Access Issues Dominate HIV Biomedical Prevention Summit
The Biomedical HIV Prevention Summit in New Orleans last December was promoted as an opportunity to "learn how to put together comprehensive biomedical HIV plans to end AIDS." From the opening plenary and throughout the conference, however, most of the presentations focused on addressing structural and access issues that prevent people from obtaining pre-exposure prophylaxis (PrEP) and other HIV prevention resources they need.
In Summit workshops and plenaries, heated conversations focused on key factors that undermine efforts to get HIV prevention services to those at greatest need -- including a lack of public transportation and stable housing, a lack of community-based HIV education and testing services, and people's inability to take time off from work to access services. These structural barriers collide with the heavy stigmatization in many hard-hit communities that perpetuates their silence and inaction on HIV.
Megan Cannon of the Houston Health Department kicked off the opening plenary with an overview of what HIV prevention looks like in Texas, and she discussed the lack of access to health services -- a primary issue for PrEP access and information. One out of four Texans have no health insurance, making it the "most uninsured state in the U.S.," she said. According to estimates, nearly one million people in Texas do not have health coverage because the state hasn't expanded Medicaid under the Affordable Care Act. In addition to the lack of health coverage that would make PrEP more available, the Texas state legislature allocates no resources for HIV prevention to the Houston city health department or the Harris county health department. Given the lack of state resources for funding prevention services in the state, Cannon noted, "Almost no one is on PrEP or has even heard of it."
Texas' dilemma, while extreme, is common in many parts of the South, where information about PrEP is needed most. In Jackson, Mississippi, a third of the people coming to the University Medical Center for HIV testing services have never heard of PrEP, according to Leandro Mena, M.D., M.P.H., director of the Center for HIV/AIDS Research, Education and Policy, Myrlie Evers-Williams Institute for the Elimination of Health Disparities at Mississippi University Medical Center. Thirty-nine percent of men who have sex with men (MSM) in Jackson are HIV positive, the highest rate among MSM in any city in the nation. Latesha Elopre, M.D., M.S.P.H., assistant professor of medicine at the University of Alabama, is studying attitudes about HIV and PrEP among the MSM they serve. One participant, she reported, told her that "no one in our family or community ever talks about HIV even though we all know people who have it or died from it."
The stigmatization of HIV is well documented, but with the advent of PrEP, stigma also exists for people who are using PrEP where notions of "safe sex" are still tied to condoms and physical barrier methods, and not biomedical prevention. Like women using birth control pills, people using PrEP can be accused of being sexually reckless. People express stigma in complex ways, and it is especially powerful in resource-poor communities where social acceptance may be the key to one's survival. At the Summit, a growing consensus about addressing stigma, education, and access issues emerged together with the need to tailor all strategies to local needs.
One strategy addressing local conditions is the use of telemedicine mechanisms to deliver "telePrEP," as it was called in one Summit session. TelePrEP enables consumers to get much-needed care while avoiding the potent threat of being publicly identified as someone at risk of HIV. The Iowa Department of Public Health presented on their TelePrEP program, which is designed to overcome geographic isolation and protect users' privacy while also helping to compensate for the shortage of medical providers trained to prescribe and monitor PrEP use. In essence, it addresses stigma and access issues in one program. Health department staff connect with potential users online for private counseling and screening. Those who can't or don't want to be seen accessing PrEP are directed to local generic labs for the necessary blood testing and swabs. Eligible participants then receive their prescription by mail, and their progress is regularly monitored by health department staff. The hardest aspect of the program, according to staff, is finding the funding to keep the program going.
Such locally informed strategies require serious new funding commitments. The Ryan White Care Act provisions and the limited insurance coverage currently available are insufficient, especially in non-Medicaid expansion states. Substantial new investment is required to pay for more local peer educators and patient navigator nurses, as well as to do effective media outreach. "One-stop shopping" must be instituted by integrating PrEP services into other health care venues, such as family planning and sexually transmitted infection clinics.
Gina Brown of Southern AIDS Coalition reiterated the need for community-based solutions, noting that we have to take HIV prevention to communities because "if you have to take three busses to get there [for HIV testing or care], it won't happen."
Dawn K. Smith, M.D., M.P.H., M.S., biomedical interventions activity lead, Epidemiology Branch, Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention (CDC), pointed out that we already have a vivid example of what success can look like when a truly community-based approach is used for HIV prevention. Between 2008 and 2014, a 56% decline occurred in the estimated annual incidence of new HIV infections among people who inject drugs. That drop was generated by local harm reduction services: a community-based, structural approach to HIV prevention.
Perhaps the most explicitly confrontational speaker at the conference was Sarit Golub, Ph.D., M.P.H., professor of psychology at Hunter College. She urged people in the HIV field to "stop ignoring the obvious problems and just doing another awareness campaign." Challenging the audience, she added: "We know where inequality lives. We need to go there!"
Anna Forbes is a Washington, D.C.-based writer, organizer, and activist working in HIV/AIDS since 1985. Now an independent consultant focused on women's HIV-related needs and rights, her current and recent clients include a wide range of HIV-focused domestic and international NGOs and human rights initiatives.