Editor’s Note: This post by Maeleigh Tidd is the second in our Pharmaceutical Inequalities series. She explores the recent Ending the HIV Epidemic Initiative in the US, with a particular focus on prevention strategies, specifically PrEP, that are being implemented to assist in ending the epidemic. The Pharmaceutical Inequalities series is funded by the Holtz Center and the Evjue Foundation.
Although the most recent pandemic continues to hold the spotlight of discussion, the HIV epidemic remains a national public health crisis. Fortunately, the rapid response from our exceptional scientist and researchers during the COVID-19 breakout has paved the road for next steps in ending the HIV epidemic.
Just prior to the spread of the coronavirus in the U.S., the United States Department of Health and Human Services (HHS) announced the American plan to ending the HIV epidemic (Ending the HIV Epidemic Initiative, EHE). The EHE aims to reduce new HIV infections by 75% by 2025 with the targeted goal of ending the epidemic by 2030.
The EHE initiative is focusing on four key strategies that together can end the epidemic:
Diagnose people with HIV as early as possible
Treat people with HIV rapidly and effectively to reach sustained viral suppression
Prevent new HIV transmissions by using proven interventions, including PrEP and sterile syringe programs
Respond quickly to potential HIV outbreaks with need prevention and treatment services to those who need them
However, to meet the goals of the initiative, these resources being deployed MUST be sourced to the communities and populations most affected by HIV. In fact, HHS Secretary Alex Azar acknowledges this, as he states: “Not everyone is benefiting equally from these advances [in HIV prevention and treatment tools]”.
For this post, the focus will be on prevention strategies, specifically PrEP, that are being implemented to assist in ending the epidemic. However, the other strategies will be acknowledged in post(s) to come.
Image from AID Upstate
PrEP, or pre-exposure prophylaxis, is a medication that was first approved in 2012 for the use of preventing the transmission of HIV among HIV-at-risk individuals. Currently there are two FDA-approved PrEP treatment options, a once-daily pill (i.e., Truvada with a generic option and Descovy) and an injectable (i.e., Apretude). Yet, despite PrEPs options and their clinically proven effectiveness, PrEP use remains low. The HHS/CDC estimates there to be more than 1 million individuals in the U.S. at risk of contracting HIV that could benefit from the use of PrEP, however, less than 25% of these individuals are being prescribed it. There are many underlying barriers for individuals seeking PrEP including access and affordability, and the apparent disparities and inequalities involved.
PrEP has been available for a decade, yet physically locating a PrEP-provider for a prescription continues to be a prominent hurdle. As of 2020, there were only about 2,000 identified PrEP-providing clinics in the U.S., where 86% of the U.S. states had less than one clinic per 100,000 persons in the population. Although any licensed-to-prescribe healthcare physician can prescribe an individual PrEP, without identifying as a PrEP-provider, many are not – partially due to a lack of education on PrEP and its benefits but also due to the stigma and misconceived perceptions about PrEP and its influence on risky behaviors.
Image from the Centers for Disease Control and Prevention
Despite provider density disparities, the increasing trend of PrEP prescribing should not go unrecognized (even before the launch of the EHE). Since 2015, PrEP prescribing has increased by 20%. However, there are apparent racial and ethnic disparities involved in the prescribing of PrEP. In 2020, only 20% of African American and Latino individuals accounted for PrEP prescriptions in the U.S., yet they make up over 70% of the new HIV diagnosis annually. Studies have assessed awareness, willingness to use, and the use of PrEP among men who have sex with men (MSM) to explore potential underlying disparities in PrEP. Yet, as demonstrated by Sullivan et.al. in the below figure, percentages of non-Hispanic white MSM and other racial/ethnic MSM are similarly aware of PrEP. Yet, despite racial/ethnic MSM being more willing to use PrEP, non-Hispanic white MSM are more likely prescribed it. There is a notable inequity in preventative care.
Image from the National Institute for Drug Abuse
Additional pharmaceutical disparities involved in the provision of PrEP include the cost of PrEP therapy. Prior to insurance coverage (and the launch of the EHE), a prescription alone for PrEP would cost roughly $1,800 for a 30-day-supply. Furthermore, prescriptions and prescription refills require extensive laboratory testing (i.e., HIV testing, HEP-B & C, STD, and renal/kidney screenings), that adds to the cost of therapy that are often not covered by insurances. The cost of PrEP poses a potential threat to the use among key populations that could benefit from it; Black, Latinx, and transgender individuals are disproportionately uninsured, which could explain part of why these individuals are not being prescribed PrEP equally to their counterparts.
Fortunately, the EHE has begun to address some of these disparities and inequalities in PrEP/HIV prevention. Specifically, the initiative has eliminated the barrier of cost to PrEP through the Ready, Set, PrEP program, providing PrEP medications at no cost to thousands annually. Additionally, this month (March 2022), the Biden-Harris Administration announced that the 2023 budget will invest 9.8 billion dollars over 10 years for the PrEP for All program, expanding access to and funding for PrEP (pills and injectable) – including required labs (which was not included in Ready, Set, PrEP).
Additional actions involved in the EHE initiative to reduce inequities in HIV prevention include implementing innovative and culturally responsive interventions and programs that increases PrEPs access among and in Black/African American and Hispanic/Latinx communities. The Division of HIV Prevention at the Centers for Disease Control and Prevention states:
EHE is working to address these disparities and achieve health equity through a comprehensive approach that focuses on providing resources where they are needed the most, and meeting people where they are with the services they need. This includes acknowledging the root causes that contribute to these disparities, such as poverty, unequal access to health care, limited education and employment opportunities, stigma, and systemic racism and homophobia, and working to implement policies, practices, and programs that help overcome these obstacles.
The future of PrEP is promising, as long as eliminating inequalities and disparities associated with the provisions of PrEP continue to be forefront.
Feature image: King County Department of Public Health