Amid a global pandemic that has been the foreground of thought and development in medicine the past two years, another epidemic has been lingering for decades: HIV and AIDS were first recorded in the early 1980s, and their presence has grown exponentially over the last 40 years. In that time, HIV has fostered significant innovations and advancements across various fields including pharmaceuticals, access to care, public health education, and legislation, yet the U.S. still can’t seem to get control on the HIV epidemic.
Factors such as continued education around disease transmission and safe sex have been vital to reducing infection over the years, but in 2019, the government took steps to increase access to the daily HIV pill known as pre-exposure prophylaxis, or PrEP.
Because PrEP is so highly effective—appropriate use reduces the risk of getting HIV from sex by 99% and from injection drug use by 74%—the United States Preventative Services Task Force (USPSTF) gave PrEP an “A” rating, stating that clinicians should offer PrEP with effective antiretroviral therapy to people who are at high risk of contracting HIV. This rating also led the Affordable Care Act to require all non-grandfathered health care plans to provide coverage for PrEP as well as baseline and monitoring services with no out-of-pocket costs for the beneficiary. These plans are also not allowed to restrict the frequency of monitoring services or limit coverage of products specified in the USPSTF recommendation.
However, while these efforts have made a meaningful difference in the lives of many people, they only make an impact on those with insurance. In fact, less than 25% of people who could benefit from PrEP actually take the medication, which begs the question: What else will it take to end the HIV epidemic?
Identifying the Gaps
As with many other health crises impacting the U.S., HIV disproportionately affects underserved populations across the country. For years the most affected populations have been people of Black/African American descent (incidence in 2019: 14,300) and Hispanic/Latin American descent (incidence in 2019: 10,200). It would make sense to take an aggressive approach of prevention and treatment in these populations, yet in 2019 Caucasians accounted for 59.5% of PrEP coverage, followed by Hispanic/Latin Americans at 13.5%, other races at 8.7%, and Black/African Americans at 7.8%.
To be fair, the CDC has made some attempts to reduce the burden of disease among populations that are disproportionally impacted by HIV. Its three-year, $125 million Project PrIDE (PrEP Implementation, Data to Care, and Evaluation) effort allocated a significant portion of funds to support local program processes and outcome evaluations and highlighted the importance of health equity in efforts of HIV prevention. However, there’s so much more that needs to be done. Addressing the legal requirements around PrEP coverage alongside approaches in care through the scope of health equity will make a significant impact toward ending the epidemic.
Ensuring Equitable Access
Creating equitable access to care is not without its challenges. Since its approval, PrEP has been distributed primarily through clinics. This type of delivery makes sense when you account for all of the routine monitoring and testing that comes along with taking PrEP, but similar to other health resources, inequity of access to clinics relative to PrEP-eligible candidates became evident. PrEP and HIV clinics should be developed to address barriers to health with the highest-risk individuals and populations in mind.
The good news is that COVID-19 has forced changes in health delivery that will garner lasting positive effects, including telehealth, home delivery, same-day PrEP initiation, express visits for PrEP, and utilizing other healthcare professionals in addition to doctors. These changes were expedited due to the pandemic, but they’ve made a long-lasting impact when it comes to easing access and meeting community needs.
All of these positive adjustments are the work of health departments, state and local insurance regulators, and legislators redirecting assistance to services, and hopefully this is just the beginning when it comes to new support services for people with HIV and AIDS. Improving access to highly effective tools such as PrEP not only depends on the development of these programs and initiatives, but also the resources and support of the entire healthcare system.