It’s easy to look at a medication like PrEP, and everything that it’s done in the last 10 years, and breathe a sigh of relief. Maybe even celebrate. And of course, we should. The numbers are encouraging, the stories heartening.
So let’s take a moment to celebrate. But let’s take a few more to see what we could’ve done better as an industry, as a community – and what we’ll do better moving into the next ten years.
First, for the uninitiated, what is PrEP? It’s one pill, once a day, that, when taken correctly, stops HIV from infecting the cells in your body. This keeps a constant level of the medication in the body, preventing HIV from taking hold if you’re exposed. But the biggest headline about PrEP is that it reduces your risk of contracting HIV through sex by 99%, and through IV drug use by at least 74%. A drug like PrEP was unimaginable at the dawn of the epidemic. So let’s go back to the beginning.
Over 700,000 Americans have lost their lives to HIV since the epidemic began in 1981, while more than 1.1 million Americans are currently living with HIV. The risk of exposure remains high for many, and the government still spends $20 billion a year on HIV prevention and care.
PrEP was an almost immediate turning point after being approved by the FDA in 2012. Just 3 years after being introduced, the CDC estimates that new HIV infections fell from 37,800 in 2015, to 34,800 in 2019. Unfortunately, that reduction in new infections has plateaued, and without intervention, nearly 400,000 more Americans will be newly diagnosed over 10 years, despite the availability of tools, like PrEP, to prevent transmissions.
So, this plateau makes it clear that HIV comes with a host of symptoms that are not medical. Symptoms PrEP doesn’t address and can’t address. Those are societal. And as we look back, it’s those symptoms that present the largest challenges to furthering and expanding the success of PrEP in the real world.
How do we address them? What’s the “prescription” here? Time to, as they say, take our medicine. But before we do, let’s talk about one thing. The resurgence of HIV, and how this happened.
An increase in injection drug use. Minority groups have far less access to HIV prevention testing and treatment.
Maybe the most concerning trend, because it either causes or colors all the other issues, is that there’s a mistaken and widespread assumption that HIV is no longer a problem. Yes, more immediate, more pressing events and trends have emerged over the past decade, the past few years – sometimes it feels like every day – that have eclipsed HIV in the news cycle, in conversation, and so in our collective consciousness. The impact of COVID-19-related disruptions in HIV prevention services is not yet known, but it’s safe to say that the media attention COVID-19 has received has severely impacted Americans’ awareness of the continuing severity of the HIV epidemic.
As a result, HIV prevention testing and treatment are no longer priorities outside of the medical community.
In 2020, for example, fewer than a quarter of the 1.2 million people who could benefit from PrEP received it. And the overwhelming majority of the new HIV infections in the US just 6 years ago were transmitted by people who didn’t know they had HIV, or who did know, but weren’t receiving proper care.
So why is this?
Almost all new infections are very highly concentrated among men who have sex with men in minority groups, especially African Americans, Hispanics, American Indians, Alaska Natives and those who live in the Southern United States. These are communities where homosexuality and related lifestyles are historically – and currently – not as accepted as elsewhere. So they’re not talked about, and so not acted upon by people for fear of revealing their lifestyle. Add this to the damage done by the disturbing rise in, and an emboldening of, homophobia and transphobia in the United States.
This trend disproportionately affects black and Latinx populations – only 9% of the nearly 500,000 black people who could benefit from PrEP received a prescription in 2020, and only 16% of the nearly 313,000 Hispanic and Latinx people who could benefit from PrEP received the prescription. Again, due in large part to stigma and limited awareness or willingness to address one’s risk or status.
Still other factors include the perception among minority groups that PrEP is not for them, and so they can’t make use of it. Whether it’s not seeing themselves in commercials for PrEP, or belonging to a group not included in research, they feel disqualified from being consumers in the market.
And of course current, harsh economic realities play a role. They’re a major roadblock for people getting the drug and properly, effectively using it.
Between 2025 and 2029, nearly 1 in 5 people with a new PrEP prescription delayed or never filled it. And “… among the people who weren’t picking up, there was about a three times higher risk of HIV,” says social epidemiologist Lorraine Dean, ScD, an associate professor in Epidemiology.
When PrEP cost $10 per month, the rate doubled at which prescriptions were repeatedly delayed or unfilled. The required lab tests – 4 per year – also cost money and lab facilities aren’t easy for everyone to get to.
Finally, the opioid epidemic has led to a meteoric rise in injection drug use over the past decade, and with that rise comes a leap in the numbers of new cases of HIV.
What does this look like moving into the next 10 years? There are so many reasons to be optimistic.
The Biden administration has earmarked $9.8 million in funding over the next 10 years for a national PrEP program – and this money will be used to do three things. First, those who are uninsured and underinsured will be eligible to receive PrEP at no cost. Next, these funds will help Medicaid recipients with increased access to the drug. Finally – to address the previously-mentioned flaws in the rollout and marketing of the drug over the last ten years – the administration will establish a network of community providers to expand access to PrEP in underserved areas.
Telehealth visits have gone mainstream in the past few years. This makes appointments with healthcare providers more accessible to those who didn’t have the time or the transportation to get to in-person visits as often as they’d like or need.
PrEP’s relatively new “A” rating from the U.S. Preventive Services Task Force in 2019 means private insurers must cover PrEP and PrEP care services without copays or deductibles. The U.S. Department of Health and Human Services also launched the Ready, Set, PrEP program that year, which makes PrEP medication available at no cost to people without insurance drug coverage, regardless of income.
The CDC’s Ending the HIV Epidemic in the U.S. (EHE) initiative, which seeks to reduce new HIV infections in the US by 75% by 2025 and by 90% by 2030, has identified 57 priority areas or jurisdictions that have the greatest need for federal HIV assistance.This includes seven states, 48 counties, Washington DC, and San Juan, Puerto Rico, where more than half of new HIV diagnoses occurred in 2016 and 2017. The Center hopes to implement nationwide intensive case management to maintain the number of new infections at fewer than 3,000 per year.
A sweeping, interagency coalition, made up of the CDC, the Centers for Medicare and Medicaid Services (CMS), the Departments of Labor, Health and Human Services, and the Treasury Department have coordinated to clarify that nearly all commercial health plans, and many public insurance plans, must cover patient costs related to PrEP medication, as well as associated clinic visits and laboratory tests with no out of pocket cost to patients.
This refocusing on the federal level, the money and attention that brings, and the drive to open up access to more people, all inspire hope.
And hope does wonders for our health. This is where r
enegade.health and PrEP for Better come in.
Equitable access for all begins with visibility on that access. We work to make marginalized or overlooked groups understand that, yes, PrEP is for them and yes, it is readily available.
At Renegade we believe that in addition to making effective test kits and timely, accurate results available to everyone, there are there’s a great need at the grassroots level, to get the word out to groups that feel – and very much are – marginalized.
The scientists and experts at Renegade.health are focused on providing the best service, partnership, insights, and science to patients and the HCP community. We pride ourselves on our people-first approach and on sharing our knowledge and insights to transform our industry and those it serves.
- At the end of these next ten years, when we look back, our hope at Renegade is this.
- That we’ll be talking about much smaller numbers.
- We’ll be talking about much larger gains.
- And we won’t be talking about the shortcomings of universal access at all.