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Research on oral pre-exposure prophylaxis in sub-Saharan Africa is an example of biomedical tunnel vision

Richardson, Eugene T.a,b

doi: 10.1097/QAD.0000000000000256

aDivision of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine

bDepartment of Anthropology, Stanford University, Stanford, California, USA.

Correspondence to Dr Eugene T. Richardson, Division of Infectious Diseases and Geographic Medicine, 300 Pasteur Road, Lane Building, L134, Stanford, CA 94305-5107, USA. E-mail:

Received 1 February, 2014

Revised 6 February, 2014

Accepted 6 February, 2014

‘A technical solution may be defined as one that requires a change only in the techniques of the natural sciences, demanding little or nothing in the way of change in human values or ideas of morality.’

–Garrett Hardin (1968) [1]

I read with interest the Opinion piece by Cowan and Macklin [2], which concluded: ‘pre-exposure prophylaxis [is] ready for prime time use in HIV prevention research’. Presumably, this prime time research will occur in sub-Saharan Africa, where several trials of oral pre-exposure prophylaxis (PreP) have already failed in high-risk women [3,4]. The enthusiasm surrounding PreP highlights the current paradigm for HIV prevention: namely, that we will treat our way out of the pandemic.

The idea of chemoprophylaxis is problematic on many levels, but mainly stems from our attempts to ‘force nature into the conceptual boxes supplied by [our] professional education’ [5]. Here, I am speaking mainly to clinical researchers, public health professionals, and other specialists in the biomedical paradigm.

Despite growing opinion that oral PreP will not likely be efficacious outside the research arena [6], our incremental efforts to gain a couple of extra percent of prevention at the cost of medicalizing a disease-free state gloss over the structural drivers of generalized epidemics. This type of approach shapes society's view that the problem of HIV prevention is one that has been handed over to the scientists and that we will find a solution. In other words, legitimation of the biomedical approach – in this case chemoprophylaxis – ‘gives a normative dignity to its practical imperatives’ [7]. Or, better yet, the expectation of a biomedical solution shapes the way we see the phenomena on which we are trying to intervene.

Consider the following social psychology experiment: individuals were shown a deck of cards in which the color of certain cards was exchanged for its opposite (e.g. an individual might be shown a black queen of hearts). The individuals would consistently identify the card as belonging to suit (i.e. as a queen of spades in the previous example.) After repeated trials and a growing sense of uncertainty, the individuals (in general) would finally recognize the anomaly [8]. Analogously, we live in a world where health policy makers and research funders (e.g. Gates Foundation) increasingly demand technical solutions to the issues of public health. Just like the expectation of a standard deck precludes our seeing a black queen of hearts, technocratic lenses preclude us from seeing societal factors as determinants of disease.

Only a radical unsettling of our biomedical tunnel vision will provide the mobilization necessary to break free from the fetish for technical (and chemical) solutions – an unsettling which recognizes that the penchant for magic bullets is sometimes misplaced – an unsettling which helps policy makers and citizens alike realize that meaningful social interventions (e.g. abolishing school fees for girls, ‘real’ enforcement of domestic violence laws, affirmative action for increased participation in the labor market, banning child marriage, etc.) will likely provide better prevention then pills or microbicides.

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Conflicts of interest

There are no conflicts of interest.

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