Outward

Truvada on the NHS: How Public Health Care Shapes the British Debate Over PrEP

Labour’s Ed Balls speaks during the 2015 British general election campaign. (He lost.)

Carl Court/Getty Images

As night follows day, a court decision declaring that Britain’s National Health Service should fund the provision of PrEP for at-risk people was met with irresponsible and homophobic media coverage. More commonly known by the brand name Truvada, if taken daily, PrEP can help prevent someone who is HIV-negative from getting the virus.

The Daily Mail—whose high horse is usually tethered nearby for occasions such as this—labeled PrEP a “promiscuity pill” that would cost “taxpayers up to £20 million a year” ($26 million) and “encourage men to have sex with multiple partners without condoms and may even lead to higher HIV rates.” Both the Mail and the Times claimed the money spent on PrEP would divert funds from other conditions. The Wright Stuff—a morning TV talk show that makes The View seem like a Mensa summit—led with the crazed chyron, “FREE £20M HIV DRUG FOR GAYS WHO WON’T USE CONDOMS?”

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British society’s indefatigable reactionaries—the conservative press, right-wing members of Parliament, heads of Christian charities—continue to politicize HIV. During the 2015 general election, the U.K. Independence Party’s Nigel Farage declared that people who are HIV-positive shouldn’t be allowed to settle in Britain. Now, dinosaurs like Conservative MP and men’s rights bore Philip Davies are weaponizing PrEP against potential beneficiaries, asserting that the NHS mustn’t “[deprive] cancer patients of crucial drugs at the expense of other treatments,” as if gay men seeking to keep themselves healthy will make others sick.

Davies’ remark contains a clue as to what colors the opposition to PrEP in Britain, where the centrality of the NHS to everyday life can be difficult for outsiders to comprehend. From cradle to grave, British people are in the care of one health care provider: birth, vaccinations, prescriptions, primary care, dentistry, ophthalmology, accident and emergency, scans, surgery, and long-term care. Everybody uses the NHS, and almost everyone pays into it—so the entire country and her sister feels entitled to an opinion about it, including who should be allowed access to care and on what grounds.

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In a system of universal, publicly funded health care, the rich through their higher insurance contributions subsidize coverage for the poor, and the healthy, using the system less often, support the sick. Everyone is in it together in that sense. The system would collapse otherwise. The unfortunate and often tedious downside of this is that it creates a morally righteous atmosphere around health care, in which the sick become divided between the innocent and the guilty: those free of blame for the illnesses they’ve contracted and those who can, in some fashion, be condemned.

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The system itself does not differentiate—a sick person in need of care is a sick person in need of care—but a good chunk of the population seems to feel entitled to cast judgment on those deemed the deserving sick: smokers who develop lung cancer; habitual users of alcohol who require a liver transplant; the clinically obese who need a gastric band or become diabetic. Also subjected to this kind of shaming are HIV-positive people who became infected and then require courses of life-preserving medication. British conservatives have long suggested that a system like ours, which is free at the point of use, should not be open by right to the deserving sick. If the wound is self-inflicted, if the sick person is at fault for their own illness, they should pay for their misdeeds.

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What this means for British gay men who wish to go on PrEP is that they currently have to pay out-of-pocket to order Truvada off the internet. Never mind that, as a preventive drug, PrEP would ease pressure on the health service in spite of the upfront cost of procuring the drugs and introducing them into the prescription system. For the morally virtuous, this is the government using their hard-earned taxes to fund the abominable lifestyle choices of those too irresponsible to use a condom, when those funds should be spent on the innocent, undeserving sick. (No one ever thinks of themselves as being part of the deserving sick, of course. The deserving sick are always other people.)

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So pushback against the expense of PrEP was predictable. Because of the inherent tension of the healthy paying for the sick, the NHS gives people license to express opinions about everyone else’s health care—a tension exacerbated in times of scarcity. The health service in England is facing a funding crisis, which will either result in tax increases or spending limits. The latter would mean fewer staff or the rationing of care. In such circumstances, why should an elderly lady be denied cataract surgery (the Daily Mail’s example) or a child with cystic fibrosis refused a drug to help them breathe (the Times’) just so gay men can have their party drug? That this is an entirely false choice doesn’t seem to bother those perpetuating the narrative.

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The idea that the victim is at fault for contracting HIV is as old as the condition itself, since, as Susan Sontag wrote in AIDS and Its Metaphors, it is “understood as a disease not only of sexual excess but of perversity.” What’s flavoring the debate in Britain, though, and what makes political reactionaries capable of great callousness, is a perception that somehow they are the ones paying for the recklessness of others. Those so hard of heart as to deny gay men PrEP should hope that they don’t one day develop a malady and have such wickedness and cruelty visited upon them in their hour of need.

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