PrEParing for the Neediest: How Battling Inequality is at the Heart of the Fight against HIV/AIDS

By Sean Luna McAdams*


Do we have the potential to reverse the spread of HIV? The first HIV prevention treatment called Pre-Exposure Prophylaxis treatment (PrEP) otherwise known as Truvada could radically change infection projections. While a promising development, if we do not rethink our national and global healthcare strategies in terms of access and cost, this will likely deepen health inequalities pending its introduction in the Global South.

What is PrEP and how does it differ from existing HIV treatments?

There are three types of HIV treatments:

  • Antiretroviral Therapy (ART): Helps to treat HIV-infection by keeping viral loads low, which postpones onset of aids and reduces infection risk by as much as 96%.
  • Post-Exposure Prophylaxis (PEP): Mitigates risk of HIV-infection after a single high-risk event such as sexual assault or unprotected sex with an infected person.
  • Pre-Exposure Prophylaxis (PrEP): Offers a preventative measure for uninfected at-risk populations. The U.S. Center for Disease Control (CDC) cites that PrEP treatments can reduce HIV infection risk by as much as 92%. In order to be effective, Truvada must be taken daily, and does not take full effect until after seven to twenty daysTruvada costs approximately USD$13,000 per year.

Deepening Health Inequalities: Lack of Access and Prohibitive Costs


  Courtesy of the World Health Organization   What does this mean for HIV Prevention?

Courtesy of the World Health Organization

What does this mean for HIV Prevention?

What does this mean for HIV Prevention?

While PrEP does not replace condom use, condoms are only 70% effective at reducing risk of infection as reflected in worrying infection projections both internationally and in the U.S.  PrEP has the potential to drastically reduce new infections. Although U.S. politicians and health administrators advocate PrEP, where its costs less than ART treatmentsit is still not available as a treatment option in the Global South, pending approval from health ministries.

While I consider this new treatment option an exciting advance in the fight against HIV/AIDS, we need to consider how this may exacerbate existing health inequalities particularly with its likely introduction to the Global South.

If we take ART as paradigmatic of how PrEP treatments may be implemented in the Global South, a little bit more than third (36%) of those qualifying will receive it in low and middle-income countries. Some countries like Cuba and Botswana have managed to treat almost all those in need (> 95%) while other countries lag significantly behind like Yemen (14%) or Indonesia (17%). Yet successful cases rely on significant public spending or national manufacture of generics to provide universal treatment, which often are not viable options for most countries in the Global South. Discriminationalso plays a role: men who have sex with men, people with disabilities, and people living in poverty have less access and are at higher risk. Effective treatment requires consistent access to healthcare providers, a challenge across the Global South where those most in need of healthcare often have the least access. For example, Venezuela has a high treatment index (71%) but loses more than a third (35%) of patients after 5 years. The high attrition rates for Global South ART programs will likely be duplicated in PrEP treatment programs due to similar demands for consistent care.

PrEP treatments also present a particular challenge to Global South healthcare systems because of its prohibitive cost. Lack of funds limits ART’s effectiveness and will likely limit PrEP programs as Global South policy makers have to pick and choose between treatment options and employ “strategic use” of HIV medicines. Given the prohibitive cost of PrEP treatments I find this prevention scheme makes little sense for the Global South, especially considering the already precarious treatment of people living with HIV/AIDS.  In contrast, condoms offer much more cost-effective prevention.

This all points to a larger structural problem: new treatments are designed for urban middle classes and rich countries that have immediate access to high-quality and high-cost healthcare. Yet those that can benefit the most from these new treatments are the urban and rural poor, most of who live in the Global South. The Universal Declaration of Human Rights states that “everyone has the right … to share in scientific advancement and its benefits.” While everyone equally shares this right, not everyone faces the same risks to their right to health. Under our current system, any advancement will likely deepen health inequalities, and thus provide a continual impediment to effectively battling epidemics like HIV/AIDS. If these advancements are indeed intended to stem the tide of HIV, then we must place those at highest-risk at the center of the development and implementation of treatment schemes. Otherwise we risk providing incomplete health solutions for some, thereby putting everyone at risk of renewed infections and drug-resistant strains.


*Sean Luna McAdams is a researcher at Dejusticia (The Center for Law, Justice and Society)

Photo credit: US Embassy Namibia