Whether you’re a clinical type or not, you probably know that it means Pre-Exposure Prophylaxis. It is a disease prevention strategy in which folks who have risk factors for a particular infection take medication to prevent that infection. Because of modern advertising practices, PrEP is most well known as a strategy to prevent HIV infection. However, HIV is not unique in that regard. For many years, vulnerable individuals such as nursing home residents have been given chemoprophylaxis (what PrEP used to be called) for Influenza. If there is a single case of Influenza, we offer preventative treatment to everyone in the home simply because Influenza is very contagious and can have lethal effects among this demographic.
I think of vaccination in a way similar to the way I think of PrEP although they are distinctly different things. Both are disease mitigation strategies that are deployed before infection takes hold. PrEP depends on a therapeutic to prevent the disease whereas vaccination depends on alerting an individual’s immune system so that it is prepared to respond early and briskly to the infection that the vaccination is meant to mitigate.
In the case of COVID, there is actually a PrEP therapy called Evusheld. It’s an injection of two mono-clonal antibodies. If you’re thinking Regeneron, that’s the right idea. Of course, the Regeneron antibodies don’t stop the Omicron variant of COVID. Evusheld is being marketed as PrEP for folks with underlying conditions that make it unlikely that they will develop immunity even if vaccinated. Most of those folks have immune system impairments such as Common Variable Immuno-Deficiency (CVID) or take treatments that make the immune system less likely to respond normally to vaccination – conditions like chemotherapy, treatment with antibodies that deplete B-cells to treat Multiple Sclerosis (MS), or illnesses caused by auto-immunity. To summarize, there are millions of people who would qualify for treatment with Evusheld. Unfortunately, there are at least millions more people who are eligible than doses of Evusheld to give them.
Needless to say, this creates an ethical challenge. The question is, “Who gets the medicine when there are many more eligible than doses of medicine for them?” Do we create a lottery for those who are eligible? Do we create a tiered lottery based on things like estimated likelihood of survival or age or specific risk factors? Today, this ethical conundrum falls on the healthcare providers who have access to the drug. There are as many ways to select the individuals treated as there are entities to receive and distribute the medication. It’s a system that often favors the well-heeled, the tech savvy, and the well-connected. It doesn’t really favor the poor, those with poor access to healthcare, or those with low health literacy.
When I ponder these things, I find myself wishing that there were a PrEP for bigotry, injustice, inequality and of host of other communicable afflictions of our body politic. Alas!