Hitch HIV prevention to a rolling wagon
HIV is making a comeback, threatening to infect minority communities en masse. But our nation has yet to mount an adequate response. If our incoming congressional representatives want to truly deliver on their social justice promises, they need to prioritize this issue in 2019. A practical way to do so is to collaborate with other initiatives that are already receiving widespread media attention and bipartisan support.
While HIV infection rates have stabilized among some groups, CDC data show that certain demographics are experiencing dramatic increases in viral incidence. This is particularly true for Black and Latino men who have sex with men (MSM). Without corrective action, it is projected that 1 of every six MSM will get HIV, a lifelong illness requiring expensive treatment for the duration.
These devastating infections need not occur. There exists a highly efficacious and cost-effective pill that at-risk individuals can take to avoid contracting the virus. The pill is called Truvada, or PrEP for Pre-Exposure Prophylaxis. PrEP is over 90 percent effective at preventing HIV — up to 99 percent if taken exactly as prescribed.
It is estimated that 1.1 million people would benefit from PrEP, either because they are MSM, have a partner who is HIV positive, or use intravenous drugs. But awareness among patients, providers, and politicians is extremely low. And the gap between those who need prophylaxis and those who receive it has remained far too large for far too long.
Since its FDA approval in 2012, only 150,000 people have gotten a PrEP prescription. White men on the West Coast constitute a large portion of these recipients, even though minorities living in the Southeast are at greatest risk. In 2015, only 1/3rd of local health departments had engaged in PrEP promotion, and a small fraction of the uninvolved departments expressed plans to become PrEP promoters by 2019.
There are obvious obstacles to achieving widespread prophylaxis: stigma, cost, coverage, awareness, uptake, adherence, and retention, among others. But these are the same barriers we have faced and successfully overcome for other public health problems. In fact, many of the challenges and opportunities associated with PrEP initiatives are like those of medication-assisted treatment (MAT) programs for opiate addiction.
One striking similarity between PrEP and MAT is the need to address fundamental elements of our psychology when designing outreach campaigns. It’s been shown that we humans are bad at estimating risk, and calculating our probability of contracting HIV is no exception; in a 2018 AIDS Care survey, only 17 percent of PrEP-eligible women recognized their increased odds of HIV exposure.
Moreover, humans tend to exhibit a strong present bias. This is part of why we have difficulty contemplating the possibility of future illness and why we don’t invest present time or energy in preventive care, such as PrEP. In the case of opiate addiction, seeking MAT is neglected because the disease impairs one’s ability to recognize the need for self-care.
PrEP and MAT initiatives also have overlapping target populations, which are disproportionately represented in our criminal justice system. According to a recent JAMA publication, about 40 percent of heroin users had been involved with the criminal justice system within the past year. Meanwhile, a study in the American Journal of Public Health revealed that we incarcerate gay and bisexual men at a rate nearly three times that of the overall adult population.
While these statistics are unfortunate, they do suggest that PrEP could hitch a ride on the bi-partisan, multi-sector bandwagon already rolling in support of MAT and other opioid endeavors. With their collaborative momentum, PrEP and MAT programs could foster public health synergy by recognizing prisons as critical intervention points.
Offering PrEP and MAT to eligible inmates is just one approach our leaders could embrace to curtail the spread of HIV while simultaneously lowering drug overdose deaths.
Multiple analyses have demonstrated that this pill form of prevention is markedly cheaper than treating the disease. So, perhaps the biggest hurdle we are facing is a lack of political will.
I am hopeful, however, that as our newly elected officials take office in January, they will leverage the unifying force of public health to launch PrEP programs around the country, focusing on areas of greatest need.
Americans do not want to re-live the HIV/AIDS epidemic. We want increased prevention, broader health equity, and enhanced social justice.
Maggie Salinger has a Master’s in Public Policy from Harvard Kennedy School of Government and a Medical Degree from Emory University. She previously served as a Dukakis fellow in the office of Governor Gina Raimondo to design a comprehensive, statewide strategy for addressing the opioid epidemic.