A patient was recently interested in starting pre-exposure prophylaxis, known as PrEP, to protect himself from getting H.I.V. A Black man who had lost many friends to AIDS, he was nervous but eager to try it. After we discussed his sexual practices and I reviewed his blood work, I thought he was a great candidate.
When I asked whether he preferred the once-daily pill or the long-acting injection, he said he wanted whichever option was cheapest with cash. I explained his insurance would almost certainly cover both options free of charge, but he expressed fear that going through his insurer would alert the government.
Since I am a clinical pharmacist and do not dispense medications, I asked which pharmacy to send the prescription to. He seemed especially anxious that a prescription would create a paper trail. Though there was not yet a specific threat to his safety, he was scared that recent cuts to H.I.V. care may be a first sign of worse fears to come. It was one of the most agonizing conversations of my career. No one should have to worry that preventing H.I.V. could endanger them.
And yet, as the Trump administration lays waste to essential H.I.V. prevention and care, I’m having more of these painful discussions, especially with Black and Latino people and patients from other groups that have typically faced higher rates of infection and worse care.
Among other cuts to federal health agencies, Health and Human Services Secretary Robert F. Kennedy Jr. is said to be planning to lay off the entire staff of the Office of Infectious Diseases and H.I.V./AIDS Policy, which was working to end the H.I.V. epidemic in the United States and to solve related racial health disparities. The National Institutes of Health has canceled more than 100 grants for research into the disease. Marginalized groups fear they may lose access to PrEP from the gutting of federally supported programs — and this may worsen if congressional Republicans follow through with plans to cut Medicaid. Later this month, the Supreme Court will hear oral arguments over whether private insurance companies must continue to pay for PrEP and other preventative medications.
These events — coupled with the attempted dissolution of America’s global H.I.V./AIDS program, the scrubbing of language from federal websites on H.I.V. said to promote “gender ideology,” and the termination of L.G.B.T.Q.-focused H.I.V. programs and research — have terrified my patients and colleagues. It’s enraging to watch the Trump government, which previously set a goal to eradicate the virus in the United States by 2030, abandon vulnerable Americans and retreat from its longstanding global H.I.V. response.
Eventually, I convinced my patient that taking PrEP was the best way to protect himself from infection, and was all the more important amid this administration’s eroding support for H.I.V. care. H.I.V. prevention is something all health care providers need to integrate into their practice. Despite being one of the best tools at our disposal for preventing the spread of H.I.V., PrEP continues to be especially under-prescribed to those populations most burdened by the disease. Health care providers can start by educating themselves on PrEP and imploring their practices to make prescribing easier. It’s a disservice to delay or withhold it from those for whom prevention may be a matter of life and death.
The disparities in diagnosis and care are grim. The incidence of H.I.V. in the United States is about 0.4 percent. But studies have estimated that 14 percent to 42 percent of transgender women are living with H.I.V. Compared to other women with H.I.V., transgender women are less likely to receive care that suppresses the virus to undetectable levels in the blood or to have adequate medical care at all. Men who have sex with men represent 67 percent of new infections, and yet Black and Latino men in this group are the least likely to be virally suppressed. Overall, Black and Latino people account for 70 percent of new diagnoses and 61 percent of deaths among individuals with H.I.V.
That’s why health care providers should make PrEP screening and prescribing a routine part of their work, akin to checking for high blood pressure and cervical cancer. For some, this won’t be difficult; others may need help working through their own biases. Studies suggest that even many clinicians buy into stereotypes that PrEP encourages people of color to engage in unprotected sexual activity, or that they do not take their medications as instructed, which could allow drug-resistant H.I.V. strains to flourish. Those assumptions contribute to PrEP being prescribed at inequitably low rates. But research suggests these risks are overstated, and they are far outweighed by the ability of PrEP to reduce H.I.V. infections.
For each patient who discloses fears about what will happen under this administration, I wonder how many others are too afraid to seek the care they need altogether. As health care providers, we have committed ourselves to protecting our patients from harm. Words of support are not enough to combat policies and rhetoric that could worsen public health inequities for marginalized groups.
Estimates suggest that there could be 2,000 daily new H.I.V. infections globally, and 10 times more related deaths if American funding remains frozen or is not replaced. My colleagues and I certainly cannot avert mass death on that scale. But to continue with business as usual is to surrender the future. Intensifying PrEP prescribing is one of the best forces at our disposal to prevent a new H.I.V. crisis.
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