PrEP for a Healthy Life
Much has changed in the treatment and management of Human Immunodeficiency Virus (HIV) over the last 40 years. In fact, between 2015 and 2019, new HIV diagnoses in the United States actually declined by around nine percent: by 2019, approximately 1.2 million individuals 13 years or older were living with HIV, with about 38,000 newly diagnosed cases.
A cornerstone to HIV management and prevention over the past decade has been advances made in pre-exposure prophylaxis (PrEP) medications. Yet in spite of the benefits, awareness of PrEP medications has remained low, and lack of awareness disproportionately affects individuals of color.
In 2012, the US Food and Drug Administration (FDA) approved Truvada (emtricitabine/tenofovir disoproxil fumarate) for HIV pre-exposure prophylaxis to reduce sexually-acquired HIV-1 infection in at-risk adults, in combination with safer sex practices. Later, in 2018, the FDA extended the use of Truvada for PrEP in adolescents weighing at least 35 kilograms (77 pounds). The FDA approved a second medication regimen, Descovy (emtricitabine/tenofovir alafenamide), in late 2019 for use in at-risk adults and adolescents weighing at least 35kg.
PrEP has proven beneficial for those who test negative for HIV; have had anal or vaginal sex in the past six months; and: 1) have or had a sexual partner with HIV; 2) have not consistently used a condom; or 3) have been diagnosed with a sexually transmitted infection in the past six months. In addition, PrEP is beneficial for those who inject drugs; have an injection partner with HIV; or share needles, syringes, or other injection equipment.
Both Truvada and Descovy are once-daily prescription medications that, when taken correctly, reduce the risk of getting HIV from sex by about 99 percent. Among people who inject drugs, PrEP reduces the risk by at least 74 percent when taken as prescribed. However, PrEP is much less effective when it isn't taken regularly. In 2021, Apretude (cabotegravir), an every-other-month injection, was approved for PrEP to reduce the risk of getting HIV-1 infection in adults and adolescents who weigh at least 35 kg.
Under the Affordable Care Act, all PrEP medications are free under most health insurance plans. For those that use Medicare Part D, a cost sharing may be incurred. Individuals who do not have prescription drug insurance may be eligible for Ready, Set, PrEP (readysetprep.hiv.gov), a national program that makes PrEP oral medications available at no cost. All medications are fully covered for qualifying participants; however, the costs of necessary clinic visits and lab tests may vary depending on a person’s income.
Despite the medications’ effectiveness and the fact that PrEP has been available for a decade, key barriers exist to PrEP usage. Some structural barriers include PrEP access, potential costs associated with the medication, stigma surrounding populations who benefit from PrEP, lack of provider knowledge, or a lack of prescribing providers. PrEP is only available by prescription and only certified practitioners can prescribe PrEP. Moreover, those on PrEP need periodic blood testing (HIV and kidney function tests), so access to routine clinician care is required.
Awareness of PrEP also has remained low and disproportionately affects individuals of color (Black and Hispanic). Awareness is the lowest in Black men who have sex with men (MSM) and transgender women. Not surprisingly, these groups are also disproportionately more likely to acquire HIV.
In 2019, African Americans represented 13 percent of the US population but accounted for 44 percent of new HIV diagnoses; Hispanics composed 18 percent of the US population but accounted for 30 percent of new HIV diagnoses. From 2015 through 2019, Black MSM accounted for more than 36 percent of new HIV infections annually among MSM. The number of diagnoses of HIV infection for transgender adults and adolescents increased between 2015 and 2019, with the highest percentage (93 percent) of HIV diagnoses for transwomen.
The HIV National Strategic Plan (2022-2025), the nation’s third consecutive national HIV strategy, sets forth bold targets for ending the HIV epidemic in the United States by 2030. Those targets include a 75 percent reduction in new HIV infections by 2025 and a 90 percent reduction by 2030.
The plan goes hand in hand with the UNAIDS 90/90/90 strategy. Announced in 2014, the strategy outlined that by 2020, 90 percent of people living with HIV would know their status, 90 percent of individuals diagnosed with HIV would be on treatment, and 90 percent of individuals with HIV on treatment would achieve an undetectable viral load. Although the initial targets were missed, UNAIDS revised the goals with 95/95/95 benchmarks by 2030.
Prevention is a key piece to achieving these strategic goals. PrEP awareness, access, and correct usage can help ensure an end to the HIV epidemic, here and globally. ▼
Additional information on HIV and PrEP is available on many credible websites, including HIV.gov, HIVinfo.nih.gov, FDA.gov, CDC.gov, and KFF.org.
Sharon A. Morgan is a retired advanced practice nurse with over 30 years of clinical and healthcare policy background.