Michael Montess

For many men who have sex with men, the risks, treatment, and prevention of HIV are central and unavoidable aspects of their experiences of sex and romance. This constant vigilance around HIV complicates their lives in medical as well as interpersonal and socio-political ways. Pre-exposure prophylaxis is a relatively new method of HIV prevention that is already revolutionizing the lives of MSM by lessening the need for this ongoing vigilance. However, the wide-ranging effects of PrEP on MSM are as of yet unclear. Therefore, the ethics of using PrEP among MSM is a timely issue that demands philosophical engagement. As MSM in North America face decisions of whether or not to use PrEP and the consequences of those decisions, philosophy has an important role to play in helping us think more clearly about the situation today by moving away from a strictly medical conception of the ethics of PrEP. In my first chapter, I motivate my investigation into the social and political dimensions of the ethics of PrEP by providing a critical history of HIV and HIV prevention. In my second chapter, I challenge the prevalent risk assessment approach to the ethics of PrEP, arguing that it has a distorting effect, overblowing some risks while overlooking others. The second half of my dissertation demonstrates how a relational approach, focused on the conditions for trust and solidarity, better reveals the ethical terrain facing MSM with decisions about PrEP. In my third chapter, I examine the role of trust in sexual and romantic relationships between MSM as well as relationships between MSM and healthcare providers. In my final chapter, I argue that PrEP complicates relationships of solidarity within gay communities, focusing in particular on intergenerational differences in perspectives on HIV and HIV prevention. Overall, my dissertation helps move us towards a more socially and politically informed conception of the ethics of PrEP, which helps us understand how MSM can live ethically within communities whose sexual and romantic lives continue to be medicalized, both internally by members of gay communities and externally by a broader culture and public health establishment.

In order to demedicalize the ethics of pre-exposure prophylaxis as HIV prevention, I consider the social effects on men who have sex with men. The Centers for Disease Control and Prevention considers MSM to be the highest risk group for contracting HIV in the USA. The ethics of using PrEP as HIV prevention among MSM, however, has both a medical dimension and a social dimension. While the medical dimension of the ethics of PrEP includes concerns about side effects, drug resistance and distribution, the social dimension of the ethics of PrEP includes concerns about stigmatization, sexual and romantic relationships and sexual freedom. The medical concerns of the ethics of PrEP may take precedence over the social concerns, but there is a growing body of literature that already addresses the medical concerns. Much less attention has been given to the social concerns of the ethics of PrEP, and in this article, I aim to fill this gap in the literature. Therefore, I focus on the often-overlooked social dimension of the ethics of PrEP to help understand the connection between the risks, relationships and communities of MSM using PrEP as HIV prevention.

In this article, I challenge the risk assessment approach to the ethics of pre-exposure prophylaxis (PrEP) as HIV prevention among men who have sex with men (MSM). Traditional risk assessment focuses on the medical risks and benefits of using medical technologies, but this emphasizes certain risks and benefits over others. The medical risks of using PrEP are presently being overblown and its social and political risks are being overlooked. By recontextualizing risk within the history of HIV and considering the lived experiences of MSM with sex, HIV, and HIV prevention, we can broaden the present risk assessment framework to include all of the relevant risks involved in using PrEP. We can also better situate risk as one of several moral concepts, including trust and solidarity, which move us towards a more nuanced analysis of the social and political effects of PrEP on the relationships and communities of MSM.

The COVID-19 pandemic is not the first pandemic that many of us have faced in our lives. The HIV/AIDS pandemic continues to affect women, racialized people, and LGBTQ2S+ people around the world today, and there are significantly fewer resources to address, and less political will and news coverage of, this other pandemic.1 Although many see COVID-19 as an unprecedented public health crisis that is challenging our societies and our relationships with each other in unique ways, I argue that we actually have a lot to learn from our responses to HIV/AIDS and that feminist bioethicists can help us understand how the present situation is actually an extension of several underlying medical and social issues and...

While the WHO, public health experts, and political leaders have referenced solidarity as an important part of our responses to COVID‐19, I consider how we build solidarity during pandemics in order to improve the effectiveness of our responses. I use Prainsack and Buyx's definition of solidarity, which highlights three different tiers: (1) interpersonal solidarity, (2) group solidarity, and (3) institutional solidarity. Each tier of solidarity importantly depends on the actions and norms established at the lower tiers. Although empathy and solidarity are distinct moral concepts, I argue that the affective component of solidarity is important for motivating solidaristic action, and empathetic accounts of solidarity help us understand how we actually build solidarity from tier to tier. During pandemics, public health responses draw on different tiers of solidarity depending on the nature, scope, and timeline of the pandemic. Therefore, I analyze both COVID‐19 and HIV/AIDS using this framework to learn lessons about how solidarity can more effectively contribute to our ongoing public health responses during pandemics. Whereas we used institutional solidarity during COVID‐19 in a top‐down approach to building solidarity that often overlooked interpersonal and group solidarity, we used those lower tiers during HIV/AIDS in a bottom‐up approach because governments and public health institutions were initially unresponsive to the crisis. Thus, we need to ensure that we have a strong foundation of respect, trust, and so forth, on which to build solidarity from tier to tier and promote whichever tiers of solidarity are lacking during a given pandemic to improve our responses.

In this paper, I consider how trust affects the decisions of men who have sex with men (MSM) around using pre-exposure prophylaxis (PrEP) as HIV prevention in their sexual and romantic relationships, and how the use of PrEP affects their relationships with healthcare providers. MSM have to trust their sexual and romantic partners as well as their healthcare providers for PrEP to be successful as a relatively new HIV prevention strategy. This trust includes both interpersonal trust and institutional trust and it is complicated by different kinds of relationship dynamics and the history of prejudice against MSM in healthcare institutions.