EXPOSURE ETHICS: DOES HIV PRE-EXPOSURE PROPHYLAXIS RAISE ETHICAL PROBLEMS FOR THE HEALTH CARE PROVIDER AND POLICY MAKER? FRANCOIS VENTER, LUCY ALLAIS AND MARLISE RICHTER Keywords PreP, pre-exposure, HIV, prophylaxis ABSTRACT The last few years have seen dramatic progress in the development of HIV pre-exposure prophylaxis (PrEP). These developments have been met by ethical concerns. HIV interventions are often thought to be ethically difficult. In a context which includes disagreements over human rights, controver- sies over testing policies, and questions about sexual morality and indi- vidual responsibility, PrEP has been seen as an ethically complex intervention. We argue that this is mistaken, and that in fact, PrEP does not raise new ethical concerns. Some of the questions posed by PrEP are not specific to HIV prophylaxis, but simply standard public health consid- erations about resource allocation and striking a balance between indi- vidual benefit and public good. We consider sexual disinhibition in the context of private prescriptions, and conclude that only unjustified AIDS- exceptionalism or inappropriate moralism about sex supports thinking that PrEP raises new ethical problems. This negative conclusion is significant in a context where supposed ethical concerns about PrEP have been raised, and in the context of HIV exceptionalism. EXPOSURE ETHICS: DOES HIV PRE-EXPOSURE PROPHYLAXIS RAISE ETHICAL PROBLEMS FOR THE HEALTH CARE PROVIDER AND POLICY MAKER? HIV prevention has a new but complex addition to its armamentarium: Pre-exposure prophylaxis (PrEP) – the provision of medication to prevent HIV transmission through sex. 1 In addition to raising medical and policy questions concerning, for example, delivery and monitor- ing, PrEP is thought to be ethically complex. 2 We argue that this is a mistaken view, and that PrEP does not raise new ethical problems. HIV post-exposure prophylaxis (PEP) is well estab- lished in the clinical context and is used by health care workers with occupational exposure (such as needle-stick injuries), for infants exposed to HIV-positive mothers during birth, for prevention of infection after rape, and increasingly, after consensual sex or exposure to possibly HIV-positive bodily fluids (such as bites, or exposure at 1 J. Cohen. Breakthrough of the Year. HIV Treatment as Prevention. Science 2011; 334: 1628; R. Steinbrook. Preexposure Prophylaxis for HIV Infection. JAMA 2012; 308: 865–866. 2 Stop AIDS Project. undated.PrEP: Ethical questions and key concerns. Available at: http://stopaids.org/initiatives/prep-ethical- questions-key-concerns [Accessed 16 September 2012]; A. Leibowitz. 2011. Effectiveness and Ethics of Widespread PrEP Dissemination. Available at: http://chipts.ucla.edu/2012/02/02/musings-of-a-researcher- arleen-a-leibowitz-ph-d/ [Accessed 6 February 2013]; J. Cohen. AIDS Research. Complexity Surrounds HIV Prevention Advances. Science 2011; 333: 393; T. Myers. 2012. HIV Prevention Pill Will Do More Harm Than Good. Available at: http://www.usnews.com/opinion/ articles/2012/08/03/hiv-prevention-pill-will-do-more-harm-than-good- hiv-pill-will-give-a-false-sense-of-security [Accessed 29 September 2012]; D. Tuller. 2011. Questions on Tactic to Prevent H.I.V. Available at: http://www.nytimes.com/2011/10/11/health/11hiv.html?pagewanted= all [Accessed 10 October 2012]; L.O. Gostin & S.C. Kim. Ethical allo- cation of Preexposure HIV Prophylaxis. JAMA 2011; 305: 191–192; J.S. Jay & L.O. Gostin. Ethical Challenges of Preexposure Prophylaxis for HIV. JAMA 2012; 308: 867–868. Address for correspondence: Prof. Francois Venter, Wits Reproductive Health and HIV Institute (WRHI), Hillbrow Health Precinct, 22 Esselen Street, Hillbrow, Johannesburg 2001, South Africa. E-mail: fventer@wrhi.ac.za Conflict of interest statement: No conflicts declared Bioethics ISSN 0269-9702 (print); 1467-8519 (online) doi:10.1111/bioe.12021 © 2013 John Wiley & Sons Ltd