New strategies for HIV prevention for men who have sex with men (MSM): pre-exposure prophylaxis (PrEP) and an ethical evaluation of its potential and its problems

Wirth, Mathias; Inauen, Jennifer; Steinke, Hubert (2020). New strategies for HIV prevention for men who have sex with men (MSM): pre-exposure prophylaxis (PrEP) and an ethical evaluation of its potential and its problems. Ethik in der Medizin, 32(4), pp. 351-368. Springer 10.1007/s00481-020-00589-9

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Objectives: Given that condoms provide ample protection against both HIV as well as other sexually transmitted infections (STIs), and given that safe access to HIV postexposure prophylaxis (PEP) also exists (relied upon after condom fatigue, for example), it should be thoroughly investigated if and when the increasingly popular HIV pre-exposure prophylaxis drug (PrEP) presents itself as the superior alternative. In the context of a generalized everyone at risk approach towards MSM, PrEP is becoming increasingly established as a standard of care. There is no doubt that this is desirable for certain MSM with a particular risk profile; however, variance in MSM (e.g., engaging in casual condomless sex versus random condomless sex) must be assumed and taken into account in order to avoid disproportionate medicalization. Methods: In the area of conflict between medicalization, in particular of men who have sex with men, and highly potent HIV prevention methods, it should be determined when exactly PrEP (either via daily dosing or on-demand dosing) trumps the use of condoms or PEP. Therefore, a focus on the current status of clinical research and on the medical-ethical debate is required. The medical history of prevention and of HIV proves relevant for the largely ongoing ethical study of PrEP usage. The methodology of this work is based on an evaluation of the literature on PrEP in particular and on HIV prevention in general. In accordance with PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), studies on the current clinical practice of PrEP or medical-ethical discussions of PrEP were selected from the PubMed/MEDLINE database. The resulting discursive discussion and examination of the currently known pros and cons of PrEP is based on this literature. Results: Resultant preventative measures often appear as ambivalent instruments of health promotion torn between liberating and restricting the individual. Overall, on-demand dosing enables individuals to personalize their usage based on the specific risk behaviors they engage in, in contrast to daily dosing. On-demand PrEP also poses significant advantages over PEP and daily PrEP in cases where there is no continuous and sustained level of risk. Conclusion: This medical-ethical inquiry stresses the heterogeneous group of MSM whose individual sexual behavior requires especially individualized HIV prevention strategies. Thus, this study argues for highly personalized decision-making in the possible indication for PrEP among MSM. This constitutes an essential factor in avoiding the medicalization of MSM.

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