP is a high-cost intervention that will have maximum effect only in high-prevalence countries (where it may be less accessible) (44).
Other ethical principles of relevance to Prep beneficence – to promote benefits, and non-maleficence – avoid harm. 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. For example, ethical questions may be raised about PrEP’s long-term safety, side effects and the development of resistance (44). In addition, with the advent of injectable long-acting treatment and PrEP, safeguards must be considered to prevent its coercive or involuntary use in marginalised populations, whilst ensuring equitable access to PrEP for those vulnerable groups who may benefit most from it (45).
There is a long history of medical mistrust amongst some groups – for instance, people with mental health problems who may have been subjected to court-ordered treatments, people who use substances, people who have been incarcerated, and other PLHIV in minority groups (46) Pregnant women with HIV can be subject to coercive practices including mandatory testing and forced treatment (47-49). Community engagement is critical to ensure PrEP can reach those most at risk (equity of access) whilst respecting their autonomy and human rights, and upholding the ethical principles of justice, respect, beneficence, and non-maleficence (46).
Nurses worldwide are central to the roll-out of treatments such as PrEP, in policy development around access, and research. PrEP programs will be optimally designed, implemented, and evaluated with the inclusion of nurses’ and midwives’ informed ethical perspectives, alongside those of other health professionals, PLHIV, and those most at risk. This discussion serves to emphasise the importance of examining the ethical implications of new technologies and participating in ethical inquiry, debate, and policy development in an informed and critical manner.