The Pharmaceuticalisation of Prevention
Public Health in the PrEP era
Dr Sara Paparini
SMALL GROUP PROJECT: JUNE 2016 – MAY 2017
The Research Idea
The pharmaceuticalisation of disease prevention generates new ideas regarding public health and infection control. Recent trials have proven antiretroviral medication pre-exposure prohylaxis (PrEP) in preventing HIV transmission amongst men who have sex with men. These trials herald the possibility of a pill that prevents HIV. They constitute a turning point in community and policy advocacy regarding the promise of PrEP. How PrEP is portrayed in trial and other forms of evidence will shape its meaning and implementation. At least two scenarios can be anticipated: (i) PrEP has ‘zero sum’ effect whereby it overrides, or substitutes, current prevention (for example, condoms); or (ii) PrEP generates ‘synergy’ between new and existing efforts towards higher impact prevention. PrEP will shape new forms of patienthood and prevention responsibility, while questions of equity, eligibility and how to navigate multiple systemic and material factors are core to its delivery. Documenting the ‘making of PrEP’ alongside its ‘actualization’ into the ‘real world’ is an invaluable opportunity to explore the ‘pharmaceuticalisation of public health’. This Award will develop a funding proposal and collaboration to investigate PrEP and its implementation across three European cities (London, Paris, Amsterdam) at the forefront of innovation in the post-trial era of its implementation.
The processes through which pharmaceuticals are shaping public health, and especially disease prevention, is under studied. This is particularly important when new pharmaceutical agents interact in areas of public health previously reliant upon the responsibilisation of individuals towards behaviour change. The pharmaceuticalisation of disease prevention generates new ideas regarding public health and infection control.
Persistent rates of HIV incidence amongst men who have sex with men (MSM) in different settings highlight the limitations of current public health strategies and the complexities of intervening in intimate spheres of human behaviour. In 2015, two clinical trials (London, Paris) established efficacy for a new biomedical HIV prevention option for MSM: PrEP, or ‘pre-exposure prophylaxis’, where antiretroviral medication (taken regularly or before sex) prevents HIV transmission. The trials herald the possibility of a pill that prevents HIV, and constitute a turning point in community and policy advocacy.
The making of PrEP into a public health reality is complex. First, this new pharmaceutical solution is subject to debate, promotion and resistance among different actors of vested interest – from those in policy to potential users. Second, the actualization of PrEP in the ‘real world’ is fraught with material and symbolic challenge. Health systems questions arise regarding licencing, prescription, distribution, funding and commissioning. Third, the pharmaceuticalisation of prevention presents new public health scenarios: the substitution of current prevention tools (for example, condoms) or a synergy of new and existing prevention efforts.
This ISRF will help build the foundations, collaborations and a large funding proposal to investigate how clinically-trialled pharmaceutical interventions for prevention are incorporated into local practices, and the effects these have for public health disease management. The proposal to be developed is acomparative sociological and anthropological study of ‘the making of PrEP’ in three European cities (London, Paris, Amsterdam) at the forefront of innovation in the pharmaceuticalisation of HIV prevention. It will link with a large European Research Council project currently led by Professor Vinh-Kim Nguyen investigating biomedical HIV ‘eradication’ in the same three cities.
The study to be developed for funding is a complex and ambitious one. Theoretically, it will be informed by an ontology of ‘multiplicity’. This enables study of the multiple meanings of PrEP produced by different actors, envisaging PrEP as an ‘object in the making’. We envisage PrEP implementation as an ‘assemblage’ of the coming together of ‘actor networks’ interacting with their health and social systems. The ISRF Award will enable us to develop our theoretical framework and locate how the study will contribute theoretically. Methodologically, because the larger study needs to capture reciprocal interactions between how PrEP is represented and delivered, it will combine analyses of public discourses about PrEP (for example, policy and other texts), actor accounts (for example, interviews) and ethnographic observations (for example, of key moments in policy debate, community action and decision-making). The ISRF award will thus enable us to develop the research design and the combination of methods and to plan the academic partnerships required as well as an initial strategy for analysis and dissemination.
1) Via network-building activities:
establishing the collaborations and expertise through which the proposed comparative 3-city project will be delivered
2) Via review and debate:
consolidating shared learning regarding the funding opportunities to which the larger study proposal to be developed will be targeted.
Six day-long meetings will be held (three in Paris and three in London) between the four co-applicants in the ISRF award. The meetings will enable the structure and content of a larger comparative project grant investigating ‘the making of PrEP’ in three European Cities.
Professor Rhodes and Dr Paparini will lead the social science London component in collaboration with Professor Anderson, a key stakeholder in public health policy in the UK, HIV consultant and member of the PrEP UK trial. Professor Nguyen co-ordinates ongoing collaboration between epidemiologists, clinicians and social scientists in Paris and Amsterdam working on PrEP implementation.
The applicants will jointly assemble the design of the comparative element of the 3-city proposal. This is an ambitious design which requires the respective extensive knowledge and expertise held by the applicants collectively regarding the contexts for the making of PrEP in each of the three cities.
The first meeting will serve to consolidate a comprehensive list for the establishment of a broader network to be mobilised in preparation for the grant proposal. Each subsequent meeting will be attended by additional key local stakeholders in the field as appropriate.
Face-to-face meetings are invaluable for the exchange, development and synthesis of ideas. This programme of work will allow the co-applicants sufficient time for discussion, decision making and task allocation which can be then carried out remotely and via other means of communication that do not require travel and physical presence.
Meetings will be held in the co-applicants respective institutions.
1) A fully worked draft funding proposal for the proposed 3-city comparative project comprising: (i) theoretical framework; (ii) research design; and (iii) research methodology
2) A network of academic collaborators in the UK (to integrate as the ‘London component’ of the proposed 3-city project).
3) A co-authored commentary peer-reviewed publication on the pharmaceuticalisation of HIV prevention through the making of PrEP