Editors Note: On Aug. 22, the U.S. Preventive Services Task Force (Task Force) published a final recommendation statement on pre-exposure prophylaxis (PrEP)―that healthcare professionals should offer or suggest a prescription for the biomedical intervention to people who face increased exposure to HIV. The Task Force has determined that recommending PrEP in this instance carries a "high certainty that the net benefit is substantial."
Though this is a sign of progress for HIV prevention―and, as written, acknowledges that Black and Latino people are disproportionately affected HIV (while facing lower rates of PrEP initiation than white people)―it does not address a major barrier to uptake: provider bias and discrimination. In his first article for TheBody, Doron Dorfman, J.S.D., outlines how ongoing stigmatization of PrEP among some providers has negatively affected other aspects of American life.
PrEP has been a major biomedical advancement in preventing HIV infection for over 10 years. What started out as an orally administered daily pill under the brand name Truvada, then later Descovy, has in recent years been approved as an injectable option under the brand name Apretude, which lasts for two months. The medication is aimed at protecting people who are seronegative from acquiring HIV―even when having condomless sex―and has become popular among gay and bisexual men.
For decades, gay sex and relationships have been socially constructed as being dangerous because of the possibility of HIV transmission. Using PrEP has had psychological benefits for people who use it because it helps them feel safer and offers some peace of mind regarding their sex lives. Yet, since its first approval by the Food and Drug Administration in 2012, some health professionals and lawmakers have expressed opposition to the endorsement of the prevention drug by the Department of Health and Human Services or its coverage under health insurance plans that are offered through the Affordable Care Act.
Many of these opponents have portrayed PrEP as a gateway to promiscuity―a party drug that would allow its users to “slut around” with numerous partners and with no condoms [i.e. the "Truvada whore" slur]. While these concerns may be intuitive, research on whether PrEP use increases “riskier” sexual practices has been inconclusive. Regardless, in order to keep their prescription, PrEP users must undergo screenings for HIV and sexually transmitted infections every three months, ensuring timely treatment of any type of infection.
As a legal scholar who conducts research that shows how psychological and social processes affect health law, I have focused on how stigmatizing PrEP users penetrates the law. Specifically, I show how policy decisions that are supposed to promote public health are oftentimes colored by moral judgment and actually end up jeopardizing people’s well-being.
This has been the case with insurance discrimination against PrEP users. Over the years, there have been quite a few documented incidents in which gay men who tried to purchase long-term health insurance, disability insurance, or life insurance were denied eligibility because they were using PrEP.
In a 2018 Massachusetts court case against Mutual of Omaha, the organization’s medical director speculated during his deposition that using PrEP may “foster promiscuity.” While he refused to acknowledge that promiscuity was grounds for the denial of insurance, the director paradoxically admitted that a “promiscuous” person who takes PrEP as directed is at low risk of getting HIV and that PrEP is “highly effective” against HIV. This type of statement demonstrates how moral judgments can creep into decision-making around health care―decisions that need to only be guided by assessment of risk and informed by science.
Massachusetts’ attorney general investigated other cases against Mutual of Omaha around the same time, for denying coverage on the basis of PrEP use. In January 2019, the parties reached a settlement that required Mutual of Omaha to correct its practice, stop denying or charging higher rates to PrEP users, and pay a $25,000 fine. Other states―New York, New Jersey, California, and Maine, among others―have taken steps to prohibit insurance discrimination, such as publishing guidance to insurance companies or enacting laws that prohibit insurance discrimination concerning PrEP.
Yet biases against PrEP users penetrate even court decisions. The most recent example is of a federal court judge who prohibited the government, through an injunctive relief, from enforcing the Affordable Care Act section requiring employer-sponsored insurance plans to cover PrEP because it could violate employers’ religious beliefs under the Religious Freedom Restoration Act.
In Braidwood Management v. Xavier Becerra, this judge accepted the claims that PrEP “facilitate[s] and encourage[s] homosexual behavior, intravenous drug use, and sexual activity outside of marriage between one man and one woman.” Though the the Fifth Circuit has issued a stay until it can render a judgment, this decision has already had a grave impact on access to PrEP as well as other preventive health measures like the HPV vaccine.
Working to reduce PrEP stigma is not only about LGBTQ rights―it concerns the possibilities of everyone’s health care. As such, decisions about public health should use scientific knowledge to promote a healthy society and dispel misinformation. Judgments about supposed morality and biases against individual behaviors should not be included in the decision-making process when it comes to PrEP or any other health care.