The pill prevents HIV but it won’t cure behaviours that caused crisis
The widespread use of the HIV-prevention drug is a dilemma as well as a solution,
AND so the debate about PrEP — the daily HIV prevention pill — continues to rage. On the one hand, you have campaigners who argue that the pill must be publicly funded — it is currently available, but only on prescription from a doctor (and it costs around €450 a month). This, they say, is going to be one of the most important bulwarks against the rising levels of HIV infection that have been recorded in Ireland.
On the other hand, you have people like journalist Derek Byrne, who argued last week in the Irish Times that making PrEP so widely available discourages personal responsibility, since why bother with self-control when the stakes are no longer life and death.
He believes that “we need to look at the long-term prognosis and not be wooed by short-term gain at the cost of long-term pain”.
Leaving aside for a second the ethical and human question of whether you should sacrifice some people’s health to prove a point to others, Byrne might actually be somewhat thinking along the right lines, with the wrong conclusion.
Because of the money involved, PrEP, like abortion, is currently very much a class issue, so publicly funding it is a no-brainer.
Also like abortion, you can wholeheartedly agree we need to bring it in, while also being slightly horrified that it is needed quite so much — al- though campaigners on both issues will predictably attack this viewpoint. They have to put up with the debates though. The drumbeat for Repeal grows louder, and PrEP is the new big thing.
In the US popular dating apps like Grindr now allow people to display on their homepage that they are taking the drug, as though it were as basic a piece of information as what they look like. In the UK, the drug has been called “game-changing” and there are the same calls for it to be publicly funded on the NHS.
What is seldom acknowledged in the debate is that “gay men’s health” — the baby in the arms of campaigners for the drug — is not merely physical. There are psychological underpinnings which fuel the type of sex lives which places people in very high-risk categories for infection and these need to be examined. It’s easier and more morally ‘clean’, it seems at least, to just give people a drug and let them do their own thing, however.
This is why the HSE has only recently begun to research destructive trends like chemsex (risky sex and drugs) — and look more closely at the nexus of behaviours that lead to sexual health crises.
Why does this take so long? There is still a sense that questioning how often and why people have sex is very close to the kind of moralism we fought against when Ireland was still a theocracy. If we sense there is a whiff of that about a case then we tune out or smear the person as a closet conservative.
But something is lost with that and it’s the very thing campaigners are trying to protect.
There is little linking up between the mental health services and the sexual health services in this country, and only a handful of psychologists who specialise in psychosexual issues.
So nobody asks if, religious and moral objections aside, it’s good for the head and the soul to be having so much casual sex that you need to wear the metaphorical belt and braces as standard.
It’s a tragedy and a shame that campaigners for PrEP can’t see that, in many cases, the drug is the sexual equivalent of allowing people to be addicts, while protecting them against an overdose. The drug is used to prepare for a treadmill of one-night stands, after which the user is likely still HIV-free, but no closer to fleeing their problems than they ever were. In a sense, HIV is a bit of a red herring in this whole area. The current clamour for PrEP is more representative of the enduring symbolism of the illness, than the medical consequences of it.
HIV is still the ‘big one’ that nobody wants to get, the one everyone was raised fearing, but today the virus is nothing close to the death sentence it once was.
In an interview some years ago, Dr Derek Freedman, one of the leading sexual health specialists in the country, told me that the condition was on a range of seriousness about equivalent to diabetes.
There are lots of more common, yet still serious, illnesses that are passed on through sexual contact — and it could be argued that the increasing prevalence of PrEP will actually increase the incidence of these illnesses, since the person will be having presumably unprotected sex. There is no preventative medicine for Syphilis, for example.
There is also the issue that the toxicity of PrEP for the liver is not far behind the maintenance drugs for HIV itself. But, because of the stigma of contracting the illness, that is a price worth paying for many people.
None of these concerns are enough to stall bringing in the drug. We would be insane in this country to listen to the likes of Derek Byrne: PrEP needs to be introduced on public health, and quickly. But there needs to a bit more joined-up thinking about why people, gay or straight, need the drug.
Dr Dominic Rowley, a consultant in the Guide clinic at St James’s Hospital, was recently quoted as saying that he would presume that someone who asks for the drug is “taking good care of themselves”.
This might be true in its most literal, physical sense, and he is assuredly doing his job well in prescribing it — but that statement also ignores the ragged life behind the prescription. Somewhere between sloughing off the moralism of the Church and embracing the dating app present, we lost sight of the fact that some modes of living are unhealthy, regardless of whether they are punctuated by a cataclysmic event like incurable illness, or not. And addressing the risky behaviours and personal pain that make PrEP necessary will take a lot more work than a mere pill.
‘Questioning how often we have sex seems close to Church moralism’