Public health's social contract: An obstacle in the advancement of effective HIV technologies

Evidence from the past 40 years of HIV technology development and implementation indicates that the public health social contract - with its expectations of patient/citizen compliance - has hampered global disease control efforts. Despite the availability of a wide array of effective technologies, including antiretroviral drugs as treatment and prevention, voluntary medical male circumcision procedures, and newly developed intravaginal ring products, new infections among adults globally have not decreased significantly. In this paper, I describe a historical trend of limiting access to effective biomedical technologies to those deemed most deserving and compliant given concerns of misuse (non-adherence), product repurposing (not using the product for purposes originally intended), and the incitement of autonomy (increasing the risk of public exposure to diseases given personal protection from a specific disease). Examining the expectations of good citizenship (compliance, adherence, appropriate product use, and continued risk reduction) as it relates to human-technology interactions, reveals a continuing narrative of initially restricting access to newer technologies perceived fragile or costly based on an assessment of patient/citizen worth. In this, the conventional public health social contract continues to be an obstacle in the advancements of technologies to effectively reduce the global burden of HIV.