On December 3, 2016, I presented at the opening plenary session of the National HIV PrEP Summit in San Francisco. At the summit, NMAC released a State of the State report that Jeffrey S. Crowley and I prepared as the first part of a two-part Blueprint for HIV Biomedical Prevention. The State of the State report provides an overview of policies and programs that are critical to effective biomedical HIV prevention in communities of color. The report highlights current health department and community efforts to implement the new science in the United States. It also includes descriptions of the roles played by selected federal agencies in supporting biomedical HIV prevention and identifies some of their key recent initiatives.
Biomedical HIV prevention strategies offer a range of tools that can effectively prevent HIV infection. These tools include treatment as prevention (TasP), pre-exposure prophylaxis (PrEP), and post-exposure prophylaxis (PEP). TasP involves providing early and sustained HIV treatment to HIV-infected people that first and foremost treats their HIV infection for their own health, but is also a very powerful tool for preventing HIV transmission to others. PrEP involves giving high-risk HIV negative individuals a reduced dosing of HIV medication (currently in a daily pill) and other services to prevent HIV infection. PEP involves providing persons who may have had a very recent exposure to HIV a short course of treatment (usually around a month) to prevent them from becoming infected.
As the report notes, to increase the effectiveness of HIV prevention tools in communities of color, it is important that community members know about these tools, find them acceptable, want to use them, and have access to them. It is also important to have medical providers who are knowledgeable and up-to-date about the latest research around all forms of biomedical prevention and who are willing and equipped to engage in honest conversations about sexual and other intimate behaviors, treat people with HIV, and prescribe both PEP and PrEP.
Building on our work on the report, we are focusing on critical policy issues that impact access to PrEP for young people. Ensuring that young people benefit from PrEP is critical to reducing disproportionately high rates of HIV in communities of color. Even as HIV infection rates declined nationally over the last decade, rates have increased among young gay and bisexual men of all races and ethnicities. HIV infection rates have increased most rapidly among young Black and Latino gay and bisexual men.
Young people face numerous barriers to accessing PrEP. Adults are able to consent to PrEP, but adolescents often cannot. In most states, PrEP is not available to adolescents without parental consent. Parental consent requirements can be a barrier because adolescents may not have disclosed their sexual behaviors to their parents or may fear the repercussions of disclosure.
Limited payment options are another barrier for both adolescents and young adults. Truvada, the only FDA-approved PrEP medication, is indicated for adult use only. This can make it more difficult for adolescents to access and use insurance or patient assistance programs to pay for Truvada as PrEP. Moreover, adolescents and young adults often access health care through their parent’s health insurance, which raises questions about confidentiality if insurance companies mail explanation of benefits forms or other documents to their parents.
The O’Neill Institute is committed to advancing the policy dialogue on PrEP. With support from amfAR, we have established a new project to explore how to support uptake of effective HIV prevention and treatment modalities for adolescents and young adults.