Supporters have lauded this move as a major step toward President Trump’s plan to end HIV in the United States. Others have criticized it as not going nearly far enough: They would rather the government expedite generic drug production and lower the cost of PrEP.
Both are missing an important point: Free or reduced-cost drugs will have no impact if patients can’t access them in the first place.
The rural South is a growing epicenter for HIV, but while the South accounts for more than half of all new HIV diagnoses, it has only a quarter of all PrEP-providing clinics. In West Virginia, only 27 percent of the state’s rural counties offer any HIV prevention services. In North Carolina, only two of the state’s 85 local health departments reported to researchers last year that they prescribed PrEP. In Mississippi, patients have had to drive three or more hours to access the one health center that dispenses 80 percent of all PrEP pills in the state.
And that’s if the patient knows to ask for PrEP in the first place. Only half of all uninsured patients have a regular source of medical care. Patients who are at high risk of contracting HIV are even less likely to do so since they often belong to marginalized communities that have deep distrust of the medical system. A Centers for Disease Control and Prevention report found that while African Americans account for 44 percent of individuals who would qualify for PrEP, they account for only 11 percent of those on PrEP. African American men who have sex with men have a 1-in-2 lifetime risk of contracting HIV, yet only 26 percent are on PrEP (compared to 42 percent of their white peers). Without concerted outreach efforts to these vulnerable communities, the promise of free drugs will not translate to patients actually taking them.
Furthermore, the administration’s new program covers only medications themselves. The medical appointment to obtain the prescription isn’t covered, nor are lab tests or ongoing care. CDC guidelines require that patients undergo multiple blood tests before starting PrEP and then regular testing every three months while on it. For the uninsured, these tests cost thousands of dollars a year and will effectively price patients out of PrEP care.
Instead of giving free medications to some uninsured people, a much better solution is helping these patients get health insurance. Medicaid already covers 42 percent of adults with HIV (compared to 13 percent of the general adult population), and patients on state Medicaid programs receive coverage not only for PrEP and HIV drug therapies, but also other comprehensive services such as lab testing, care coordination and community-based services.
Access to these public insurance programs is particularly important for prevention. The federal Ryan White program, which funds cities and states to care for low-income people with HIV, supports only those already diagnosed with HIV. It does not support those who could be prevented from getting HIV and does not cover PrEP. Expanding Medicaid to those at high risk for HIV would allow them to receive PrEP and coverage for the other services they need.
Patients also need more places to access HIV prevention and treatment. A key access point is clinics funded by the Title X family planning program. Of the approximately 4,000 Title X clinics across the country, 90 percent provide HIV testing and a third offer PrEP. These clinics serve low-income patients in rural and underserved areas, but now are threatened with closure because of the Trump administration’s new Title X restrictions.
If the Trump administration really wants to achieve its goal of eradicating HIV, it needs to stop harmful policies such as the Title X gag rule. And instead of dismantling the Affordable Care Act, it should support state-based Medicaid expansion. It needs to remove discriminatory policies such as the conscience rule and the public charge rule that further stigmatize LGBTQ, minority and immigrant populations that already face the greatest barriers to care.
The Trump administration’s free medication program distracts from the real challenges of HIV prevention and treatment. Pills are no panacea when patients can’t access them in the first place, and then can’t afford the rest of the medical care that comes along with treatment. The administration has the power to fulfill its promise to end the HIV/AIDS epidemic, but it must begin with an honest examination of its existing policies. Otherwise, it will keep making tiny steps forward against a backdrop of giant steps backward.