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The Moral Implications of PrEP - Truvada

The British High Court has just ruled that the NHS is responsible for administering Pre-exposure Prophylaxis (PrEP) by giving the drug "Truvada" to men who might be infected by HIV due to risky sexual practices such as antipathy to the wearing of condoms.

The cost of PrEP (under £10,000 per annum) is less than the huge expense of treating AIDS victims over a lifetime (£100,000 - £350,000 per lifetime) but not less than the £3000 to £10,000 annual cost if AIDS patients live for 30 years. The cost of PrEP is a bit more than having a hip replacement or heart bypass surgery annually.  Almost all media outlets have announced that PrEP is cost effective and hence it is a worthwhile therapy.

Whatever the true cost effectiveness of PrEP, the argument is clear: if you indulge in risky behaviour that has an expensive outcome for the government  then the government should finance measures that prevent this outcome if such measures are cost effective.

How does this argument differ from these cases?:

What about poverty? Poverty can reduce life expectancy by up to 25 years and for many poor people has a lifetime cost to the government in welfare etc. of over £300,000 so those with poverty should be given £10,000 a year.

Personally I would like poor people to be richer.  The only difficulty is that there are so many poor people that the balance point between providing an incentive between striving and paying money to the poor may not allow truly large payouts to the poor.


And prison? The average cost of a prison place in the UK is £40,000 per annum so those with the possibility of criminal behaviour should be given free accommodation and £40,000 a year tax free.

This seems superficially credible but, in the same way as Truvada users may forget to take the tablets, potential criminals may forget to be law abiding.

Lastly, a "Protection Racket": I will destroy your expensive business if you do not make weekly payments to me.

Is this like someone who prefers condomless sex saying "if you don't give me the tablets I'll cost you a fortune by not wearing a condom?".

The cases above were all about "Cost Benefit Analysis" and suggested that expensive outcomes deserve expensive cures.  Most diseases cost the NHS relatively little money compared with AIDS, should these all be allocated less money for prevention or cure than AIDS? 


What is the morality of PrEP?

If a person deliberately hurts themselves this is normally considered to be a mental illness. If a person deliberately infects themselves this must also be a mental illness.  So is PrEP a treatment for mental illness? Once PrEP becomes widely available then having condomless sex would no longer be "deliberately infecting yourself" but then the cost benefit analysis no longer applies because people will take it who otherwise would not have indulged in risky behaviour.  Would the NHS only be able to justify its PrEP budget if it restricted dispensing Truvada to the mentally ill?  Would they have the temerity to announce this as a policy?

If Truvada is given generally to male homosexuals are we entering a new era for the NHS where it provides drugs for recreation?  It has frequently been demonstrated that acquiring marijuana from dealers carries a risk of moving on to heroin and other hard drugs so should the NHS provide free Grass to those who desire it?

There is no doubt that well organised homosexual groups have lobbied for access to PrEP.  The numbers of people who will be taking Truvada are relatively small so it is within the largesse of government to pay for the treatment and hence avoid a scream of bad publicity in the media.  But what is the morality of PrEP?



Note: "As of 2013, there were 81,500 people accessing HIV care in the UK. The good life expectancy of people with HIV and continued high rates of new diagnoses – 6500 in 2013 – means that the number of people living with HIV in the UK is likely to increase significantly in coming years. "  http://www.aidsmap.com/UK-Life-expectancy-on-HIV-treatment-improving-shows-importance-of-prompt-diagnosis-and-treatment/page/2101259/




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