‘What a skewed sense of values’: Discussing PreP in the British press

Abstract

In this article I examine the public discussion of pre-exposure prophylaxis (PrEP) in the UK and investigate how this treatment and its key beneficiaries were framed by the British press between 2012 and 2016. Drawing upon an archive of articles published in national newspapers, I identify the discursive transformation that PrEP underwent during this period, as it moved from being a ‘wonder drug’ that benefited the health of the general population, to a ‘promiscuity pill’ that threatened the lives of the most vulnerable. I illustrate how this transformation was accompanied by a shift in the representation of gay men – who were almost universally positioned as the future beneficiaries of PrEP in the UK. Utilizing critical discourse analysis methods, I explore how gay men went from being ‘upstanding citizens’ to ‘dangerous outsiders’, and how the British press mapped older stereotypes of the diseased gay male body onto newer homonormative representations of the ‘good gay’ and the ‘evil queer’. This analysis reveals the precarious status gay men occupy in ‘post-equalities’ Britain – a status that requires adherence to a particular code of sexual and moral conduct, and the disavowal of long-term health inequalities.

Keywords

HIV/AIDS homonormativity news framing newspapers PrEP

At the time of writing this article, pre-exposure prophylaxis, or PrEP, remains unavailable on the NHS in England – the universal healthcare system that anyone ‘ordinarily resident’ in the country has access to. This is not to say that PrEP isn’t being used by people in England and I should point out that PrEP is available via standard NHS prescription in Scotland. In England, PrEP is currently accessible on private prescription and via a flourishing online trade in generic medication. Since December 2016 NHS England has also been funding a study of the treatment (the PrEP Impact Trial), which will target approximately 20,000 individuals, and provide access to the drug under trial conditions. PrEP is being used in the UK, and NHS England has been spending money on it, but as yet, the drug Truvada has not been commissioned for use as PrEP. This means that unlike other preventative treatments (such as female oral contraception or blood thinners), a patient cannot receive PrEP from their GP unless they are enrolled in a medical trial.

I begin this article by mapping out this context precisely because the current situation is due in part to the way PrEP has been discussed in the British public sphere. Today, we take for granted the fact that media not only frame public understandings of health, but also act as mediators (in the Latourian sense) shaping policy responses to health issues (see Gollust and Latz, 2009; Hong, 2013; Kim and Willis, 2007). Yet it was still something of a shock to learn in September 2016 that the then health secretary Jeremy Hunt responded to a call to fund PrEP by asking, ‘What will the Daily Mail say?’. Indeed, the Daily Mail has had a great deal to say about PrEP over the past seven years. Kim and Willis (2007: 359) argue that ‘the media … tell the audience not only which issue to think about but also how to think about it’ (author’s emphasis). This audience includes those charged with commissioning and funding healthcare and, as Hunt’s response illustrates, the British press are ever-present in the minds of politicians and policymakers. We cannot separate decisions about health spending from the reporting of those decisions.

It is for this reason that I focus on the representation of PrEP in the British press in this article, and it is my contention that whether supporting or criticizing PrEP, journalists routinely drew upon frames of reference that share common ground with what Lisa Duggan (2002) terms the politics of a ‘new homonormativity’ when constructing their reports.

Homonormativity, Duggan argues, articulates the cultural politics of neoliberalism, and this brand of identity politics has come to dominate lesbian and gay politics in the Global North over the last two decades. It represents a distinctive break from older forms of queer activism rooted in left-wing thinking, which challenge the social, economic, legal and political structures that support multiple forms of oppression (see Robinson, 2011) In contrast, and in keeping with the neoliberal approach to government, economics and society, the politics of homonormativity seeks assimilation rather than revolution, and concentrates its focus on securing a narrow set of rights in order to award ‘a place at the table’ (Bawer, 1993) for (some) LGBTQ people, while leaving existing hegemonies in place.

In keeping with the broader neoliberal agenda, this political position citizens as (private) consumers in all matters of life (including in matters of healthcare, education and social services). As such, it argues that any challenges that queer folk face can be resolved by acquiring personal (private) rights, such as marriage equality, pension equality and job-related benefits. In this way, and while seeming to argue for equality through increased legal recognition, the politics of homonormativity supports, rather than challenges, the dominant heteronormative paradigm that pervades contemporary Western society.

This leads Duggan to define homonormativity as:

a politics that does not contest dominant heteronormative assumptions and institutions but upholds and sustains them while promising the possibility of a demobilized gay constituency and a privatized, depoliticized culture anchored in domesticity and consumption. (2002: 179)

Central to these politics are the twin concepts of privatization and individualism. For Duggan, these concepts manifest themselves in homonormativity’s promotion of a ‘domesticated’ and apolitical understanding of same-sex desire, practice and identity. Importantly, in the context of this article, homonormative thinking subscribes to the belief that LGBTQ people are ‘virtually normal’ (Sullivan, 1996) and that issues such as HIV, mental health or substance misuse are therefore a matter of personal responsibility, having little to do with the structural inequalities and pervasive forms of discrimination that queer folk continue to experience, and which define heteropatriarchal society. This intense focus on the individual – both in terms of rights and responsibilities – obscures the fact that HIV continues to represent a significant health inequality for gay men in the UK today. In this article, I demonstrate how the arguments for and against PrEP provision that were reported in the British Press illustrate an investment in this homonormative approach to gay men’s health. This, I argue, resulted in PrEP being treated solely as a matter of personal responsibility and cost, rather than as a solution to a health disparity that gay men in the UK continue to grapple with.

Framing PrEP

I am not alone in focusing on the representation of PrEP within a national mediascape, and several scholars have examined public discussions of PrEP, both in the UK and elsewhere. Spieldenner (2016) provides a critically informed analysis of what he calls the ‘queer communication’ of PrEP, identifying the different discourses and ideologies that have permeated discussions of the treatment. Meanwhile, McGlaughlin et al. (2016) and Schwartz and Grimm (2017) point towards the important role that Twitter has played in the development of arguments for and against PrEP. These public discussions have had real world effects, shaping gay men’s understandings and attitudes towards HIV, sex and prophylactics (see Dean, 2015; Race, 2016). Such findings resonate with Owen’s (2018) work on the mediatization of HIV/AIDS, in which he identifies the emphasis that gets placed on certain aspects of a social phenomenon at the expense of others.

All of this points towards the fact that the way in which health and medical news is reported is key to our understanding and evaluation of it:

Framing essentially involves selection and salience. To frame is to select some aspects of a perceived reality and make them more salient in communicating texts, in such a way as to promote a particular problem definition, causal interpretation, moral evaluation, and/or treatment recommendation for the item described. (Entman, 1993: 52 original emphasis)

Framing, alongside standard journalistic tools of persuasion (including practices of naming, quoting, narrative organization, source prioritization and stereotyping) is integral to shaping public attitudes towards health and well-being stories, including medical advancements, health scares and funding concerns. Perhaps, most importantly in the context of this article, framing is as much about exclusion as it is about inclusion. To refer once more to Entman,

… frames simultaneously direct attention away from other aspects. Most frames are defined by what they omit as well as include and the omissions of potential problem definitions, explanations, evaluations, and recommendations may be as critical as the inclusions in guiding the audience. (1993: 54)

It is therefore imperative that we pay attention to what is not being articulated in news reporting as much as what is being said (see also Lawrence, 2000). This is something that I will return to later, precisely because understandings of PrEP in the British public sphere have been shaped by such absences and omissions.

Of all the work undertaken on public discourses of PrEP, the work of Jaspal and Nerlich (2016) is perhaps the closest to the project I undertake here. Their examination of PrEP stories in the British press overlaps with my own corpus of material. In their analysis the authors identify three ‘social representations’ appearing in the British reporting of PrEP: PrEP as hope, as weapon and as risk. While agreeing with these insights, I identify two key differences between our respective work. Firstly, there is the issue of timeframes. Published in 2016, Jaspal and Nerlich’s study was unable to capture the dramatic shift in news frames that occurred in the summer of that year. August 2016 saw a fundamental alteration in the reporting of PrEP by the British press and threw earlier public discussions into sharp relief. As such this article might be considered as a continuation from where Jaspal and Nerlich left off: the next chapter in the history of PrEP reporting in the UK.

The second key difference is the approach that I adopt in my analysis. While I utilize a similar framing analysis, my work focuses on how the reporting of PrEP demonstrates an investment in a particular politics of sexuality, namely homonormativity. As such, while the earlier analysis is attentive to the polarizing nature of PrEP reporting, I am interested in how these surface divisions belie deeper points of similarity, serving to tie together arguments made for and against the funding of PrEP. In particular, I focus on how two key themes – individualism and privatization, which lie at the heart of homonormative thinking, pervade the otherwise divergent responses to PrEP, and highlight the way these themes foreclose avenues of discussion when it comes to addressing HIV as a health inequality in the UK.

A note on methodology

Using LexisNexus, I initially sourced a total of 339 news articles from British national newspapers (including both their print and online forms) that mentioned PreP. Deleting duplicates resulted in a corpus of 125 articles published between July 2012 (the date of the first article to mention PrEP) and September 2016. These articles were then uploaded to NVivo software for analysis. This analysis focused firstly on the structure of the article, and considered where support for, or criticism of, PrEP appeared in the report. Articles regularly included both supportive and critical statements about the treatment, but the amount of space given to each side of the ‘debate’, and the placement of each argument in the article determined the overall attitude towards PrEP that the report adopted.

I then analysed the formal elements of each article. These included references to individual spokespeople, the manner in which they were identified (e.g. the inclusion of professional credentials), the use and placement of direct quotations, and the tone of the article’s headline. Finally, I considered the language used to discuss the treatment itself, its assumed beneficiaries, other patient populations and references to the ‘general public’. This detailed analysis provided a basis for determining the article’s evaluation of PrEP, which was then measured on a five-level Likert scale ranging from ‘very negative’, through ‘neutral’ to ‘very positive’. For example, while a news article could include criticism of PrEP funding, the headline, placement of supportive statements early on, use of quotations from named health professionals and the selective use of quantitative data, might work in concert to produce a positive evaluation of PrEP. It was this evaluation that was then recorded using the Likert scale to produce a qualitative evaluation of the article.

‘It gets better’: Introducing PrEP as a public good

After more than a decade of apathy towards HIV/AIDS and its treatment (Owen, 2015, 2018; Parker, 2011), the British Press began discussing PrEP in July 2012. This was the month the Food and Drug Administration (FDA) approved Truvada for use as a pre-exposure prophylactic in the USA. The FDA decision was not unanimously celebrated and the first articles about PrEP quoted the response of AIDS Healthcare Foundation (AHF) Director, Michael Weinstein, to the decision, which he argued was ‘completely reckless’ and had ‘set back years of HIV prevention efforts’ (Boseley, The Guardian, 2012: 17). Criticisms and concerns over PrEP continued to be reported throughout the period under investigation, but by and large, these voices were marginalized, often appearing towards the end of news articles that promoted a more positive attitude towards treatment.

Between July 2012 and the beginning of August 2016, a total of 83 original articles discussed PrEP and HIV. Of these 83, only 5 articles framed PrEP in wholly negative terms. While the remaining 78 articles included voices of dissent or concern (including those of AIDS activist Larry Kramer and film star Zachary Quinto), none of them scored below ‘neutral’ on the Lickert scale during the analysis, with 62 articles being assigned the label ‘positive’ or ‘very positive’. Of particular note was the way in which PrEP was repeatedly hailed as a scientific revolution in the fight against AIDS:

HIV drug may make ‘biggest dent yet’ in virus. (Brown, The i, 2014a: 22)

‘Wonder drug’ which can reduce HIV risk by 92% could be offered on the NHS. (Davies, MailOnline, 2014)

Contrasting the militarized language often invoked in discussions of HIV (see Nie et al., 2016), there was relatively little ‘fighting talk’ in the British press coverage of PrEP. Instead, both the virus and the new treatment were discussed in a global context (echoing Persson and Newman, 2008), with reports on drug trials in Africa, France and the UK published alongside details of PrEP uptake in different countries and future interventions such as the PrEP ‘injection’ and a vaginal delivery system. In many of these reports PrEP was contextualized as an intervention that could halt the transmission of HIV and save entire populations:

By treating enough inhabitants, the whole ‘viral load’ of a city can be lowered. That protects everyone – just as vaccination could protect whole communities from smallpox. (Stoppard, Daily Mirror, 2014: 32)

widespread use of anti-retrovirals could curb the HIV epidemic in Africa and may even snuff it out within a generation. (Connor, The Independent, 2015: 4)

Daily HIV prevention drugs ‘could reduce new cases of the disease by a THIRD over the next decade’. (Parry, MailOnline, 2016)

Hallin et al. (2013) identify the historical framing of audiences as ‘citizens’ in coverage of new medical treatments and this frame was commonly deployed in reporting about PrEP. Hence the article from the Mirror, quoted earlier, explains PrEP by referring to a well-known medical technology already familiar and relevant to all members of society: vaccination.

According to Petersen (2005: 204) the use of metaphor in communicating medical advances is ‘inescapable’ and ‘serve[s] to direct attention along certain avenues and away from others’. This isn’t to suggest that such rhetorical work is accurate: PrEP does not vaccinate users against HIV infection. Nevertheless, invoking vaccination in discussions of PrEP offered British journalists a method for rendering PrEP both intelligible and relevant to the British public. In doing so, such reporting suggested that PrEP was a public health issue relevant to a broad audience.

Pills (but no) thrills

The other metaphor that was regularly deployed in reporting was that of female oral contraception. The birth control pill regularly featured in reports that sought to explain how PrEP worked, and arguably helped to build public support for the treatment:

Taking the drug, called Truvada, could become a daily routine for men who have sex with men in the same way that the contraceptive pill is for women, some believe. (Boseley, The Guardian, 2015)

What is PrEP? Ground-breaking new drug labelled the ‘contraceptive pill for HIV’ explained. (Stoppard, Daily Mirror, 2016: 26)

The HIV treatment pill Truvada containing PrEP can be taken on a daily basis – in a similar way that women take the contraceptive pill. (Slawson, The Guardian, 2016)

Myers and Sepkowitz (2013) have written of the parallels between the development of PrEP and of the contraceptive pill, and the alignment of HIV/AIDS treatment with birth control predates PrEP. Furthermore, it wasn’t just journalists that made a comparison between PrEP and contraception; even Professor Sheila McCormack, the project lead on the PROUD study, referred to contraception when making a case for funding PrEP:

Do we make people pay for a pill that stops them getting pregnant and allows them to have sex without a condom? Some precedents have been set there. Pleasure is one thing, but a happy sex life is a good thing for wellbeing. (quoted in Brown, The i, 2014a: 22)

In another article, Justin Harbottle of Terrence Higgins Trust also used female oral contraception as an epistemological hook on which to fasten an understanding of – and support for – PrEP:

Whenever you get a new type of prevention launched, you get this moral angst around it … It’s even been compared to the female contraceptive pill. (quoted in Brown, The Independent, 2014b)

As with the vaccination metaphor, the primary reason for referencing the Pill was to render PrEP familiar to the British public. At the same time, references to the Pill also framed understandings of, and attitudes towards, the treatment. In particular, the Pill metaphor was used to frame PrEP as an issue of personal responsibility. This is perhaps surprising given the fact that the Pill has historically been aligned with the issue of sexual freedom (Myers and Sepkowitz, 2013). Echoes of this sexual freedom can be found in advertising campaigns for PrEP in the USA (see Aslinger in this issue). By contrast, the British press deployed the Pill metaphor to promote a new era of individual responsibility and the metaphor was utilized to frame PrEP as a vehicle for personal control and self-regulation:

One of the great things about PrEP is it allows you to make the rational health choice at a time when it might be easier and without needing your partner’s agreement. (Godfrey, The Independent, 2015: 1, author’s emphasis)

This is about helping people to be responsible. (Smythe, The Times, 2014: 27)

I shall discuss the issue of personal responsibility later, but here I wish to direct attention to the partial and selective use of the contraceptive metaphor by the press. Unlike popular understandings of the Pill, PrEP was never represented as liberating gay men, but rather as helping them to become rational sexual actors (see Adam, 2005). It was on this basis that the press accepted PrEP as a viable treatment. Via the metaphors of vaccination and birth control, and with reference to studies by the Medical Research Council, Center for Disease Control and the World Health Organization, support began to be built within the British public sphere for providing PrEP on the NHS. For almost four years, PrEP reporting was decidedly positive in tone, strengthening the case for making the treatment available on prescription:

This is a treatment that would benefit many and will reduce the impact of HIV across society (Smithson, The Independent, 2016)

Every provider … wants to see far fewer men and women presenting for care with a new diagnosis of HIV infection … PrEP can be a part of that outcome, especially if pragmatic approaches are sought, aimed at achieving the coverage necessary to gain population impact at scale. (Baeten quoted in Parry, MailOnline, 2016)

The NHS submitted PrEP to its commissioning process in late 2015, the outcome of which would determine whether the treatment would be made universally available in the UK. As the commissioning process moved along, the press continued to publish good news stories about the ‘wonder drug’. Everything was looking good for PrEP in the UK.

Passing the buck

But the path to PrEP came to a grinding halt on 21st March 2016, when the NHS withdrew PrEP from the commissioning process. In a statement issued the same day, the organization explained that its decision was based on the legal belief that PrEP, being a prevention measure, could only be funded by individual local authorities:

As set out in the Local Authorities … Regulations 2013, local authorities are the responsible commissioner for HIV prevention services. Including PrEP for consideration in competition with specialised commissioning treatments as part of the annual CPAG prioritisation process could present risk of legal challenge from proponents of other ‘candidate’ treatments and interventions that could be displaced by PrEP if NHS England were to commission it. (NHS England, 2016a)

Shifting the responsibility for PrEP provision onto local authorities had potentially dire consequences. Unlike the NHS, local authorities do not have to act in unison to provide access to health promotion initiatives. The NHS decision effectively promised to make PrEP provision a postcode lottery.

The NHS decision was considered insincere and disingenuous by campaigners, and their anger was given voice in the headlines of the national dailies:

Charities slam NHS England ‘U-turn’ over plans to roll out ‘HIV wonder drug’. (Davies, MailOnline, 2016)

Pill to stop HIV will not get funding. The NHS has been accused of a ‘shameful’ U-turn after refusing to foot the bill for a drug that protects men from HIV. (Badshah, The Times, 2016: 4)

The National AIDS Trust (NAT) challenged the NHS decision and filed a case with the High Court the following month. This action also found support in the press, with the Daily Mail reporting that the NAT action was ‘prompting NHS to reconsider controversial decision not to prescribe ‘HIV wonder drug’’ (Lloyd, MailOnline, 2016). The following month, The Times published a letter, signed by representatives of 25 leading HIV/AIDS organizations calling for the funding of PrEP (Gold et al., The Times, 2016: 28). Days later, The Independent reported that the ‘health service is now “sitting on” a drug that could be “the beginning of the end” of the HIV epidemic in the UK’ (Cooper, The Independent, 2016). Even The People tacitly sided with the pro-PrEP campaign, writing that ‘if a private firm behaved this way, heads would be rolling’ (Macaskill, Sunday People, 2016: 7). Pressure was mounting on the NHS – and the government – to fund this ‘wonder drug’ and put an end to HIV/AIDS in the UK and all eyes turned to the High Court for a decision.

On 2 August 2016 Mr Justice Green handed down his ruling in the case and ruled in favour of the NAT. While NHS England confirmed that it would appeal the ruling, the verdict was a victory for the NAT and for the constituencies most affected by HIV/AIDS. A treatment that offered the opportunity to significantly reduce HIV infection could now be made available on the National Health Service.

Suffer little children

For the most part centre-left publications such as The Guardian and The Independent celebrated the verdict, but the Daily Mail, Britain’s most widely read newspaper, immediately changed its attitude towards this ‘wonder drug’ following the ruling:

NHS fights back against ruling forcing it to hand out ‘promiscuity pill’ that prevents HIV as the £20m cost will hit its ability to treat cancer and give limbs to amputees. (Robinson, MailOnline, 2016)

This headline heralded a radical reframing of PrEP and signposted the strategies deployed by some quarters of the British press as they reoriented their attitude towards PrEP. One of the most disturbing facts about this discursive U-turn was the role the NHS itself played in reframing the narrative of PrEP. In a press release issued on the day of the ruling, NHS England suspended all but the most immediate funding decisions for new treatments:

NHS England cannot now confirm funding for those treatments and services in levels three and four. This is to ensure that sufficient funding remains available for PrEP should it be prioritised in the event that the Court of Appeal upholds the judge’s decision. (NHS England, 2016b)

When the Daily Mail wrote of cancer patients and amputees being denied treatment because of PrEP, they were technically correct. NHS England effectively prohibited access to new treatments or medical procedures in order to assess the cost of PrEP. In doing so, it pitted the health and well-being of a specific population against that of the broader British public. This was a cynical co-option of conventional diseased-based activism, which ‘tend[s] to position the various distinct patient groups as engaged in competition that is inevitably zero-sum’ (Epstein, 2016: 247). Sections of the press amplified this division, representing the court ruling as a decision between the treatment of the deserving sick and the privileging of the undeserving well:

Here’s a question for you: whom, do you suppose, is more deserving of our tax cash? Children suffering with cystic fibrosis struggling for breath, or gay men who fancy unprotected sex? (Ferrari, Express Online, 2016)

To put it bluntly: gays are being given scarce taxpayer-funded NHS resources for a lifestyle drug which could encourage sexual risk-taking when those suffering from cataracts, sick children and cancer-sufferers face rationing of their treatments. (Spencer and Borland, Daily Mail, 2016)

The rhetoric adopted by the reactionary tabloids echoes Stone’s (1989: 290) analysis of ‘causal politics’, whereby ‘the effects of an action [are cast as] the intended purpose of the actor’. The history of HIV/AIDS funding in the UK is a history of the discursive battle to frame the virus as a health inequality and human rights issue, not the appropriation of funding from other, more deserving groups (Smith and Whiteside, 2010). This battle has often been challenged by conservative media bias, which has tended to both individualize the virus – and its transmission – and frame it as the consequence of ‘bad’ or morally dubious behaviour. What is interesting in the case of PrEP is that the conservative section of the press did not condemn gay men for having sex (as was the case decades earlier), but instead criticized them for seeking state support in this endeavour. The mention of PrEP as a ‘lifestyle drug’ is relevant here, identifying the fact that homosexuality continues to be framed as a personal choice that deviates from the normal and the natural, and is therefore, something that is subject to personal responsibility. Needless to say, such framing reveals the ongoing dominance of heteronormative thinking, which pervades the British media system, and which situates homosexuality as abnormal.

Wolves in sheep’s clothing

At the same time that they fell back on heteronormative stereotypes of diseased outsiders, the press also enlisted gay men to promote the idea that PReP access should be privatized. The rhetoric of these gay men is of particular importance here because it reveals both the dominance of homonormative voices in the press at this time, and the way a politics of homonormativity colluded with ‘dominant heteronormative assumptions and institutions’ by promoting a ‘privatized, depoliticized culture anchored in domesticity and consumption’ (Duggan, 2002).

Broadcaster and political commentator, Iain Dale, used his popular drive-time radio show to berate gay men for wanting PrEP on the NHS, and his tirade was extensively quoted by the Daily Express the following day:

Why should the taxpayer have to fork out £400-per-person to prescribe this drug. I imagine a lot of people will think Iain Dale’s a gay man, he must be in favour of prescribing this drug. But on what I’ve read about it, I’m certainly not at the moment. (Dale quoted in Beer, Daily Express, 2016)

Dale, a former Conservative candidate, criticized gay men for being irresponsible and ‘indulgent’ and called for more ‘personal responsibility’, stating that ‘I actually do believe in personal responsibility’ before pointing out that ‘if you want this drug it is available on private prescription, so pay for it yourself’ (Dale quoted in Beer, Daily Express, 2016). The theme of personal responsibility, which shaped arguments for PrEP prior to the court ruling, was thus co-opted by Dale in his criticism of the High Court judgment. However, where PrEP provision was previously promoted as offering gay men a new opportunity to become sexually responsible, here Dale argued that such responsibility meant that gay men should fund the treatment themselves.

Dale’s admonishment was echoed by political journalist and author Andrew Pierce a day later, who felt it necessary to identify himself as gay when he called upon gay men to pay for their sexual lifestyle out of their own pocket:

it’s time to exercise responsibility and not expect the State to keep picking up the bill for our sexual gratification, particularly if it means denying NHS treatment for the elderly and young. (Pierce, Daily Mail, 2016)

Lending further credence to Pinion’s (2015) claim of a ‘growing acceptance of gay marriage and of certain gays’ by mainstream culture, the comments of both Dale and Pierce were prioritized in reporting by the right-wing press. In both cases, and complicating the earlier discourse of personal responsibility, these figures argued that State provision of PreP would create promiscuous ‘Truvada whores’ who were not only in opposition to British society, but actually placed the health of the public at risk.

These diatribes from two prominent conservative gay male commentators helped legitimize the broader attack on PrEP funding being mounted by the reactionary press. And, echoing the beliefs of this arm of the media, both commentators validated the argument that PrEP itself was not the problem; rather it was access to PrEP that was the issue. In the light of the NHS commissioning decision, this focus is understandable, but it remains significant that gay male voices were heard in discussions of PrEP provision, rather than in discussions of PrEP itself. For the most part, the task of stoking fear about PrEP, promiscuity and increased STI transmissions was left to traditional conservative voices such as James Mildred of CARE, and Andrea Williams of Christian Concern. Meanwhile, gay commentators were deployed by the reactionary press to criticize the cost of making PrEP available on the NHS. In both instances, the argument put forward was that gay men can do whatever they like, so long as they pay for it themselves.

Cost/benefit?

While titles such as the Daily Mail, the Daily Express and the Daily Telegraph performed a U-turn in their attitude towards PrEP funding, progressive news outlets continued to support its provision, following the court ruling. However, the financial implications of PrEP were repeatedly reported by all newspapers and this bears further consideration. Where the reactionary press focused on the ‘zero-sum’ competition between different patient groups, articles in the liberal press routinely targeted their criticisms at the government for underfunding universal healthcare. Meanwhile, concerns over the cost of the treatment were primarily addressed via the language of cost-benefit analysis.

This is just a straightforward, everyday business decision for [NHS England]. They must make a decision on the clinical effectiveness, and the bean counters have to do it on the money. (Forster, The Independent, 2016).

PrEP would take up 0.2 per cent of the NHS’ budget, less than what is spent on aspirin.

(Eastman, The Independent, 2016)

The cost at the moment is around £400 a month, or £4,800 a year per person treated. The NAT and other Aids campaigners rightly argue that is low compared with the estimated average of £360,000 over a lifetime for treating somebody with HIV … In that context, PrEP looks very cost-effective. (Boseley, The Guardian, 2016)

One might convincingly argue that the story of PrEP in the summer of 2016 was a financial story and that it makes sense that defences of the court ruling focused on the NHS funding crisis. Yet this focus also (re)framed PrEP and, by extension, the health and well-being of gay men, as solely an issue of cost. By discussing PrEP purely in economic terms other epistemological frames were obscured, most notably the framing of PrEP as an intervention that addresses a 40-year-old health inequality affecting generations of gay men.

In June 2014, Public Health England (PHE) published a summary of its research into the health and well-being of gay men (and other MSM). In this summary, they specifically identified the health inequalities faced by this population:

Adult MSM are the group most affected by HIV in the UK – with an estimated 1 in 20 living with HIV in 2012, compared to 1 in 667 in the general population. MSM are also at greater risk of mental health problems and unhealthy behaviours and lifestyles. (Public Health England, 2014)

The report went on to state that ‘MSM bear a disproportionate burden of ill-health’ when it comes to sexual health (Public Health England, 2014). Given the fact that HIV/AIDS represents one of the most well-known health inequalities associated with gay men it is surprising that the liberal media did not frame the treatment as a solution to this historical imbalance, focusing instead on a cost-benefit analysis of the treatment. One might ask why the media struggled to formulate a response to the PrEP funding issue that took into account this health inequality. Surely publications such as the PHE review provide compelling evidence for funding PrEP? The answer to such a question is apparent in the criticism levelled at Owen Jones, the one journalist who did frame PrEP in relation to gay men’s health inequalities. Attacking Jones’ discussion of HIV as a ‘gay issue’, Paul Renteurs argued against such a framing:

Put simply, this is not a gay problem. And any success in the continuing fight against these diseases is not a victory for gay men. If we portray it that way, people with an axe to grind and little access to realistic information will keep framing HIV as a problem of lifestyle issues – rather than a public health crisis with the potential to affect everyone. (Renteurs, The Independent, 2016)

Renteurs misused data on HIV infections in order to support the argument that ‘you can call HIV a “gay issue” all you like – but the numbers just don’t back it up’. He criticized Owen Jones for politicizing HIV and making a direct link between gay men’s health and the virus, and sought to universalize HIV. While well meaning, this move revealed the liberal media’s resistance to seeing gay men as living with the effects of structural and social inequalities, which factor into the different health outcomes they face.

By obscuring the realities of HIV health inequalities, this arm of the British press subscribed to the same rhetoric of universal subjectivism that bell hooks (1992) critiqued in Eating the Other. This rhetoric suggests equality can only be reached through the disavowal of difference; a disavowal that includes ignoring the consequences of such differences. The limitations of such rhetoric in the context of PrEP should be patently obvious. By ignoring difference, we risk ignoring the health disparities that gay men face. By treating everyone ‘as if’ they were the same, we risk obscuring the needs of specific groups and privileging the needs, values and beliefs of the (white, male, heterosexual) majority.

Narratives of (homo)normativity

The liberty we have won is incomplete, conditional, and ultimately revocable. (Vaid, 1995: 3)

What does the reporting of PrEP in the UK reveal about the position of gay men in contemporary Britain? Arguably, the way the press responded to PrEP reveals the extent to which homonormativity underpins the UK’s growing acceptance of gay men, and frames the terms and conditions of that acceptance. To repeat my earlier statement, a politics of homonormativity recasts issues such as health as a personal problem, requiring personal responsibility and personal investment, while simultaneously promoting the idea that gay men are the same as the rest of the population – that we are all equal. This focus on responsibility and investment shaped the right-wing media response to the court ruling. The issue here was not that men were having sex with each other (as it perhaps was in the 1980s), but that they were asking the state to support their sexual ‘freedom’. Gay sex was permissible, so long as it was ‘privatized’ and did not rely on state intervention.

Of course, such an argument overlooks the fact that heterosexual people commonly rely on the state to ‘fund’ their ‘lifestyles’ and sexual practices. This includes the provision of birth control, erectile dysfunction medication and fertility-focused healthcare. As such, the discussion of PrEP in right-wing newspapers also reveals the heteronormative conditions upon which gay acceptance has been offered in the UK; conditions that are supported by a politics of homonormativity, which positions gay men as depoliticized sexual consumers rather than public sexual citizens. What the analysis of the right-wing press reveals is that some forms of same-sex desire have gained entrance into what Gayle Rubin (1994) refers to as the ‘charmed circle’ of sex, without disrupting the heteronormativity that continues to pervade the British mediascape. Thus homosexuality is tolerated so long as it does not demand recognition, call attention to itself or, heaven forbid, cost the ‘taxpayer’ anything.

This belief has long been supported by gay conservatives such as Andrew Sullivan (1996) and Bruce Bawer (1993), who have both made arguments regarding the responsibility that gay men must display – both in the face of AIDS and in relation to the general public. Both commentators have criticized ‘radical’ gay activism for creating ‘obstacles’ that limit assimilation and acceptance by the mainstream. For if, as Sullivan suggests, gay men are ‘virtually normal’, then they must act accordingly, drawing as little attention themselves as possible. We might think of this as the moral face of homonormativity, and that calls for PrEP to be funded run counter to this moral policing, bringing the ‘private’ matter of gay sex into public. This is antithetical to homonormative thinking, which seeks only to secure the rights it needs to go back home and live a happy, domesticated life. Seeking public funding for a drug that allows gay men to not only have sex, but to have condomless sex, with numerous men, jeopardizes the ‘happy ever after’ of homonormativity, and this is why conservative figures like Pierce and Dale criticized the High Court ruling.

Where the reactionary press utilized the conservative moralism of homonormativity, the liberal arm of the media drew on the individualizing discourse that underpins much homonormative thinking. This was evident in their repeated framing of the gay male individual as a ‘rational sexual actor’:

The neoliberal view constructs human actors as rational, adult, contract-making individuals in a free market of options. It does not account for the much more complex motivators and vulnerabilities, emotions and tough dilemmas faced by people in their everyday life. (Adam, 2005: 344)

While newspapers such The Guardian, The Independent and the Daily Mirror were far more supportive of state-funding, their framing of PrEP as an opportunity for individual gay men to become more responsible foreclosed any framing of HIV as a health inequality. This inequality has been created and compounded by the same ‘complex motivators and vulnerabilities’ that Adam alludes to in his study of bareback subculture, and the reification of gay men as responsible social actors does little to address these issues, while tacitly demonizing those who ‘fail’ to remain ‘rational’. Indeed, by focusing on gay men as individuals, rather than a diverse population, the notion that HIV is a collective health inequality became impossible to articulate. This inevitably made it harder to discuss the issues that gay men as a group continue to face; issues such as the (internalized) homophobia that many of us continue to grapple with.

It is within this context that we should understand the representation of gay individuals in the liberal press. When Owen Jones was criticized for suggesting that PrEP was a ‘gay issue’, he was being attacked for suggesting that HIV remains part of the broader reality of gay male life today. In effect, he was condemned for making PrEP a ‘gay issue’, as opposed to an ‘individual issue’. This is where we see opposing attitudes towards PrEP funding coalescing in the British media. This prioritizing of the individual played into the hands of those who argued that the treatment be privately funded by recipients of PrEP. By eschewing the idea of a gay ‘community’ in PrEP reporting, gay men’s health was (re)framed as a personal issue, which invariably made it vulnerable to the market rhetoric of neoliberalism and logic of homonormative thinking. Finally, focusing on the cost of PrEP in comparison to the cost of living with HIV, runs the risk of (re)stigmatizing HIV positive people, tacitly marking them as irresponsible and aberrant sexual actors, who were not ‘rational’ enough to make the right life ‘choices’.

Conclusion

The story of PrEP in the British press is ultimately a story about the position of gay men in British society today – particularly in English society. Homonormativity is not the only reason why PrEP caused such controversy in the summer of 2016. Indeed, while the UK’s decision to leave the EU (the referendum having taken place in June of the same year) was not directly mentioned in stories about PrEP, the ongoing disinvestment in the NHS, twinned with the hollow promises of Brexiteers (who claimed that withdrawal from the EU would see £350 million per week being directed to the National Health Service), were topics of public discussion at the time. Brexit certainly coloured the reporting of PrEP in that fateful year. At the same time, it is worth considering how other political movements – other political framings – came into play when discussing this treatment and its funding. My argument in this article is that a politics of homonormativity, allied as it is to a broader project of neoliberalism, and in support of the dominant heteronormative ideology, helped shape public understandings and attitudes towards PrEP.

An analysis of British press coverage reveals how PrEP, and by extension gay men’s health, was framed according to a politics of homonormativity; a politics that supports rather than challenges heteronormative thinking. This is why much of the reporting on PrEP – with its focus on privatization, personal responsibility and rational sexual actors – masked a crucial reality: that heteronormative thinking continues to play a key role in the health outcomes of LGBTQ people. As such, and whether reactionary or liberal, the coverage of PrEP illustrates the contingent position gay men occupy in British society today; a position that is based upon an adherence to the neoliberal principles of homonormativity, and which promotes consumption, individualism and privatization over collectivism and queer rebellion.

Footnotes

Sharif Mowlabocus has recently changed from Sussex and is now an Associate Professor in the Department of Communication and Media Studies at Fordham University, New York. His research is located at the intersection of LGBTQ studies and digital media studies. His current work examines the politics of homonormativity in the context of 21st century Britain.

References

Adam

(2005) Constructing the neoliberal sexual actor: Responsibility and care of the self in the discourse of barebackers. Culture, Health & Sexuality 7(4): 333–346.

Badshah N (2016) Pill to stop HIV will not get funding. The Times, 22 March, 4.

Bawer

(1993) A Place at the Table, New York: Poseidon.

Beer S (2016) ‘Use a condom or pay for it yourself’ presenter damns court ruling to fund HIV on NHS. Express Online, 3 August, n.p.

Boseley S (2012) US approves pill that guards against HIV: Truvada to be available to people at extreme risk; Aids support group labels move ‘completely reckless’. The Guardian, 17 July, 17.

Boseley S (2015) Daily pill Truvada cuts spread of HIV by 86%, study shows. The Guardian, 25 February, n.p.

Boseley S (2016) PrEP HIV drugs: Fight for limited NHS funds takes unedifying turn. The Guardian, 3 August, n.p.

Brown J (2014a) HIV drug may make ‘biggest dent yet’ in virus. The i, 17 October, 22.

Brown J (2014b) NHS to offer tablet which can reduce HIV risk by 90%. The Independent, 17 October, n.p.

10.

Connor S (2015) The logic of paying £500 a month so gay men don’t have to wear condoms. The Independent, 25 February, 4.

11.

Cooper C (2016) Government under pressure to overturn NHS’s ‘truly shocking’ decision not to fund revolutionary HIV drug Prep. The Independent, 1 June, n.p.

12.

Davies M (2014) ‘Wonder drug’ which can reduce HIV risk by 92% could be offered on the NHS. MailOnline, 17 October, n.p.

13.

Davies M (2016) Charities slam NHS England ‘U-turn’ over plans to roll out ‘HIV wonder drug’. MailOnline, 22 March, n.p.

14.

Dean

(2015) Mediated intimacies: Raw sex, Truvada, and the biopolitics of chemoprophylaxis. Sexualities 18(1–2): 224–246.

15.

Duggan

(2002) The new homonormativity: The sexual politics of neoliberalism. In: Castronovo

Nelson

(eds) Materializing Democracy: Toward a Revitalized Cultural Politics, London: Duke University Press, pp. 175–194.

16.

Eastman D (2016) I wrote this piece while getting chemotherapy, because people have started using cancer patients like me as a weapon against gay people. The Independent, 19 September, n.p.

17.

Entman

(1993) Framing: Toward clarification of a fractured paradigm. Journal of Communication 43(4): 51–58.

18.

Epstein

(2016) The politics of health mobilization in the United States: The promise and pitfalls of ‘disease constituencies’. Social Science & Medicine 165: 246–254.

19.

Ferrari N (2016) Nick Ferrari: Counting the cost of £20m HIV drug. Express Online, 7 August, n.p.

20.

Forster K (2016) Jeremy Hunt said ‘what will the Daily Mail say?’ when told about HIV prevention drug. The Independent, 2 September, n.p.

21.

Godfrey C (2015) Why we need PrEP: Four gay men share their views on the HIV prevention drug. The Independent, 4 August, 1.

22.

Gold D, Green I, Carlin E, et al. (2016) HIV breakthrough: Letters to the Editor. The Times, 28 May, 28.

23.

Gollust

Lantz

(2009) Communicating population health: Print news media coverage of type 2 diabetes. Social Science & Medicine 69: 1091–1098.

24.

Hallin

Brandt

Briggs

(2013) Biomedicalization and the public sphere: Newspaper coverage of health and medicine, 1960s–2000s. Social Science & Medicine 96: 121–128.

25.

Hong

(2013) The effects of human interest framing in television news coverage of medical advances. Health Communication 28(5): 452–460.

26.

hooks b (1992) Eating the Other. In: hooks b Black Looks: Race and Representation. Boston, MA: South End Press, pp. 21–39.

27.

Jaspal

Nerlich

(2016) Polarised press reporting about HIV prevention: Social representations of pre-exposure prophylaxis in the UK press. Health 21(5): 478–497.

28.

Kim

S-H

Willis

(2007) Talking about obesity: News framing of who is responsible for causing and fixing the problem. Journal of Health Communication 12(4): 359–376.

29.

Lawrence

(2000) The Politics of Force: Media and the Construction of Police Brutality, London: University of California Press.

30.

Lloyd P (2016) Legal threat prompts NHS to reconsider controversial decision not to prescribe ‘HIV wonder drug’. MailOnline, 19 April, n.p.

31.

Macaskill G (2016) Brexit blow to NHS budget. Sunday People, 3 July, 6–7.

32.

McLaughlin

Meng

, et al.(2016) Propagation of information about pre-exposure prophylaxis (PrEP) for HIV prevention through Twitter. Health Communication 31(8): 998–1007.

33.

Myers

Sepkowitz

(2013) A pill for HIV prevention: Deja vu all over again? Clinical Infectious Diseases 56(11): 1604–1612.

34.

NHS England (2016a) Update on commissioning and provision of Pre Exposure Prophylaxis (PREP) for HIV prevention. Available at: https://www.england.nhs.uk/2016/03/prep/ (accessed 15 June 2018).

35.

NHS England (2016b) August update on the commissioning and provision of Pre Exposure Prophylaxis (PREP) for HIV prevention. Available at: https://www.england.nhs.uk/2016/08/august-update-on-the-commissioning-and-provision-of-pre-exposure-prophylaxis-prep-for-hiv-prevention/ (accessed 14 June 2014).

36.

Nie

Gilbertson

de Roubaix

, et al.(2016) Healing without waging war: Beyond military metaphors in medicine and HIV cure research. The American Journal of Bioethics 16(10): 3–11.

37.

Owen

(2015) Patents, Pills, and the Press: The Rise and Fall of the Global HIV/AIDS Crisis in the News, New York: Peter Lang.

38.

Owen

(2018) Twenty-one years of HIV/AIDS medicines in the newspaper: Patents, protest, and philanthropy. Media, Culture & Society 40(1): 75–93.

39.

Parker

(2011) Grassroots activism, civil society mobilization, and the politics of the global HIV/AIDS epidemic. The Brown Journal of World Affairs 17(2): 21–37.

40.

Parry L (2016) Daily HIV prevention drugs ‘could reduce new cases of the disease by a THIRD over the next decade’. MailOnline, 14 July, n.p.

41.

Persson

Newman

(2008) Making monsters: Heterosexuality, crime and race in recent western media coverage of HIV. Sociology of Health & Illness 30(4): 632–646.

42.

Petersen

(2005) The metaphors of risk: Biotechnology in the news. Health, Risk & Society 7(3): 203–208.

43.

Pierce A (2016) Why I, as a gay man, think this is morally wrong. Daily Mail, 4 August, n.p.

44.

Pinion

(2015) Homonormativity and the National Fray. International Journal of Political Science and Development 3(1): 1–14.

45.

Public Health England (2014) Promoting the health and wellbeing of gay, bisexual and other men who have sex with men: initial findings. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/339041/MSM_Initial_Findings__GW2014194.pdf (accessed 15 June 2018).

46.

Race

(2016) Reluctant objects: Sexual pleasure as a problem for HIV biomedical prevention. GLQ: A Journal of Lesbian and Gay Studies 22(1): 1–31.

47.

Renteurs P (2016) Why Owen Jones and others aren’t helping when they call PrEP and HIV a ‘gay lives matter’ issue. The Independent, 4 August, n.p.

48.

Robinson

(2011) Gay Men and the Left in Post-war Britain: How the Personal Got Political, Manchester: Manchester University Press.

49.

Robinson M (2016) NHS fights back against ruling forcing it to hand out ‘promiscuity pill’ that prevents HIV as the £20m cost will hit its ability to treat cancer and give limbs to amputees. MailOnline, 2 August, n.p.

50.

Rubin

(1994) Thinking Sex; notes for a radical theory of the politics of sexuality. In: Abelove

Barale

Halperin

(eds) The Lesbian and Gay Studies Reader, New York: Routledge, pp. 3–44.

51.

Schwartz

Grimm

(2017) PrEP on Twitter: Information, barriers, and stigma. Health Communication 32(4): 509–516.

52.

Slawson N (2016) NHS England stalls plans for HIV prevention drug. The Guardian, 22 March, n.p.

53.

Smith

Whiteside

(2010) The history of AIDS exceptionalism. Journal of the International AIDS Society 13(1): 47.

54.

Smithson K (2016) This drug could halt HIV – so why has the NHS decided to turn its back on it? The Independent, 3 June, n.p.

55.

Smythe C (2014) Coming soon: The daily pill that can protect against HIV. The Times, 17 October, 27.

56.

Spencer B and Borland S (2016) How the blameless sick are paying price of this HIV drug. Daily Mail, 4 August, n.p.

57.

Spieldenner

(2016) PrEP whores and HIV prevention: The queer communication of HIV pre-exposure prophylaxis (PrEP). Journal of Homosexuality 63(12): 1685–1697.

58.

Stone

(1989) Causal stories and the formation of policy agendas. Political Science Quarterly 104(2): 281–300.

59.

Stoppard M (2014) Revolution that could halt epidemic of HIV. Daily Mirror, 8 September, 32.

60.

Stoppard M (2016) Giving healthy gay men HIV drugs could ‘help reverse epidemic’. Daily Mirror, 8 February, 26.

61.

Sullivan

(1996) Virtually Normal: An Argument about Homosexuality, London: Vintage.

62.

Vaid

(1995) Virtual Equality: The Mainstreaming of Gay and Lesbian Liberation, London: Anchor Books.