It is possible to end HIV in the United States within the next decade - lawmakers must make it a reality

by Carl Schmid | HIV+Hepatitis Policy Institute
Thursday, 1 June 2023 05:00 GMT

AIDS patient receives his daily dose of medication at Broadway House for Continuing care, New Jersey's only specialized nursing facility for people living with HIV/AIDS in Newark, New Jersey May 9, 2012. REUTERS/Mike Segar

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* Any views expressed in this opinion piece are those of the author and not of Thomson Reuters Foundation.

While the end of HIV transmission in the U.S. is in sight, lawmakers need to take account of the disparities in the accessibility of PrEP

Carl Schmid is executive director of the HIV+Hepatitis Policy Institute, which promotes high-quality, affordable healthcare for people living with or at risk of HIV, hepatitis, and other serious and chronic health conditions

On World AIDS Day, December 1, last year, U.S. President Joe Biden recommitted to the ambitious goal of ending the HIV epidemic by 2030.

Key to reaching that target is a 75% reduction in new HIV infections by 2025 and at least a 90% reduction by 2030.

However, there are nearly 40,000 people diagnosed with HIV in the United States annually. To meet the target, we need to reduce cumulative diagnoses by 250,000 through 2030. With the right policies and programs, it is not an exaggeration to say that ending HIV is within reach.

Any successful effort to lower new infections has to include wider use of pre-exposure prophylaxis, or PrEP – a daily pill or bimonthly injection that prevents HIV infection. PrEP reduces the risk of getting HIV via sex by roughly 99% and via injection drug use by 74%.

Less than one-third of 1.2 million eligible Americans are on PrEP, far below the U.S. government's Ending the HIV Epidemic initiative's goal of 50% uptake by 2025.

We could address this shortcoming with a national PrEP program, aimed towards educating the public about the benefits of the drug and support necessary training for providers. Such a program could also increase uptake among the uninsured by covering medications and required ancillary services.

When designing a national PrEP program, policymakers must recognize that the burdens of HIV do not fall on all communities evenly. Meeting the 50% usage goal is critical, but we must do so with an eye toward addressing existing inequities.

PrEP usage varies widely by race and ethnicity. Nearly 80% of eligible white people were prescribed PrEP in 2021, compared with only 11% and 20% of Black and Hispanic communities, respectively.

These disparities are especially concerning because minority communities bear a disproportionate disease burden. Black people account for 42% of HIV diagnoses but just 14% of PrEP users. Hispanic people represent 27% of HIV diagnoses while making up only 17% of PrEP users.

Racial and ethnic disparities are often intertwined with other social determinants of health. A patient's insurance status is also a powerful predictor of whether they use PrEP.

For instance, while 55% of the PrEP-eligible population have private insurance, nearly half of PrEP users today are privately insured. Uninsured patients, by contrast, are underrepresented among PrEP users.

Two in 10 people who could benefit from PrEP – an estimated 242,000 people – lack insurance coverage, but just 6% of current PrEP users are among the uninsured.

The federal government is currently carrying out a limited set of PrEP programs. Under the former administration of President Donald Trump, community health centers began receiving grant funding to conduct PrEP activities.

Three hundred and two centers have since received funding, providing PrEP to 52,477 people in the first two years of the program.  

Our model builds on this success by scaling up the number of PrEP sites receiving grants to 2,730 clinics, including those that receive Ryan White HIV/AIDS Program funding, which offers HIV care, support, and education to low-income individuals, but are currently unable to provide PrEP services.

President Biden recognizes the pressing need to increase PrEP uptake. In his recent budget, he requested $9.7 billion in new mandatory spending over 10 years to fund a national PrEP program.

However, we believe congressional authorization for a new government program is unlikely in the near term, given the program's price tag and its reliance on a centralized mechanism for purchasing drugs and laboratory services.

A more realistic approach, given these constraints, is for Congress to increase funding at the CDC along with targeted grants to community health centers and Ryan White Program clinics, particularly those that can most effectively increase PrEP uptake among Blacks and Latinos and in the South.

It's possible to end HIV in the United States within the next decade. Lawmakers must act to make it a reality.

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