Hello, and welcome to FAB Gab. This is the podcast for the International Journal of feminist approaches to bioethics brought to you by fab Network. My name is Kathryn MacKay. And today I'm joined by Michael Montess from Western University to discuss his paper, 'creating the conditions for trust around prep as HIV prevention, the relationships of MSM with sexual and romantic partners and health care providers.' Hello, Michael.
Hi there
Thanks for joining me today.
Thanks so much for having me.
I wonder if you can just give us a little bit of an overview of your paper?
Sure, yeah. First, I was thinking I'd give a little bit of a background on PrEP what it is and the situation with HIV prevention today. And then I'll talk a little bit more about my approach to the issue in my paper, and in my research more broadly. So So prep, or pre exposure prophylaxis, is one very safe, two, highly effective, and three, a relatively new HIV prevention strategy that's being targeted, and used by MSM, or men who have sex with men or gay, bisexual, queer men, among other groups who are either at high risk for HIV, or who are still disproportionately affected by HIV today. So I'll just pick up on those three things. So prep is really safe, has really few side effects, and no serious side effects. It's highly effective. So it's actually up to 99% effective at preventing HIV depending on adherence. And it's relatively new. So there's two kinds of prep, there are available, oral and injectable versions. So oral prep was approved in the US in 2012. And in Canada, Riley in 2016. And it's a combination of two antiretroviral drugs that are used to treat HIV. And so it's a pill that's either taken daily or On Demand around possible exposure to HIV. So that's the oral kind. And then there's injectable prep, which was approved in the US in 2021. And not yet approved in Canada. Again, it's an add to the use of an antiretroviral drug that's also being used for HIV treatment. But this one's a shot that's administered every two months. And it's even more effective than oral prep because it avoids issues of adherence. So MSM are using prep and perhaps being targeted towards them, because they're high risk for HIV for several reasons, including historical factors connected to the AIDS epidemic, as well as their sexual practices, which can include condomless, sex, and sex with multiple partners, as well as their sexual and romantic relationships, which more often include open and polyamorous relationships. So one of the reasons I think it's so important to keep thinking about the issues that are involved in the ethics of HIV prevention, is that HIV rates are not actually decreasing among MSM in Canada or the US, they seem to have either plateaued, and they're even increasing among certain groups according to age, and race or ethnicity. So I think there's a lot of work to be done on PrEP as HIV prevention by researchers in several different disciplines, the social sciences, medicine, Epidemiology, history, and of course, philosophy. So my focus in this issue in this research topic is on the social political dimensions of the ethics of prep. And my focus in this paper, in particular from a feminist bioethics lens, are the relationships of MSM that are affected by using prep of HIV prevention. And I think that trumps is a particularly good moral concept for understanding the effects on various relationships. So prep is used in relationships, it's used in relation to others, specifically sexual and romantic partners. MSM have to trust their sexual romantic partners, as well as their healthcare providers who actually control access to prep, for it to be optimally successful as HIV prevention and for it to really fit into their lives. So I consider two things really how trust affects the decisions of MSM around using prep, as it should be prevention in their sexual and romantic relationships, and also how the use of prep affects the relationships between healthcare providers, healthcare institutions, and then MSM as patients. So this trust includes both interpersonal trust mostly between sexual romantic partners, as well as institutional trust between MSM and either the healthcare providers or institutions. And all of these trusting relationships, I think are complicated by different kinds of relationship or power dynamics between either partners or between, you know, healthcare providers and patients, as well as you know, the history of prejudice against them as them in healthcare institutions and society more broadly. So really, what I argue in the paper is that MSM their partners and and health care providers, have to work together They're to create the conditions for trust in these different relationships in ways that promote understanding and conversations about not just different different HIV prevention strategies, but also different sexual practices, different sexual and romantic relationships, things that MSM or, you know, the way they're they're integrating these, these HIV prevention strategies into their lives today.
Yeah, thank you so interesting. I wonder if maybe you could tell us some of the kind of key points of your argument, especially around trust between people and between people in institutions? Yeah, so
So yeah. So there's basically like kind of two parts of the paper, the first one where I talk mostly about sex and romantic partners and sexual romantic relationships. And the second part where I kind of switch the focus to be about healthcare institutions and providers. And I really liked that that second part, I mean, it's, it's something that I've been working on more recently, I gave, I gave a talk at the Center for Clinical ethics, and unity health Toronto recently to healthcare providers to kind of see what kinds of things that I can actually impart to them about this, this issue that they're going to be facing with our patients. So really, I think that the history of medicalization of homosexuality really weighs on these relationships. Because whether or not a healthcare provider is going to prescribe PrEP is gonna depend on how much they know about, about the history of HIV, but also the kinds of sexual practices their patients are engaged in and the kinds of relationships that they are building. And those kinds of conversations between healthcare providers, and especially say MSM or gay, bisexual, queer men, in an institution or in a clinical setting can be really difficult because, you know, we have to share really intimate details about our about our personal lives with our doctors, or with nurses, nurse practitioners, pharmacists. And so they might, if they don't know enough about our lives, they're not going to know which questions to ask to know, if prep is going to be a right for us. Or, you know, they might actually not even know about PrEP itself, and then it's going to the roles are going to be flipped, and we're going to have to be the ones asking for it or, or trying to educate the healthcare providers about it. And this all, of course, is going to depend on where you're at, you know, if you're in an urban center, you might have healthcare providers, especially in sexual health clinics that really know about this. And if you're in a rural setting, and you're talking to your family doctor, that might not always be the case. And so the trust in those relationships between individuals, you know, MSM who are going to be patients in the setting, and their health care provider, is really key to kind of getting that information out there. But it's also going to involve trusting institutions more broadly, because you know, we're walking in to a doctor's office or into a clinic. And if we don't feel like we're going to be able to feel comfortable in that space, sharing this kind of information about ourselves, or even going to these spaces in the first place, then we might miss out on access to prep, not to mention other other issues of access around cost. And, you know, coverage. And so, so yeah, so I kind of tried to pull apart some of the ways that, you know, the history of institutions, educational institutions, affects these relationships, and, and whether or not, you know, we can actually trust institutions in the same way that we can trust, say, healthcare providers, I find that to be a really interesting, a part of the paper and just just a aspect of the philosophy of trust more broadly, you know, whether or not, you know, the, we can trust governments, you know, institutions, corporations, you know, typically we think of trust as an interpersonal concept, we trust another individual, another person, or agent, and whether or not these institutions, whether or not trust applies, in this case, is something that's really interesting, but I think it helps us practically speaking, you know, make make these environments a little bit more conducive to, to actually, you know, linking MSM with, with prep as it should or prevention, if that's going to be something that's going to be helpful for them and for many it is.
Yeah, I think there's the question of trust is super interesting. And I want to come back to the institutional bit in a minute, but you also talk about the dynamics just within a romantic or sexual relationship, and, and how much trust is required there. And I wondered, yeah, I didn't I don't know. I just wondered if you could say something about that, too.
Mm hmm. Yeah. So that one, you know, it kind of it fits the model we have in the philosophy of trust a little bit better, right interpersonal trust. between between two people, you know, where we trust them to do something. And maybe they trust us if we're, you know, in a, in a relationship of any kind. But yeah, when I, when I tried to think about how prep is going to affect different kinds of interpersonal relationships, you know, there's this kind of nuance that I had to bring to that, that exploration because there's just so many different kinds of sexual and romantic relationships that MSM engage in, but that everyone does, you know, depends on how many partners you have depends on the relationship agreements you have with your partners, when it comes to being vigilant about HIV prevention, it matters, what people's HIV status is. And so, you know, determining what how trust is going to be affected by prep really has to do really have to appreciate all those different kinds of relationships. And so I tried to go through and think about no relationships that are dyadic, or non dyadic, relationships that are open or closed, and then more colloquially, you know, relationships that are either monogamous or polyamorous. And so what I think you can see, maybe across all of those, because I don't, I can't really get get into all of it. But it's the you know, PrEP is going to change how we trust our partners because of the weight above how it's used, right? So the main alternative, when we're thinking about HIV prevention for MSM, when we think about sexual transmission of HIV is going to be condoms. And so there's what I think's really interesting is that there's a moment when you have to trust your partners to use a condom. Whereas in your kind of together, you're in the heat of the moment, as we like to say sometimes, but there, but but for PrEP, you're taking it before. And you know, after, you know, having sex, and so what you're trusting your partner to do when they're using condoms is very different when you're trusting them to use prep. So one maybe takes a kind of courage or kind of a kind of initiative in a moment, which can be really difficult for some people, but maybe really easy for others. And when we're trusting people to take PrEP, we're trusting people to stick to a schedule, right? I mentioned adherence is important for its effectiveness. So we really need to trust that people are accessing prep, going to get their, their their supply, going for regular STI testing, which is kind of a prerequisite for accessing prep, and then actually using it correctly and consistently. And so that's going to require different different kind of strings, right, like keeping a schedule. And, and so what you're doing there is it's you're testing people in very different ways. And so your assessment of whether your partner is trustworthy or not, is going to change. I'm not friends. And I guess coming back to kind of some of those different kinds of relationships I mentioned, you know, it prep use is gonna is going to change partners perceptions of each other in different ways. So if you're in a monogamous relationship, and your partner wants to, or is using prep, then that might indicate that they want to change the relationship agreement that you have, they might want to have other sexual partners. And so that could cause some some friction, perhaps in the relationship. But if you have an open relationship, and you or your partner decide to or your partners decide to use prep, that might actually increase the kind of comfort and safety that you feel with them when you're engaging with having partners outside of the relationship. And so people sometimes are nervous about having conversations about PrEP, because because of safety associations with an open relationship or having multiple sexual partners, but again, depending on your relationship agreement, that might actually be something that is really enhancing a relationship might enhance the relationship quality. And we see that you know, different different kinds of relationships are more conducive to conversations around prep. So open relationships in polyamorous relationships, there's already a foundation of trust between partners that can be drawn on to like, add this extra ingredient to the relationship that sometimes, you know, maybe dyadic, or close or monogamous relationships might not have that same kind of trust that that goes into the ways in which we might trust the partners with prep.
Yeah, okay. Again, there's something I want to come back to what you just said. But um, before that, I want to ask you something about about trust within the relationships because I thought there's something that you said in the paper and you just said it again now, which is about kind of contrasting condom use with the use of prep and how there is a kind of symmetry in the trust between partners when people are trusting each other to take PrEP or or you're trusting the other to take PrEP. consistently, but what what I was wondering when I was reading the paper was, isn't there an element of self interest here in taking prep yourself consistently and correctly? So that yes, there is an element of trust in your partner. But there's also, but you could do a lot to protect yourself by doing this for yourself.
Yeah, that's, that's a really great question. Yeah, I'm glad you kind of saw that in the paper. Because, yeah, there's a few, there's a few things that I think are helpful for understanding that idea of protecting yourself. One is the idea of self trust, right, like I talked about, you know, both condoms and prep require different kinds of skills or different kinds of strengths, right, whether it's initiative or maintaining a schedule. And so you might know which one you're better at. And so you might choose the injury prevention strategy, that is going to be one that you trust yourself to stick to. Right. If you find it hard to use condoms in the moment, then you might want to use pap, or if you're having a hard time sticking to a schedule, then you might want to just use condoms in the moment. So the interesting thing is that, like you said, you know, taking PrEP does protect you, of course, from from from HIV transmission. But what's what's interesting, and in the paper, I talk about it a lot is that using prep is also a protection for your partners as well. Because if you're making sure that you don't have HIV, then that's going to also be helpful for your partners. And so one thing that's also interesting is that I mentioned this at the beginning that the drugs that are being used as prevention in prep are also used for HIV treatment. So so people who are who are living with HIV, they are using some of the same drugs to maintain their treatment, which if they can maintain their viral load to be undetectable, then it's actually on transmittable. So the idea of taking the medication to make sure that it's impossible for HIV positive people to transmit HIV to others, is that is kind of the same thing that they're, they're protecting their own health, but they're also protecting their partners. So I think there's something to be said about the fact that HIV is kind of this, that's like, there's an equal risk for most MSM, right, everybody's kind of at risk for the same negative consequence of sex. And so using it for yourself is also helpful for others. But what prep is often compared to is the birth control pill, which doesn't have the same kind of mechanic. Because because of the difference between between partners, when the negative outcome, or the outcome is this being avoided from sex is pregnancy, if that's how the poll is being used, then, you know, it's it's going to it's going to not create a symmetrical relationship between partners is going to be an asymmetry, right? In the case of a man and a woman having sex, you know, if a woman is using the birth control pill, then she's kind of the one who's responsible for for that prevention strategy. And, you know, that's not going to help the men not get pregnant, because he's not going to get pregnant in this one case. But for PrEP, you know, if you have two HIV negative partners, if one of them is using prep, and the other isn't, the other one is also protected from from HIV transmission. So there's, there's, there's a kind of, of symmetry there. That's really interesting. And, and again, two people who are HIV negative can both use prep, to protect themselves and each other. And the same goes for people who, you know, for partners or for who are who are HIV positive, HIV negative, if they're both using either HIV treatment or HIV prevention. They're, they're protecting their own health, but also protecting each other's health. So there is a neat way in which prep can kind of foster this kind of symmetrical trust in relationships or the symmetry that you pointed out.
I want to come back to something that you said previously, and it also kind of ties into the institutional stuff, because you've spoken about a couple of times, the sorts of things that might be the right kind of conditions for trust. So I wanted to ask you like, what are the conditions for trust?
Yeah, no, that's, that's a really great question. And so I think that, you know, some of them have to do with being knowledgeable about, about, in this case, prep, making sure that you know, sexual and romantic partners, healthcare providers and patients that everybody's on the same page with what what the facts are about how effective prep is how to use it, those kinds of things. But a lot of it has to do with him being able to have a Are conversations and share information with with with each other. So for sexual and romantic partners, you know, being able to disclose what like, you know, what kinds of prevention strategies or treatment strategies they're using is gonna is going to be something that's sometimes difficult to do. So to create a relationship where people feel like they have an open line of communication, where they can share those kinds of things, not just about the kinds of issue prevention strategies they might want to use, but the kinds of sexual practices they want to engage in, or the kinds of relationship structures they want to have. So I think one of the conditions for trust is having this open communication and being able to really discuss these things that can often be really difficult, right, like I mentioned, you know, it could, it could come across to somebody that's, you know, you want to have different more partners, or, you know, partners, more casual sexual partners, that can be hard for some partners to hear, you know, wanting to, you know, it's changed relationship agreements, or change sexual practices between, say, different partners, can be something difficult to express. And so making sure that people have an understanding of the idea that different different practices, different relationships, different strategies, are all kind of available to us at this time. And so to try to figure out what works for individuals, but also what works, in relationships with with partners is really important. And so those conversations need, the first thing is that information, right, really just how this works, and and, you know, that's gonna involve the history that's going to involve, you know, like I said, at the beginning, that the prevalence of HIV the kind of risk factors that are that irrelevant. And so that would be in relationships. And I think the same thing kind of goes for creating the conditions for trust in the relationships between healthcare providers, and MSM, as patients, it's, you know, being able to communicate things with each other. So, the healthcare providers obviously have to be knowledgeable about PrEP, but they also have to be knowledgeable about the lives of gay bisexual, queer men, right, the kinds of sexual practices that they engage in, the kinds of relationships they build, and the kind and the kinds of sexual practices that are involved in different kinds of relationships, right? If they are asking, you know, questions in the clinic that are come from a heteronormative kind of place, assuming that people are monogamous, or assuming that people only have, you know, certain kinds of sex with certain kinds with certain people, they're going to miss important information. And I think that you're making sure that health care providers are are asking questions in ways that encourage patients to share information about themselves is going to be really important. So again, that kind of open communication and being able to discuss sensitive personal things is going to be really important to be building trust, right to be able to have the conversations that actually get us to a place where we, you know, can trust people enough to open up?
Yeah, yeah, it kind of seems like, it seems like open and honest communication is a result of trust, but also a condition for trust. So it kind of seems like it's a tough one to know, when you've, when you've got enough trust as a kind of baseline to be able to engage in that. That seems like a tricky thing.
Yeah, I think, yeah, I think you got it. Right. You know, yeah, I think that to get to get to a place where you trust people, you're going to require this kind of open dialogue. And that's, that's tough to happen. That's tough to have before you really have a sense of trust. But once you do, it's hopefully more likely that you're gonna be able to continue that kind of dialogue or conversation. Well, yeah, building trust is, I think, notoriously difficult. And I think it's really different between sexual partners than it is between, you know, healthcare providers, and healthcare institutions and patients. In that sense, you know, building that kind of trusts, it's gonna take quite a lot more given some of the historical, you know, prejudice and injustice that MSM faced in those settings. And so, yeah, that's going to be an extra amount of work to go into that. And that's going to require, you know, information campaigns, you know, signaling to patients when they're in spaces, that they are welcome there. And that, you know, figuring out the wording of questions, the kind of institutional barriers that might be might be in place, and then trying to try to overcome those in order to be able to have those conversations and to build enough trust that those conversations can continue.
Yeah, definitely. So Did you face any particular challenges when you were writing the paper?
Oh, yeah, so I mean, I feel like I've encountered them again, just talking about the paper. But there are just so many nuances to the kinds of relationships that we can have, especially thinking about different kinds of sexual and romantic relationships, when we factor in different kinds of sexualities, different genders different, you know, HIV status says, like, there's, there's just so much diversity in the kinds of relationships that are impacted by HIV prevention. And I'm like, what I tried to talk about the birth control pill, it's, it's difficult to, to bring out all the nuance when you use one example. So really trying in the paper, it's, it's to carefully consider how trust might be impacted by prep. In different relationships, like I mentioned, thinking about monogamous, polyamorous open relationships was tough, you know, and then factoring in the different kinds of HIV status or serostatus, you can have between the different partners in different relationships. So trying to keep keep that all set, you know, in line, as I was writing the paper, and even talking about it can be really challenging, but I think that's it almost like proves part of the point is that, you know, relationships are going to be really unique to individuals, to partners. And so what you want to do is be able to figure out what is right for you, right, and be able to express that to to your partners to know it for yourself. And then because you know, health care providers, institutions control access to property and your prescription, you need to go for STI testing, and should be testing, you know, you need to be able to communicate that with, with, with those institutions with those healthcare providers, as well, you need to be able to share all that information. And so, yeah, kind of focusing in on how people are able to know those things, and then express them is, is it's challenging to write up in a paper when whenever there is such a diversity of those experiences. But I think it was, it's kind of an interesting part of a paper like this, to have something that I think is a little bit technical, really, when you're when you're talking about something that oftentimes people don't think of is very technical, right? They just think about it as that's their relationships, right. And so when I, when I talked about this with people, they're like, oh, so I have a, you know, close dyadic relationship, you know, you don't have to think of your relationship in those kinds of terms. But to try to get clear on, you know, the different kinds of ways prep is gonna affect trust effect relationships, and what we're going to do about that with creating the conditions for trust in those different relationships, to try to tackle all of that required a really, like, nuanced approach. And that was a little tough. Yeah.
I can imagine that. Well, thank you, this has been so interesting. I wonder if you've got any sort of takeaway messages that you hope that readers or listeners will leave with?
Um, yeah, well, I think that I have a couple takeaways. One is I think about the actual, you know, topic that I focus on in the paper, which is prep and HIV prevention. So I hope that people, you know, have the takeaway that, you know, these conversations that I've been mentioning, around prep and HIV prevention, I think need to continue to evolve, beyond discussing, you know, just different HIV prevention strategies, different options, to actually discussing the kinds of skills I've often talked about in this like communication skills, that are really necessary for new options to fit into the lives of MSM, or anyone who's, who's using them. So those are the, you know, the skills to discuss the effects of using those different those different options on relationship quality on mental health, social justice. And I think the larger takeaway, because I think that, you know, I think there's a lot in this paper for people who aren't necessarily versed in preparation for prevention. And that's the I'm trying to point to the social political dimensions of your medical or health issue. And I think that, you know, this is what feminists bioethics I think often does, which is, is trying to situate situate these issues in a in a in a broader lens that appreciates how how different medications, different treatments can affect relationships between all sorts of people, partners, family members, friends, healthcare providers, patients. So I yeah, I think I'd like to encourage people to, to obviously learn about the specific issue of prep and HIV prevention, but to think about the parallels, that might, you know, be helpful for other things, the birth control pill as one example but but so many different health care issues have these kinds of relational dimensions that I think are sometimes overlooked. And so I encourage them to apply the same kind of analysis in other ways.
Well, thank you so much, Michael.
Thank you so much as well.
And thank you for listening to this episode of FAB Gab. You can find the paper we've discussed linked in this episode's notes along with the transcript of gab is hosted and produced by me Kathryn MacKay. You can find our other episodes on Spotify, Apple, podcast, radio public or wherever you get your podcasts of quality. You can subscribe to FAB Gab so that you'll never miss an episode. Thanks again for listening. Bye
