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The Health Belief Model, Foucauldian Biopolitics, and Pre-exposure Prophylaxis (PrEP): An Exploration of Theoretical Perspectives on Biomedical HIV Prevention

By Steven Winkelman

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Winkelman. The Health Belief Model, Foucauldian Biopolitics, aand pre-exposure prophylaxis (PrEP): an exploration of theoretical perspectives on biomedical HIV prevention. HPHR. 2021:38.  

The Health Belief Model, Foucauldian Biopolitics, and Pre-exposure Prophylaxis (PrEP): An Exploration of Theoretical Perspectives on Biomedical HIV Prevention

Abstract

As we approach the 40h 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.

Introduction

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 globe7

 

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 and PrEP Use

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, Foucault, and Technologies of the Self

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 moralises  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 medicalised 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.

Theoretical Comparisons

As part of the case review process, the Case Review Team identifies gaps and missed opportunities in prenatal, HIV, intrapartum, postpartum, and pediatric care at the system and provider level (see Table 2). Preconception gaps in care included the need for support and services for individuals and/or their family members to navigate health systems, especially for individuals with behavioral health issues; contraception discussion and distribution; and improved dissemination of updated perinatal HIV management guidelines among obstetric providers and infectious disease specialists not affiliated with academic medical centers.

 

Prenatal gaps included the discontinuation of psychiatric medications during pregnancy, either by the patient herself or by a provider, and lack of access to mental health care; a lack of investigation into red flags for intimate partner violence (e.g. reports of “falls”) when they are chief complaints of emergency department visits; inconsistent interpreter and ASL services resulting in either the inappropriate use of a family member for translation assistance or discomfort in divulging sensitive and personal information to a stranger; and health and reading literacy issues. 

 

Labor and delivery gaps included inconsistent documentation of the depression screening results and poor communication between HIV, outpatient, and inpatient obstetric providers, causing an inability to access to prenatal records, particularly with transfer of care.   

 

Maternal postpartum gaps included not scheduling postpartum appointments prior to discharge from the hospital; inconsistent use of nurse home visitors; no preconception and postpartum contraception discussion at delivery; no documentation about access to social services; and maternal reluctance to accept the offer of nurse home visits due to privacy and confidentiality concerns. 

 

Infant postpartum gaps included loss of insurance after relocation out of the original jurisdiction (insurance not covering home visits or pediatric nurses) and verifying whether the mother continues HIV care after labor and delivery. 

 

HIV care gaps included poor care coordination between HIV and prenatal care providers; no HIV care records for women living out of jurisdiction prior to pregnancy; infrequent viral load testing despite being in OB care; and no CD4 counts during pregnancy. Moreover, engaging women in care is an ongoing continuity of care challenge.

 

This case review did have some limitations, however. Since it was a sentinel case review, it was not necessarily representative of all perinatal exposures in Philadelphia within the time period. In addition, because most women did not complete an interview, there are potentially missed opportunities that were not captured by the raw data alone. Neonatal abstinence syndrome and hepatitis C testing were not regularly measured until 2017, and inconsistent data collection resulted in missing data between 2013 and 2018. Lastly, outdated contact information may have limited outreach for interviewers and made postpartum follow up difficult.  

Conclusion

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.

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About the Authors

Steven Winkelman, MPH

Steven Winkelman is a student at Dalla Lana School of Public Health in Social and Behavioural Health Sciences.

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