I have been thinking about public healthcare, the PrEP (yes, I know it’s a “sensitive subject”) and antimicrobial resistance. And I felt the urge to put some of it into writing - knowing in advance that it may not be the most “PC” thing to do.
I know a person who is not a sex worker but, instead, a very successful self-employed person in the tech field, with the sort of wit I can only dream of. He has more male sex partners than he can actually count, mostly because, given his taste for chemsex parties, he can’t always be sure how many partners he’s had - or whether or not they were protected.
This is a lifestyle choice made by a highly intelligent and successful person, his chosen way to have fun, and he’s free to choose to enjoy life that way.
The welfare state of the country I live in pays for his PrEP. So I, and every other tax payer in this country pay for it.
About a year ago, next to me in a public hospital’s A&E in the country’s capital city, there was an elderly lady with oesophageal cancer who required an urinary catheterisation. It is a painful procedure normally done with lidocaine gel which both lubricates and helps numbing some of the pain. There was no such gel in that A&E. According to the staff, the department had run out of it months before, and there was no budget to buy more. Yet, budget hasn’t run out for my wealthy (and healthy) acquaintance’s PrEP.
Yes, I have read the studies and understood the numbers in the PrEP’s “profitability” projections. There will be (according to the experts) savings in the long run. That is, if we include HIV prevention vs the costs of treating HIV in the equation, and basically nothing else.
That equation, however, seems to forget “human factors”, which we know can be instrumental in producing both miracles and disasters.
Generations have grown up dreading HIV-AIDS. Other STIs are treatable, but not this one. HIV is *THE* STI. To protect ourselves from it, we use condoms, and we don’t stop to think about how many other STIs they help protecting us from. No one truly fears those other STIs - nowhere near as much as we fear HIV, at least.
Here comes the miracle of the PrEP. We are safe from HIV - and HIV is, again, *THE* STI. Remove HIV from our list of worries and sexual freedom increases exponentially. Other STIs are easily treatable - what is a meagre course of antibiotics, after all?
Well, in the great scheme of things, it is a lot, and increasingly so. Everyone has heard terms and expressions like “antimicrobial resistance” or “antibiotic stewardship” but, thankfully (lucky them), not many have come face to face with those terms’ reason for being.
We have used and, sadly, abused antibiotics for decades (we’ve been literally feeding what we once called “magic bullets” to the pigs, for goodness sake!) and, whilst the bugs have been getting used to and, therefore, immune to our “magic bullets”, no new classes thereof have been introduced into the healthcare context recently.
What we see now, are pathogens that once responded well to certain antimicrobial agents no longer doing so - some of them being those behind STIs. Superbugs like MRSA, which were once limited to healthcare facilities, are now popping out of apparently nowhere in the midst of the community. And that’s just one such superbug, many others are out there - and new ones keep showing up - they adapt according to what’s thrown at them, and what we throw at them are antimicrobial agents, such as antibiotics.
Back to the PrEP - the moment we are protected from HIV and start feeling that barrier protections are more “nice to have’s” than anything else, what happens in terms of the myriad of other STIs, some of which many of us have never even hear of? They are overwhelmingly treatable, so that’s precisely what we’ll do: treat them - with antimicrobials - thus exacerbating the major global problem of antimicrobial resistance.
We may say that a few courses of doxycycline is cheaper than a lifetime of integrase, protease, etc inhibitors, and that’s quite true. But once that doxycycline no longer works and we start going for the “heavy machinery” to handle “trivial bugs turned monsters”, can we really say how much that will cost?
And when exposing all sort of pathogens (not only STI-related ones, but everything out there) to that “heavy machinery” starts turning some amongst that virtual infinity of “benign” bugs into superbugs, how much will that cost, both in terms of the financial burden to our NHS’s and in terms of lives?
Everything is connected but, from everything I’ve read over the last year or so, not enough connections seem to have been explored as to allow us to say with any degree of certainly that “the PrEP is cost-effective in the long run”.
Add to that everything that is lacking in our healthcare systems, which our governments, whichever they are, can’t squeeze out of the tax payer to pay for and, from proton beam therapy to the widespread use of viral vectors in cancer immunotherapy (mentioning oncology alone, and there’s a lot beyond it), given that my acquaintance has chosen his lifestyle, but my A&E “neighbour” didn’t choose her cancer, can we really say that the PrEP should be our budget priority?
Up to each individual to come up with their own answer to this question - which is not being asked anywhere near often enough.
