Winkelman. The Health Belief Model, Foucauldian Biopolitics, aand pre-exposure prophylaxis (PrEP): an exploration of theoretical perspectives on biomedical HIV prevention. HPHR. 2021:38.
As we approach the 40th anniversary of the HIV pandemic, it is important to critically examine how social and behaviour health theories have impacted public health approaches to HIV testing, prevention, and management. This commentary article explores the relationship between health promotion theory and PrEP use by contrasting two theoretical perspectives: individual behaviour change theories, specifically the Health Belief Model (HBM); and post-structural theory, drawing on Foucauldian biopolitics. This article finds that individual behaviour change theories have been more commonly used to increase PrEP use and adherence, while post-structural theory has been used more critically to explore the impact of PrEP use on systems of surveillance and disciplinary power. Ultimately, an integrated theoretical perspective is called for to better understand the factors the influence PrEP use, and the broader social impact of increased biomedical HIV prevention.
In the wake of the 40th anniversary of HIV, it is important to critically examine the ways in which social and behavioural health theories have impacted advancements in HIV testing, prevention, and management. Theory has long been a favoured tool for public health practitioners in the HIV sector, used to make sense of complex perceptions of pleasure and risk, identify barriers and facilitators to HIV treatment, and develop behaviour-change interventions to prevent the transmission of HIV or improve HIV management.1–4 A recent and increasingly significant tool for HIV prevention is HIV pre-exposure prophylaxis, or Prep. PrEP is a once-daily pill, containing either tenofovir disoproxil fumarate (TDF) or tenofovir alafenamide (TAF), which can reduce the transmission of HIV to an HIV-negative person by up to 99% when taken with high adherence.5,6 In 2015, The World Health Organization (WHO) recommended that PrEP be used as an HIV prevention strategy for individuals at substantial HIV risk, and the medication has since been rapidly approved for use by numerous countries around the globe.7
PrEP has captured the imagination and attention of social theorists and health promotion practitioners, representing a shift in our approach to ending the HIV pandemic. However, uptake of the medication remains lower than expected. The use of PrEP is impacted by a wide variety of variables, including national and provincial public health policies; biomedical concerns such as efficacy and long-term health impacts; , and social and structural concerns such as perceived stigma and medical mistrust, real and perceived financial costs, sexual and gender-based discrimination, and systemic racism.8–12 Because of these barriers, notable disparities in PrEP use are observed in priority populations most heavily impacted by HIV such as gay, bisexual and other men who have sex with men (gbMSM); African, Caribbean, and Black (ACB) populations; and transgender and non-binary folks.13–15
In order to increase the use of PrEP among these priority populations, public health practitioners often draw on the constructs of individual-level behaviour change theories, such as the Health Belief Model (HBM), to guide research and interventions. Increasingly, social theorists have also begun to critically examine the impact of PrEP promotion among priority populations, particularly relating to understandings of health, power and biomedical surveillance. This article seeks to examine the relationship between theory-drive health promotion and PrEP use through two dichotomous theoretical perspectives: 1) individual behaviour change theories, specifically the Health Belief Model (HBM); and 2) post-structural theory, centering on Foucauldian biopolitics and disciplinary power. This article will begin by exploring the use of HBM in current PrEP research and interventions, before drawing on Foucault’s writings to explore how PrEP as new biotechnology may impact social relationships, hierarchies of desire, and systems of biomedical surveillance and discipline. This article aims to assess the use of both theoretical approaches in influencing and making sense of PrEP initiation and adherence, and in doing so spark a conversation on the need for a theoretically complementary critical, socio-behavioural, and biomedical approach to guide future PrEP interventions.
The Health Belief Model is one of the most commonly utilised theoretical models of health behaviour. Created by the U.S. Public Health Service in the 1950’s, the HBM seeks to understand the relationship between an individual’s beliefs or perceptions and their health behaviours.16 The model developed from the field of social psychology, and was largely influenced by two theoretical perspectives: Stimulus Response Theory, which argued that reinforcement events impact learning and determined behaviour, and Cognitive Theory, which argued that behaviour was the result of value-laden expectations of specific outcomes.16 The HBM is frequently used to examine why people take or do not take preventative actions to improve their health, and as a result has been regularly utilised to understand the initiation of HIV prevention measures such as testing and condom use.16 Proponents of the HBM argue that a patient’s actions are determined by their beliefs regarding their own susceptibility to an illness or disease, their perceived severity of that illness, and their perceived ability to act to prevent that illness; which are in turn impacted. by personal modifying factors such as age, gender, socioeconomic position, and cues to action.16 The HBM consists of seven constructs, with the most relevant constructs to PrEP use being perceived susceptibility, perceived benefits, and perceived barriers. Perceived susceptibility refers to beliefs about the likelihood of getting an illness, perceived benefits refer to the expected benefits of initiating and maintaining a preventative behaviour change, and perceived barriers refers to anticipated obstacles which may impede the behaviour change.16
Drawing on this model, PrEP-related interventions have sought to highlight specific constructs in order to increase PrEP use. In particular, these have included interventions to increase knowledge about HIV risk to increase perceived susceptibility, education campaigns which have highlighted the clinical effectiveness of PrEP to increase the perceived benefits, and policy changes such as financial coverage schemes and the introduction of generic alternatives to reduce barriers to PrEP access.11 In an exemplary thesis delivered to San Diego State University, Kendra Straub17 utilised the HBM to argue that the decision to initiate PrEP as a safer sex behaviour by queer adults was most strongly influenced by individual perceptions of the benefits of PrEP, largely through the constructs of perceived susceptibility, perceived severity, and perceived threat; ultimately advocating for further health promotion interventions to increase knowledge of PrEP among queer adults who may have low awareness of the medication. The HBM has also been used to examine and make sense of disparities in PrEP adherence among members of priority populations. Blumenthal et al.18 note that gbMSM and trans female PrEP users with higher-risk sexual behaviours demonstrated greater adherence to PrEP compared to similar PrEP users engaging in lower-risk sexual behaviour. The researchers theorized that engagement in healthcare allows PrEP users to more accurately assess their risk for HIV transmission, and modify their PrEP use in relation to their current HIV risk.
The HBM has been frequently used to identify existing barriers to PrEP use. Felsher et al.19 utilised the HBM to identify real and perceived barriers to PrEP initiation from patients who decided to not initiate PrEP.19 The authors found that the perceived costs of PrEP use, which included financial costs and practical challenges, were greater than the perceived benefits, leading to a refusal of the prophylaxis. In light of these findings, the authors concluded that greater work must be done through cues to action to increase the perceived benefits and reduce the real and perceived costs of PrEP initiation among priority populations.19 Implicit in the use of the HBM as a theory to guide PrEP interventions is the assumption that real-world factors can be modified to encourage PrEP initiation, and that people who are at-risk for HIV will rationally initiate and adhere to PrEP if these factors are adequately modified. However, critical scholars have argued that this interpretation is too simplistic, and that greater attention to complex and systemic factors is needed to fully understand PrEP initiation and adherence.
Post-structuralism is a school of theoretical thought which rejects previously held ‘grand theories’ as “reductionist and exclusionary”20 arguing instead for socially constructed and contextually-specific forms of knowledge. One of the most well-known post-structural theorists was Michel Foucault, who argued that human behaviour was determined by social interactions and relations of power.21 Foucault argued that in modern disciplinary societies order is maintained through diffuse social norms, driven by new technologies and discourses.20 The individual subject becomes governable as a result of new political and technical realities, initiated and shaped by new biotechnologies, and maintained though diffuse systems of surveillance.20 According to Foucault, health has become both commodified and individualised, with the pursuit of health becoming a political and social imperative imposed upon the individual.21
Post-structuralist research on PrEP use has focused on the creation of new forms of identity as a result of PrEP promotion and use among members of priority populations, primarily gbMSM. Jason Orne and James Gall22 argue that PrEP use creates a new form of ‘biosexual citizenship’, producing a hierarchy of desirability and access to health resources. PrEP use becomes a signal for a user’s HIV-negative status, particularly on digital dating apps, potentially further stigmatizing people living with HIV. PrEP use may also serve to signal that an individual is engaged in healthcare and has greater access to education and resources regarding HIV prevention, resulting in HIV-negative individuals who are unaware of or choose not to use PrEP being perceived as ‘suspect’ or less desirable.23 In effect, PrEP users are placed higher on the hierarchy of desire over non-PrEP users.
Orne & Gall22 argue that biosexual citizenship develops as a result of clinical surveillance and PrEP guidelines, the promotion of PrEP through public health institutions, individual-level conversions of others onto PrEP, and the prioritization of sexual health services such as streamlined HIV testing for PrEP users. This form of biomedical citizenship confers benefits to PrEP users, simultaneously encouraging new users to initiate PrEP and current users to remain adherent. The authors argue that an increased emphasis on PrEP use individualises and moralizes the sexual health of gbMSM, allowing for the governing of non-normative sex practices such as barebacking, and creating an individual burden of responsibility to limit HIV risk under the guise of public health.22This governing can be seen at the clinical level, where patients undergo surveillance through HIV and STI testing, reports of sexual activity and substance use, and confirmation of medication adherence or non-adherence. Clinicians, in a position of authority, seek to remedy the perceived risks of their patients through PrEP initiation and continued adherence.24 .
Wolfgang and Portinari25 go further in arguing that recommendations for all gbMSM to initiate PrEP, particularly those made by the World Health Organization, represent a new form of medicalized bio-control. These authors argue that PrEP represents a paradigm shift in HIV prevention away from condom usage, and through the guarantee of bodily health glosses over the potential long-term side-effects of continued PrEP use.25 They argue that this level of targeted health promotion of PrEP for gbMSM may also contribute to increased stigma for gbMSM, as HIV continues to be viewed as only a gay man’s disease in the global North. Through efforts to increase perceived susceptibility/risk to HIV among gbMSM, public health practitioners run the dual risks of further stigmatizing an already marginalized group, and reducing the perceived susceptibility of HIV infection among non-gbMSM.
Post-structuralism has also been used to critically examine the impacts of PrEP research. Through an analysis of clinical PrEP trials, Clay Davis26 argues that PrEP research creates a subject he refers to as Homo Adhaerens, who is simultaneously at high risk for HIV and who holds the burden of individual responsibility for HIV prevention through continued PrEP adherence. Davis26 identifies Homo Adhaerens as being subject to Foucault’s concept of Biopolitics through both the individualised self-maintenance of health and population-level control of the HIV epidemic. Davis26 argues that current PrEP research ignores the real-world contexts in which PrEP users operate, and public health efforts to increase PrEP uptake without this contextualization will not be effective; concluding= that PrEP research and interventions must move beyond the individual as a unit of research and responsibility and instead focus on systems-level changes to encourage widespread use of PrEP. A complementary approach to PrEP initiation and adherence, which accounts for both individual context and broader questions of power and control, is necessary.
Individual-level behaviour change theories, particularly the HBM, take a mechanistic approach to PrEP use by arguing that certain constructs can and should be modified to encourage patients to initiate PrEP. Within this model is the assumptions that patients will rationally engage with PrEP if the perceived benefits are higher than the perceived costs.16 Conversely, post-structuralist theory rejects the universal concepts and rationality implied by the HBM. Post-structuralism is more effectively utilised in understanding the high-level impact of PrEP on social relationships and relations of power. In examining these theoretical perspectives, this paper sought to highlight the tension present in public health discourses surrounding PrEP. Where the HBM encourages the manipulation of social factors to encourage PrEP use, post-structuralist theory questions the unintended side-effects of such targeted health promotion interventions. Where PrEP uptake is held to be a universal good under the HBM, post-structuralist theory questions the new social conditions and systems of surveillance created by this new biotechnology. Notably, both theoretical approaches hold PrEP to be a valuable new HIV prevention technology, although post-structuralist thought urges greater caution in the promotion and surveillance of PrEP. Together, these theoretical perspectives highlight significant gaps in our understanding of what motivates people to initiate and adhere to PrEP, and even larger gaps of knowledge regarding the long-term social impacts of PrEP use. There has been limited research on the clinical effectiveness of either the HBM or post-structuralist theory on improving medication initiation or adherence. Future research should explore the clinical, financial, and societal impacts that these theories may have when further applied to PrEP interventions.
The differences in the theoretical perspectives outlined in this article do not make them incongruent. Rather, public health practitioners who seek to bolster PrEP initiation and adherence would benefit from considering the limitations of current individual-level behaviour change theories, and work to expand the scope of current practice. Broad and deeply-ingrained systems of power limit the impact that any one behaviour-change intervention can have on PrEP use. This is not to say that efforts to increase PrEP use should be abandoned. Rather, social and behavioural theorists and public health practitioners should take strides to be critical in their work, exploring and mitigating the potential unintended consequences that further PrEP expansion may cause.
In examining the use of theory to increase and understand PrEP use, a number of questions are raised. What can be done to ensure that our PrEP promotion does not stigmatize people without access to PrEP? How does targeted PrEP promotion change the perception of who is and who is not at risk for HIV? How can we help people adhere to a medication without subjecting them to restrictive forms of discipline? What can be done to reduce the barriers to PrEP access? The answers are currently unclear, but they require taking a broader view of HIV prevention in order to accommodate the individual, socio-behavioural, structural, and biomedical contextual factors which impact a person’s PrEP use.
This paper sought to critically examine the use of the Health Belief Model and post-structuralist Theory as they relate to PrEP initiation and adherence. The paper found that the HBM was more commonly used to understand direct barriers and facilitators to PrEP use, and to guide public health interventions to increase PrEP initiation and adherence. HBM-based PrEP interventions operated through the reduction of perceived barriers, and the increase of perceived susceptibility and benefits, to rationally motivate members of priority populations to use PrEP. Conversely, Post-structuralist theory was commonly used at a high-level to examine the impact of PrEP on systems of surveillance and discipline among priority populations at risk for HIV. Both theories have been used to examine the reasons for PrEP use and disuse. While these theoretical perspectives are dichotomous, they serve to illuminate important gaps in knowledge on PrEP use. An integrated theoretical perspective, which draws on constructs from the HBM and Post-structuralist Theory, may be useful in understanding the social impacts of PrEP as an HIV prevention tool. As PrEP becomes a more common tool in the global HIV prevention toolkit, greater steps must be taken to critically examine how PrEP use is shaped by health promotion theory and practice
Steven Winkelman is a student at Dalla Lana School of Public Health in Social and Behavioural Health Sciences.