Public health’s social contract: An obstacle in the advancement of effective HIV technologies

ABSTRACT

Evidence from the past 40 years of HIV technology development and implementation indicates that the public health social contract – with its expectations of patient/citizen compliance – has hampered global disease control efforts. Despite the availability of a wide array of effective technologies, including antiretroviral drugs as treatment and prevention, voluntary medical male circumcision procedures, and newly developed intravaginal ring products, new infections among adults globally have not decreased significantly. In this paper, I describe a historical trend of limiting access to effective biomedical technologies to those deemed most deserving and compliant given concerns of misuse (non-adherence), product repurposing (not using the product for purposes originally intended), and the incitement of autonomy (increasing the risk of public exposure to diseases given personal protection from a specific disease). Examining the expectations of good citizenship (compliance, adherence, appropriate product use, and continued risk reduction) as it relates to human-technology interactions, reveals a continuing narrative of initially restricting access to newer technologies perceived fragile or costly based on an assessment of patient/citizen worth. In this, the conventional public health social contract continues to be an obstacle in the advancements of technologies to effectively reduce the global burden of HIV.

KEYWORDS:

• HIV
• prevention
• technology
• treatment
• social contracts

Acknowledgements

I thank J. Bowen, D. Lech, S. Matsumoto, and A. Roane for their assistance in collecting data by conducting all community member interviews and connecting with clinical trial personnel and relevant stakeholders. Thank you to those community members and stakeholders for taking time to patiently teach us about these important issues. I would also like to sincerely thank all the reviewers of this manuscript through its various stages. This manuscript began as a reflection of my view of the state of the global HIV response at this moment in time. It now reflects many perspectives given the care taken and generosity offered in considering my arguments and presenting reflections on how to better inform and craft the ideas.

Disclosure statement

No potential conflict of interest was reported by the author.

Notes

1 ART was available at Maluti Hospital in Maseru for US$120 per person per year as early as 2001.

2 Paediatric patients and patients with active tuberculosis followed different treatment initiation criteria.

3 In 1994, the World Trade Organization (WTO) established the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) requiring all WTO members to provide a minimum standard of intellectual property protection through patents. This agreement restricted the creation of low-cost generic antiretrovirals.

4 https://www.advocate.com/health/2009/01/05/next-condom-conundrum.

5 Microbicides delivered through varied mechanisms (e.g. gels, film, the intravaginal ring) have been explored, but at present, an effective microbicide for use in female vaginas is currently not available (WHO, n.d.).

6 https://www.cdc.gov/actagainstaids/pdf/campaigns/starttalking/stsh-prep-infographics-brochure.pdf.

7 It is worth noting that Australian jurisdictions made PrEP available at scale to MSM in New South Wales and Victoria, and have weathered concerns about disinhibition behaviours, as HIV infections have fallen in jurisdictions with rapid scale up (Grulich et al., 2018; Ryan et al., 2018; Zablotska et al., 2018). PrEP is now available to anyone at risk of HIV with a public subsidy. However, cross-sectional survey data of 17,000 MSM in Australia has indicated a decline in condom use (46%–31%) with the increase in PrEP use (2%–4%) (Holt et al., 2018). A study of MSM in Montreal also upheld fears of behavioural disinhibition revealing a clear associative increase in sexually transmitted infections following PrEP initiation (Barreiro, 2018).

8 Similar trials conducted in South Africa assessing adherence to HIV treatment methods and contraceptives, have found that persons under 21 years have lower rates of adherence (Baeten et al., 2016; Blanc, Tsui, Croft, & Trevitt, 2009; Evans et al., 2013).