December 1 marks World AIDS Day. This day is an opportunity not only to support and advocate for the more than 1.2 million people who are currently living with HIV and AIDS in the United States, but also to spotlight the need for preventing new HIV infections. There have been approximately 50,000 new HIV infections each year in the United States over the last ten years. Gay, bisexual, and other men who have sex with men (MSM) are most severely affected by HIV and have increasing incidence of new infections. They represent less than 2% of the U.S. population but account for about two-thirds of new HIV infections annually. Among this group, Black men and young people are at disproportionate risk for HIV infection.
Pre-exposure prophylaxis (PrEP) among individuals at high risk for HIV infection has the potential to substantially reduce the number of new infections. PrEP, sold under the brand name Truvada, is a pill taken daily to prevent HIV infection in individuals who do not have HIV. Studies show that with high medication adherence PrEP reduces new HIV infections by 92% in MSM. In stunning results released in September, a study at Kaiser Permanente in San Francisco found no new HIV infections among more than 600 high-risk individuals taking PrEP over a period of 2.5 years.
PrEP, however, only works if people know about it, have access to it, and take it as prescribed. While awareness of PrEP is increasing, only a fraction of individuals at high risk for HIV are currently taking PrEP. A recent report estimated that 25 percent of sexually active MSM are at substantial risk for HIV infection and should be counseled about PrEP. Even in cities like San Francisco and New York that spearheaded efforts to raise awareness and knowledge about PrEP among individuals at risk for HIV infection, just 15% of MSM are taking PrEP. It is crucial that other cities and states launch programs to inform people about PrEP and address stigma related to PrEP use.
Healthcare providers, who play a central role in increasing awareness and uptake of PrEP, need more education about PrEP. Although the Food and Drug Administration approved Truvada for PrEP in 2012 and the Centers of Disease Control and Prevention first published guidance concerning PrEP that same year, a recent nationwide survey found that one-third of healthcare providers have not heard about PrEP. Among those providers with some awareness of PrEP, many may be uncomfortable prescribing it.
There are also practical barriers to getting PrEP to everyone who could benefit from it. Truvada costs about $1300 per month without insurance, and insurance co-payments and deductibles can make it difficult for many people with insurance to afford PrEP. Gilead Sciences Inc., the manufacturer of PrEP, offers medications through a patient assistance program to low-income people without insurance and co-payment assistance regardless of income, but additional funding from service agencies is needed to cover the cost of PrEP.
Federal and state agencies should adopt programs providing financial assistance for PrEP. In April 2014, the Washington State Department of Health started the first state-funded drug assistance program for PrEP in the United States. The PrEP Drug Assistance Program, or PrEP-DAP, pays the entire cost of PrEP for uninsured people and covers co-payments and deductibles for those who do have insurance. The National HIV/AIDS Strategy, as updated in 2015 to guide the national response to HIV/AIDS through 2020, calls for the scale-up of the delivery of PrEP and other highly effective prevention services to reduce new HIV infections. On this World AIDS Day, we must commit ourselves to addressing the prevention needs of gay and bisexual men and other MSM who continue to face alarming rates of HIV infection. To do this, we must increase awareness of and access to PrEP.
The views reflected in this expert column are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.