Play Sure Kits: A Form of Harm Reduction for HIV/AIDS
The HIV/AIDS epidemic in the United States is alive and well. According to the Centers for Disease Control and Prevention in 2015, 40,040 individuals were newly diagnosed with HIV. In the United States over 1.2 million people are living with HIV. 13% of people with HIV are unaware of their diagnosis. The HIV infection rate is particularly high in the minority populations. Unless a comprehensive plan is initiated that includes more education and new prevention initiatives, the infection rate will continue to rise among the vulnerable populations and more people will die unnecessarily. The Play Sure Kit is a new prevention tool initiated in New York City and to date it is having excellent results. As part of the harm reduction theory, this new initiative should be financed by taxpayer money and begun in every major city in the United States. Unless this is done, more people will become HIV infected and more lives will be lost.
HIV/AIDS, Prevention, Harm reduction, Education
As of 2016, more than 1.2 million people in the United States are living with Human Immunodeficiency Virus (HIV), and 1 in 8 of them remains unaware of their infection. From 2005 to 2014 the annual number of new HIV diagnoses declined 19% but young African American gay and bisexual men (aged 13 to 24) experienced an 87% increase in diagnoses. Among Hispanic/Latino gay and bisexual men the diagnoses rose by 24% . The minority populations continue to experience the highest infection rates compared to all other races and ethnicities. It is estimated that 65% of the estimated 1.2 million Americans with HIV are not on treatment . This is having a devastating impact on all segments of American society. A new study by epidemiologists at Emory University and published in The Journal of Medical Internet Research: Public Health and Surveillance estimated that infection rates in the South are skyrocketing. In South Carolina and Mississippi, the study estimated, 28% of gay and bisexual men are infected with HIV. In Louisiana, the estimated infection rate is 26%, and in Georgia, 25%. In Washington, D.C., which resembles a city more than a state in its demographics, it was even higher, 32%  something has to be done to turn the tide on this increase in HIV infection rate. "If current rates persist, one in every six men who has sex with men will become infected with HIV, the Centers for Disease Control and Prevention said last week in its first lifetime risk analysis. One out of every two black men and one out of every four Latino men in this segment of the population is projected to become infected" .
There are many reasons why the HIV infection rate continues to raise in the minority communities. There has been an increase in risky behavior such as unprotected anal sex, needle sharing, etc. especially among the younger generation. There are many reasons for this increase. There is still a stigma associated with HIV in the minority communities and as a result, many young people refuse to be tested for fear of discrimination in their own communities. Many refuse to consider taking PREP because doing so would mean acknowledging their behavior. In addition, members of the minority community lack the resources, especially medical insurance. Because of the stigma still associated with HIV it is very had to reach gay minority youths. Many of them are not out to family and friends. Many live in isolated areas and financially they cannot afford to move, especially in the South . Many attend schools that do not have support groups or even guidance counselors who are gay friendly. As a result, many risk depression and a sense of fatalism. Another factor is the lack of education in our schools. HIV has now become a chronic disease that can be maintained with the proper medications . As a result, few in the present generation ever witnessed the devastation of HIV in the 1980s and 1990s. The Baby-Boomer generation experienced first-hand the horrible deaths of friends and family who contracted this lethal disease. Before Antiretroviral Therapy (ART), there was not much hope only despair. Today, young people, lacking the proper education about HIV, are under the impression that all one has to do is take a pill and you will be fine, or all one has to do is practice "sero-sorting". Sero-sorting is when those who are sero-negative on lab reports try to sleep only with other men who are uninfected. The problem is most infected men are not tested and refuse to be tested so serosorting is very easy to get wrong. Young people today, especially among the minority population are unaware of HIV facts, costs of treatment, side-effects of antiretroviral drugs, sacrifices, etc. This lack of education needs to be rectified now on a comprehensive level. To help address this issue New York City instituted the Play Sure Kit in 2016 as part of a comprehensive plan to decrease the HIV infection rate.
Play Sure Kit
The Play Sure Kit is just one component of New York City's effort to effectively end the HIV/AIDS epidemic. "The NYC Plan to End the Epidemic includes a $23 million investment in Fiscal Year 2017 to increase HIV prevention and health care programming that will benefit nearly 200,000 New Yorkers per year when implemented. The plan aims to reduce the annual number of new HIV infections in New York City to 600 by 2020 as part of a statewide goal of no more than 750 cases by year 2020. As part of the plan, the Health Department announced an increase in STD clinic hours earlier this year. The new ad campaign will be displayed on subway turnstiles, MTA buses, and online" . The Play Sure Kit is a case that allows an individual to easily and discretely transport everything needed to increase HIV prevention. The Kit holds condoms, lubricant and the prevention pill of a person's choice (e.g. PREPa HIV medications, and/or birth control). The Kits are available for free at various community events throughout the year, as well as from certain community-based organizations. These kits can also be obtained by calling 311 or using the NYC Condom Finder App. According to Assistant Health Commissioner Dr. Demetre Daskalakis, "The Pay Sure kit was developed based on a prevention pack carried by one of my young patients living with HIV. He carried a small zipper case with condoms, lubricant, and his HIV medications so he would always be sure to have his prevention at hand. His strategy of combination prevention is exactly the #Play Sure message". The original container looked like a slightly oversized cosmetic case. When Dr. Daskalakis joined the Health Department he took a picture of the case and sent it to an industrial designer. The end result is the present day black colored Play Sure Kit.
"The phrase 'Play Sure', conceived by a marketing team, with its inevitable hash tag, suggests a new era in which medical technology has made it possible for public-health messaging to seem less anxious and reproving. 'Play Sure' acknowledges pleasure while promising, essentially, the elimination of risk. The promise is credible: The Centers for Disease Control and Prevention has said that PREP, when used consistently, can reduce the risk of HIV infection by up to 92%. A San Francisco study released in September 2015 showed that among 600 people at high risk for HIV, those who took Truvada regularly for two and a half years remained free of the virus" . The members of the New York City Department of Health believe that this Play Sure Kit is an essential part a winning comprehensive strategy to help end the HIV epidemic in the city. However, there are many who believe it is just encouraging unsafe sex and additional HIV infections. To examine this issue one should examine the essentials of the Harm Reduction Theory.
Harm Reduction Theory
The driving force for those who advocate for the Play Sure Kit to be made available as a viable option to reduce HIV infections is the Kit's potential to be used as a harm reduction technique. Harm reduction is an approach focused on minimizing the negative results that go hand-in-hand with HIV infection rates . Harm reduction techniques have both a medical and ethical impact on the individual and society as a whole. Harm reduction techniques accept individuals as they are, while also tailoring that person's treatment to fit his or her needs . Furthermore, there are certain principles that are quintessential to an understanding of harm reduction, as listed by the Harm Reduction Coalition. The following principles, adapted to the HIV infection issue, are the foundation of the Harm Reduction Theory:
• Accepts, for better and or worse, that licit and illicit drug use and risky sexual behavior are part of our world and chooses to work to minimize its harmful effects rather than simply ignore or condemn them.
• Understands drug use and risky sexual behavior as a complex, multi-faceted phenomenon that encompasses a continuum of behaviors from severe abuse to total abstinence, and acknowledges that some ways of using drugs and engaging in sexual relations are clearly safer than others.
• Establishes quality of individual and community life and well-being-not necessarily cessation of all drug use and sexual behavior-as the criteria for successful interventions and policies.
• Calls for the non-judgmental, non-coercive provision of services and resources to people who use drugs and engage in risky sexual behavior and the communities in which they live in order to assist them in reducing attendant harm.
• Ensures that drug users and those with a history of drug use and those individuals who are HIV routinely have a real voice in the creation of programs and policies designed to serve them.
• Affirms drugs users and those who engage in risky sexual behavior themselves as the primary agents of reducing the harms of their drug use and sexual behavior, and seeks to empower these individuals to share information and support each other in strategies which meet their actual conditions of use and behavior.
• Recognizes that the realities of poverty, class, racism, social isolation, past trauma, sex-based discrimination and other social inequalities affect both people's vulnerability to and capacity for effectively dealing with drug-related harm and risky sexual behavior.
• Does not attempt to minimize or ignore the real and tragic harm and danger associated with licit and illicit drug use and risky sexual behavior .
The NYC Plan to End the Epidemic and specifically the Play Sure Kit's potential to reduce HIV infections has the potential to be used as a harm reduction agent in and of it self as it can save lives. Furthermore, many individuals who become HIV infected did not receive necessary medical education to increase HIV prevention and have become infected; allowing the Play Sure Kit initiative could possibly save many preventable infections and deaths. If we as a society value human life as sacred, we must find a way to prevent these deaths. Distribution of Play Sure Kits, as part of a comprehensive HIV prevention and health care program, and directed by trained health care professionals as a harm reduction agent presents a viable form of prevention to address the increasing HIV diagnoses among minorities in the United States. In addition, it has the potential to save thousands of lives.
HIV infections are increasing disproportionately in the minority communities. "African Americans represented 12% of the US population, but accounted for 45% (17,670) of HIV diagnosis in 2016 . Hispanics/Latinos represented 18% of the US population, but accounted for 24% (9,290) of HIV diagnoses in 2016". The Play Sure Kits have been shown to decrease HIV infections, similar to needle exchange programs. According to New York City Health Commissioner Dr. Mary T. Bassett, "Our joint efforts with community partners have led to the lowest number of HIV diagnoses ever and no infections diagnosed among infants in NYC. This work continues as we address persistent disparities and remind all New Yorkers to be HIV sure, play sure and stay sure" . New initiatives like Play Sure Kits have been rejected by other cities in the United States where HIV rates of infection are increasing disproportionately, especially among young minority men and women. This number is unacceptable by any standards.
Critics of both the harm reduction approach and the use of Play Sure Kits as a harm reduction agent argue that these initiatives are a waste of taxpayer's money. First many argue that the use of a harm reduction technique like Play Sure Kits only encourages people to continue their destructive action. In the case of Play Sure Kits, critics believe its use will only lead to a higher HIV infection rate because it will give some a false sense of protection. Similarly, critics argue these approaches lead people away from seeking testing and treatment since they now have a safety net of sorts for their risky behaviors. Some critics also believe that we would be wasting valuable money on producing these kits, when that money could be spent on prevention programs that are more ethical and socially acceptable. Proponents of the harm reduction theory point to the various successes of this approach. The Needle and Syringe Exchange programs have decreased the HIV infection rate among IV drug users in the United States. The Opioid Substitution Therapy (PST) or Opioid Replacement Therapy (ORT) replace illegal opioids, such as heroin, with a longer acting but less euphoric opioid such as methadone or buprenorphine under medical supervision. And Supervised Injection Sites provide sterile injection equipment, information about drugs and basic health care, treatment referrals and access to health care professionals. All three of these examples show the efficacy of the harm reduction theory. Finally to address these criticisms and to strengthen the arguments for this harm reduction approach, it must be determined whether or not broader access to Play Sure Kits would promote more good than harm, not only for the minority population but also for their associates and communities at large.
Society, in general, has always recognized that in our complex world there are times when we are faced with situations that have two consequences-one well and the other evil. The time-honored ethical principle that has been applied in these situations is called the principle of double effect. As the name itself implies, the human action has two distinct effects. One effect is intended and good; the other is unintended and harmful. As an ethical principle, it was never intended to be an inflexible rule or a mathematical formula, but rather it is to be used as an efficient guide to prudent moral judgment in solving difficult moral dilemmas . This principle focuses on the agent in terms of intentions and accountability, not just contingent consequences. The principle of double effect specifies four conditions, which must be fulfilled for an action with both a good and a harmful effect to be ethically justified:
1) The action, considered by itself and independently of its effects, must not be morally harmful. The object of the action must be good or indifferent.
2) The harmful effect must not be the means of producing the good effect.
3) The harmful effect is sincerely not intended, but merely tolerated.
4) There must be a proportionate reason for performing the action, in spite of the harmful consequence .
The principle of double effect is applicable to the issue of Play Sure Kits because it has two effects, one good and the other harmful. The good effect is that these kits have the potential to decrease HIV infections and ultimately to save lives. The harmful effect is that some believe that it may send a wrong message that risky sexual behaviors is condoned and even encouraged. This could lead to scandal. To determine if the distribution of Play Sure Kits is ethical, this issue will be examined in light of the four conditions of the principle of double effect.
The first condition allows for the distribution of the Play Sure Kits because the object of the action, in and of itself, is good. The moral object is the precise good that is freely willed in this action. The moral object of this action is to decrease HIV infections and potentially save lives by providing an effective and alternative plan to help prevent HIV infection and help eliminate the AIDS epidemic. The immediate goal is not to endorse risky sexual behavior or to encourage it. Rather, the direct goal is offer an effective prevention tool for sexually active men and women who meet the criteria for the program, in order to help individuals and in particular minority individuals and to decrease HIV infections and deaths. The second condition permits making Play Sure Kits available by health care professionals at community based organizations and clinics as an alternative prevention tool for gay and bisexual individuals and IV drug users because the good effect of offering an effective alternative prevention tool that can save lives is not produced by means of the harmful effect. The two effects are completely independent. Making Play Sure Kits available at approved community based organizations and clinics coordinated by qualified health care professionals have no intention of encouraging risky sexual behavior. In fact, the opposite is true. To argue that public health officials are encouraging or condoning risky sexual behavior is illogical. This is "like suggesting that air bags and seatbelts encourage unsafe driving" . The third condition is met because the direct intention of making Play Sure Kits available is to protect and preserve human life and to encourage HIV prevention, education, social support, professional counseling, testing and medical care. The direct intention of this program is to preserve the lives of the most vulnerable that is, gay and bisexual men and women especially those who are minorities. This is accomplished by decreasing HIV infections and indirectly, through education and other prevention techniques, the potential of spreading HIV and the potential for death. The foreseen but unintended consequence of this may be the belief by some that this is condoning and even encouraging risky sexual behavior. One might also argue that it could give a "false" sense of security to those who engage in risky sexual behavior. Nevertheless, there is no scientific evidence that proves this will encourage or even increase HIV infections. In fact research shows that the opposite is true. Finally, the argument for the ethical justification of making Play Sure Kits available by the principle of double effect focuses on the fourth condition of whether there is a proportionately grave reason for allowing the unintended possibility of scandal and the possibility of increased risky sexual behavior. Proportionate reason is the linchpin that holds this complex moral principle together.
Proportionate reason refers to a specific value and its relation to all elements in the action . The specific value in allowing for Play Sure Kits is to preserve human life by decreasing HIV infections and encouraging responsible sexual behavior to vulnerable members of society. The harm, which may come about by trying to achieve this value, is the foreseen but unintended possibility that some may view this as condoning and even encouraging risky sexual behavior. The ethical question is whether the value of preserving human life outweighs the harm of the foreseen, but unintended, possibility of scandal and possible increased risky sexual behavior? To determine if a proper relationship exists between the specific value and the other elements of the act, ethicist Richard McCormick, S.J. proposes three criteria for the establishment of proportionate reason:
1) The means used will not cause more harm than necessary to achieve the value.
2) No less harmful way exists to protect the value.
The application of McCormick's criteria to making Play Sure Kits available nationwide as an alternative HIV prevention tool supports the argument that there is a proportionate reason for allowing this program. First according to public health officials, the use of Play Sure Kits, as part of a comprehensive HIV/AIDS prevention program, can decrease HIV infection rates, decrease the use of medical resources and potentially save lives. According to Assembly Member Richard Gottfried, Chair of the New York Assembly Committee on Health, "With the number of HIV cases in the city falling below 2,500 last year for the first time since the beginning of the AIDS epidemic in 1981, the City's proactive and effective outreach through efforts like the Stay Safe campaign are proving effective in helping save lives and keeping New Yorkers healthy" . If making Play Sure Kits readily available for at risk gay and bisexual men and women, as part of a comprehensive program, saves lives and does not increase HIV infections or condone risky sexual behavior, then, this program does not cause more harm than necessary. To verify these facts, the program should be initiated on a wide-scale basis in order to collect more data. Larger clinical trials in major cities in the United States, especially cities with large minority populations, would offer valuable data regarding this issue. Second, at present, there does not appear to be an alternative that is as effective as Play Sure Kits for at-risk gay and bisexuals. It is true that other means of prevention exist such as abstinence but according to health care authorities, abstinence is not realistic for many at-risk individuals. In the United States 1 out of 8 HIV infected people out of the 1.2 million infected are unaware they are infected and continue to infect others. Many of these infected are participating in risky sexual behavior. If Play Sure Kits are effective in decreasing new HIV infections, then this program needs to be expanded to every major city in the United States. The critical aspect that cannot be overlooked in making Play Sure Kits readily available at various supervised sites for at-risk individuals is the element of human contact. This human contact allows health care workers to form personal relationships with at-risk individuals and thus provide the opportunity to offer them appropriate health care, personal counseling, testing and referrals to treatment centers. Various scientific studies have confirmed that intravenous drug users reduce risk-laden behaviors when pertinent information and services, such as counseling are made available, and especially when they are offered by peers who are members of the drug-using subcultures [16-18]. Making Play Sure Kits available to at risk individuals by trained health care professionals not only has the potential to save human lives but also to foster human dignity and respect. Third Play Sure Kits do not undermine the value of human life. One can argue convincingly that the intention of making Play Sure Kits available to at-risk individuals by trained health care professionals is to save human lives and from current data in New York City it appears to be quite effective. This is a public health issue that must be addressed because innocent people are becoming infected and potentially these lives could be lost. It seems clear that there is a proportionate reason to allow Play Sure Kits to be made available in the United States using taxpayer money. Play Sure Kits contribute to the well-being of at-risk individuals and society as a whole because this tool has the potential to decrease the HIV infection rate and ultimately, save medical resources and human lives. It also offers those who are at-risk the opportunity to realize that they are valued as persons and that with the appropriate assistance HIV infections can be avoided and the AIDS epidemic can be defeated. Therefore, it is ethically justified under the principle of double effect to allow for Play Sure Kits to be made available to at-risk individuals at approved community-based organizations that are coordinated by health care professionals. Ethically, the greater good of those individuals at-risk and the common good of society are advanced by financially supporting the use of Play Sure Kits in major cities in the United States.
Racial and ethnic minorities have been disproportionately affected by the HIV/AIDS epidemic since its beginning in June 1981. African Americans have the highest rate of new HIV diagnoses, followed by Latino. In 2015, the rate of new HIV diagnoses per 100,000 for African Americas (44.3) was 8 times that of whites (5.3); Latinos (16.4) had a rate 3 times that of whites. Survival after an AIDS diagnoses is lower in African Americans than for most other racial/ethnic groups . HIV/AIDS clearly remains a life and death issue, as risky sexual behavior in our country grows and the lack of education and prevention tools causes more and more individuals to become infected by HIV. HIV/AIDS affects thousands of lives and costs society billions of dollars each year. Evidence has shown that play Sure Kits as part of a comprehensive plan can be beneficial both at the individual level and the societal level. For the individual, it has been proven to effectively prevent the spread of HIV and to save lives. On a societal level, the use of Play Sure Kits can ultimately decrease the strain on the medical system as more individuals will be educated on the spread of HIV, which will lead at-risk individuals to use preventative measures to stop the increase in HIV transmission. Societally, it also has the potential to end the HIV/AIDS epidemic in the United States. If we as a society value human life, we must continue to increase access to preventative tools and work to effectively educate and prevent at-risk individuals in the fight against HIV/AIDS. A comprehensive approach that includes a preventative strategy, a treatment strategy, and a harm reduction strategy could serve as a new paradigm to guide our decisions regarding the HIV/AIDS epidemic. We cannot allow the appearance of scandal to stand in the way of proven scientific evidence. Human lives are hanging in the balance.
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Peter A Clark SJ, Director of the Institute of Clinical Bioethics, Saint Joseph's University, Philadelphia, Pennsylvania, USA; Professor of Medical Ethics, Loyola Center, St. Joseph's University, Philadelphia, Pennsylvania 19131, USA, Tel: 610-660-1465.
© 2017 Peter ACSJ, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.