Shaping the Future of HIV Prevention and Equity

Written by: Daryl O. Traylor, PhD, M.S., MPH, OMS-I, University of the Incarnate Word School of Osteopathic Medicine

INTRODUCTION

The HIV epidemic in America disproportionately affects vulnerable populations such as men who have sex with men (MSM), people of color (POC), Black and Hispanic/Latinx women, and transgender individuals. This article highlights the urgent need for targeted prevention and treatment strategies to address this issue. It also discusses the recent decision by a US court to allow companies to refuse coverage for pre-exposure prophylaxis (PrEP) based on religious objections and its potential consequences for public health.

The HIV epidemic has had a significant impact on public health in the US, with an estimated 1.2 million people living with HIV and 38,000 new diagnoses each year. Vulnerable populations, including POC, women, MSM, and transgender individuals, are disproportionately affected. Black individuals and Hispanic/Latinx individuals account for a substantial number of new HIV diagnoses, despite representing a smaller proportion of the population. Black and Latin MSM also have higher rates of HIV infection. Furthermore, transgender individuals, particularly Black transgender women, face increased risk and barriers to accessing healthcare.

PrEP, a highly effective preventive measure against HIV, is crucial in reducing transmission rates among these vulnerable populations. However, access to PrEP remains a challenge, especially for those who are uninsured or underinsured. The recent court decision allowing companies to deny coverage for PrEP based on religious objections further exacerbates the issue. This decision may lead to increased HIV transmission rates, health disparities, higher healthcare costs, and stigma and discrimination. To address these challenges, solutions such as enacting legislation to prevent healthcare coverage discrimination, expanding Medicaid coverage for PrEP, increasing funding for HIV prevention programs, and fostering partnerships are essential to promote public health equity and reduce HIV transmission rates among marginalized communities.

HIV IN AMERICA – UNDERSERVED POPULATIONS

The HIV epidemic in America has significantly impacted public health, particularly among vulnerable populations such as men-who-have-sex-with-men (MSM), people of color (POC), Black and Hispanic/Latinx women, and transgender individuals. According to the Centers for Disease Control and Prevention (CDC), an estimated 1.2 million people in the US are living with HIV, and approximately 38,000 people are newly diagnosed each year (Centers for Disease Control [CDC], 2020; Kaiser Family Foundation [KFF], 2019). Despite advances in treatment and prevention, HIV continues to disproportionately affect certain populations, and there is a need for comprehensive strategies to address the epidemic.

POC are also disproportionately affected by HIV in the US. In 2019, Black individuals accounted for 42% of all new HIV diagnoses, with a total of 16,964 new diagnoses; Black individuals made up only 13% of the population (CDC, 2020). Hispanic/Latinx individuals accounted for 11,597 new HIV cases, or 29% of new diagnoses, despite making up only 18% of the population (CDC, 2020; Guilamo-Ramos et al., 2019). When examined by gender, the 2019 data showed that Black women accounted for 57% of new HIV diagnoses among women, despite making up only 13% of the female population (CDC, 2019b). Similarly, Hispanic/Latinx women accounted for 16% of new HIV diagnoses among women, despite making up only 18% of the female population (CDC, 2019b).

Black and Latin MSM are disproportionately affected by HIV in the United States. According to the CDC, in 2020, Black MSM accounted for 26% of all new HIV diagnoses among MSM, despite representing only 13% of the US male population (CDC, 2020; CDC, 2019a). Similarly, Latin MSM accounted for 21% of all new HIV diagnoses among MSM while representing only 6% of the US male population (CDC, 2020; CDC, 2021). As a result, MSM accounted for 69% of all new HIV diagnoses in the United States in 2020 (CDC, 2020). This highlights the urgent need for targeted prevention and treatment strategies to address the HIV epidemic in these communities, including increased access to PrEP, HIV testing, and treatment.

Additionally, HIV infection rates among young MSM of color (18-24) have increased in recent years, indicating the need for early prevention interventions and education (CDC, 2020; Human Rights Campaign [HRC], 2019). Social determinants of health, such as stigma, discrimination, and lack of access to healthcare, also contribute to disparities in HIV rates among MSM of color and must be addressed through comprehensive approaches considering the multiple factors influencing health outcomes.

While Black and Latino individuals are disproportionately affected by HIV in the United States, it is essential to note that HIV also affects White Americans. According to the CDC, in 2019, White individuals accounted for 23% of all new HIV diagnoses in the United States (CDC, 2020). While this proportion is lower than that of Black and Hispanic/Latinx individuals, it still represents many new infections. Additionally, HIV infection rates among White MSM have increased in recent years, highlighting the importance of prevention efforts among this population.

Transgender individuals are also at increased risk of HIV infection. According to a recent study, 42% of transgender women have HIV, and the lifetime risk of acquiring HIV is 49 times higher for transgender women than for the general population (CDC, 2019c). Transgender individuals face unique barriers to accessing healthcare, including discrimination and lack of culturally competent care (Reisner et al., 2015).

Black transgender individuals are particularly disproportionately affected by HIV in the US. According to a 2021 report by the HRC, 24.9% of Black transgender women are living with HIV, compared to 21.6% of transgender women overall. The report also found that Black transgender women experience significant barriers to accessing healthcare and HIV prevention services, such as discrimination, lack of insurance, and lack of culturally competent care (HRC, 2021). These disparities highlight the need for targeted efforts to address the HIV epidemic among Black transgender individuals.

It is important to note that these numbers may not be representative of the true prevalence of HIV in these communities as access to testing and healthcare may be limited, and there may be underreporting of cases. The disparities related to HIV among underserved individuals are driven mainly by social determinants of health, such as poverty, discrimination, stigma, and lack of access to healthcare (Martin et al., 2021). Additionally, women and transgender individuals who experience intimate partner violence or have sex with individuals at high risk of HIV are also at increased risk of HIV infection (Reisner et al., 2015; Martin et al., 2021).

DISTRICT COURT DECISION

An effective prevention strategy for individuals at high risk of contracting HIV is PrEP. PrEP is a daily medication that can reduce the risk of contracting HIV by up to 99% when taken as prescribed (CDC, 2019d; CDC, 2019e). PrEP is particularly effective among men who have sex with men, transgender individuals, and people of color at increased risk of HIV infection (CDC, 2019e). PrEP is an important tool in the fight against the HIV epidemic, and increasing access to PrEP can potentially reduce HIV transmission rates and improve health outcomes for vulnerable populations.

However, despite the proven effectiveness of PrEP, access remains a challenge for many individuals, particularly those who are uninsured or underinsured (Bonett et al., 2020; Finlayson et al., 2019; Tuller, 2018). Additionally, the September 7, 2022, decision by the United States District Court of the Northern Division of Texas to allow companies to refuse to cover PrEP for religious reasons may have significant public health implications (Braidwood Management Inc. v. Xavier Becerra, n.d.; Kelley et al., n.d.; Mcnamara et al., 2023; Roehr, 2022; “The legal threat”, 2022). Despite being an effective prevention strategy for individuals at high risk of contracting HIV, denying coverage for PrEP may have various negative outcomes, such as increased HIV transmission rates, health disparities, increased healthcare costs, and stigma and discrimination. While the focus of the court's findings was on PrEP, it is important to note that denying coverage based on religious objections may pose a slippery slope for other preventive measures, such as vaccines, contraceptives, and mental health services (“The legal threat”, 2022). Overall, the precedent set in this case may eventually allow employers and healthcare providers to prioritize personal beliefs over evidence-based care.

DISCUSSION

Other similar court decisions based on religious objections have been made in the past, with harmful implications for public health. For example, in the 2014 Supreme Court case Burwell v. Hobby Lobby Stores, Inc., the court ruled that closely held for-profit corporations with religious objections could be exempt from providing contraceptive coverage to their employees (Fitzgerald, n.d.). This decision was criticized for potentially limiting access to birth control for women and perpetuating gender-based health disparities. Another example is the ongoing controversy surrounding mandatory vaccination policies. Some parents and religious groups have objected to vaccination requirements, leading to decreased vaccination rates and outbreaks of vaccine-preventable diseases such as measles (Korn et al., 2020; Weithorn & Reiss, 2018). Again, this has highlighted the tension between individual autonomy and the public health benefits of vaccination (“Individual Rights”, 2021).

In general, policies prioritizing personal beliefs over evidence-based care can negatively affect public health and exacerbate health disparities (Basu, 2021). Therefore, healthcare decisions need to be guided by scientific evidence that prioritizes the health and well-being of all individuals (Carman et al., 2016).

When policies and healthcare practices are based on personal beliefs rather than scientific evidence, these policies may undermine the effectiveness of public health interventions and interventions aimed at reducing health disparities. Evidence-based care involves the use of rigorous research and empirical data to inform decision-making in healthcare. This approach ensures that interventions and policies are based on the best available evidence and have been shown to be effective in improving health outcomes.

By prioritizing personal beliefs over evidence-based care, policymakers and healthcare providers risk implementing interventions that may be ineffective or even harmful. This can lead to a waste of resources and missed opportunities to address pressing public health issues. Furthermore, such policies can perpetuate health disparities by disproportionately affecting marginalized communities who already face barriers to accessing quality healthcare.

Health disparities refer to the unequal distribution of health outcomes among different population groups, often resulting from social, economic, and environmental factors. (Basu, 2021). These disparities can be exacerbated when healthcare decisions are not guided by scientific evidence. For example, if a policy prioritizes personal beliefs that are not supported by scientific research, it may overlook or dismiss interventions that have been shown to be effective in reducing health disparities among specific population groups.

To ensure the health and well-being of all individuals, it is essential that healthcare decisions are based on scientific evidence and prioritize the use of interventions that have been proven to be effective. This requires a commitment to rigorous research, ongoing evaluation of healthcare practices, and an understanding that personal beliefs alone should not dictate policy or individual treatment decisions.

One of the primary public health implications of denying coverage for PrEP may be the increased transmission of HIV. PrEP is highly effective when used as prescribed, and denying coverage may lead to increased HIV transmission rates, particularly among vulnerable populations such as MSM, transgender individuals, women, and people of color. In addition, without access to PrEP, individuals may be more likely to engage in risky sexual behavior, which can increase HIV transmission rates (Golub et al., 2019). The denial of coverage for PrEP may also increase the burden on public health-sponsored HIV prevention programs. Individuals unable to access PrEP through private insurance may have to turn to public health programs to obtain the medication. This may place additional burdens on these programs, which may not have the resources to meet the increased demand, ultimately reducing the entire community's access to PrEP.

Secondly, the decision to deny coverage for PrEP based on religious objections will likely face legal challenges (Mcnamara et al., 2023). Individuals or organizations may challenge the legality of such policies under federal or state anti-discrimination laws prohibiting discrimination based on sexual orientation or gender identity. This could result in costly, lengthy legal battles and create uncertainty for patients and providers regarding PrEP access.

Thirdly, denying coverage for PrEP based on religious objections raises ethical considerations. Healthcare providers should strive to provide evidence-based care to their patients (Olejarczyk & Young, 2022). Denying coverage for an effective HIV prevention strategy like PrEP conflicts with this duty. Moreover, healthcare providers have a moral obligation to provide care that is in the best interest of their patients (Olejarczyk & Young, 2022).

Denying coverage for PrEP based on religious values will disproportionately affect marginalized communities, leading to health disparities and inequities in health outcomes (Mayer et al., 2020). Marginalized communities and those living in poverty who are denied coverage for PrEP may in turn experience worsening HIV disparities, access to preventive care, and worsening health outcomes. These disparities may contribute to a cycle of poverty and ill health, making it difficult for individuals to break free from the cycle and access the care they need. Denying coverage for PrEP may also increase healthcare costs for individuals and the healthcare system. Without access to preventive measures like PrEP, individuals will be at higher risk for contracting HIV and may ultimately require expensive treatments and ongoing care if they are infected with HIV. This will increase healthcare costs, which can further exacerbate health disparities and negatively impact the economy.

While the US Northern District Court of Texas' decision may have immediate implications for PrEP access in the United States, there is the potential that the decision may have global implications. The global effort to end HIV relies on widespread access to effective prevention strategies like PrEP (Assefa & Gilks, 2020). Denying coverage for PrEP based on religious objections in the United States may send a message to other countries that prioritizing personal beliefs over evidence-based care is acceptable, potentially hindering global efforts to end the HIV epidemic. 

Denying coverage for PrEP based on religious objections has two additional major implications. First, it infringes on patient autonomy, which is the right of patients to make decisions about their health care based on their own values and beliefs. Patients have the right to access effective and evidence-based preventive measures like PrEP, regardless of the religious beliefs of their healthcare providers or insurance companies. Denying coverage based on religious objections is a violation of this fundamental right and can have a negative impact on patient trust in the healthcare system.

Secondly, denying coverage for PrEP based on religious objections can undermine trust in healthcare providers and institutions, particularly among LGBTQ+ individuals and other marginalized communities. This can further exacerbate health disparities and result in reduced access to care for these populations. Denying coverage based on religious objections sends a message to these communities that their health and well-being are not valued, leading to increased stigma and discrimination. This can also result in reduced healthcare seeking behavior and avoidance of healthcare providers, leading to worsened health outcomes. Therefore, it is essential that healthcare providers and institutions prioritize evidence-based care and work to build trust among marginalized communities to improve access to preventive measures like PrEP.

Finally allowing companies to deny coverage for PrEP based on religious objections may further stigmatize people living with HIV and those at risk of HIV infection. This will contribute to continued discrimination against LGBTQ+ people and other marginalized groups, increasing social and psychological harm, which can further worsen health outcomes (Travaglini et al., 2018; Rueda et al., 2016). In addition, stigma and discrimination lead to individuals avoiding seeking care and disclosing their HIV status, further contributing to the spread of HIV (Rueda et al., 2016).

POSSIBLE SOLUTIONS

The decision by the United States District Court of the Northern Division of Texas to allow companies to refuse to cover PrEP for religious reasons may have significant public health implications, such as increased HIV transmission rates, health disparities, increased healthcare costs, and stigma and discrimination. Thus, it is important to consider solutions to mitigate this issue. Here are a few solutions to consider:

Firstly, the federal government should enact legislation prohibiting healthcare coverage discrimination based on religious beliefs or any other discriminatory factor. This will ensure that individuals at risk of HIV infection have access to PrEP regardless of their employer's religious beliefs. Concomitantly, Medicaid coverage should be expanded to include PrEP for uninsured or underinsured, as Medicaid is a federal program that provides health insurance coverage to low-income individuals and families (Kay & Pinto, 2020). This will ensure that individuals at risk of HIV infection have access to PrEP regardless of their economic status. Additionally, the government should increase funding for HIV prevention programs, including PrEP, to help offset the costs for individuals who cannot access PrEP through their insurance or who do not have insurance. This will ensure that individuals at risk of HIV infection have access to PrEP regardless of their economic status (Killelea et al., 2022).

The U.S. Centers for Disease Control and Prevention (CDC) and state and local health departments should work with faith-based organizations to mount public awareness campaigns to educate individuals on the importance of PrEP in HIV prevention and the potential negative consequences of denying coverage for PrEP. In addition, these health communication campaigns should encourage employers to voluntarily provide PrEP coverage to their employees. These actions may protect access to PrEP for insured individuals.

Grassroots partnerships between healthcare providers and community organizations should be developed to increase access to PrEP and provide education and support for individuals at high risk of HIV infection. Additionally, healthcare providers and payers should collaborate to develop alternative funding sources for PrEP, such as subsidies or grants, to ensure that individuals at high risk of HIV infection have access to this important prevention tool (“Are Funders”, 2020). This may help reduce the financial burden of PrEP and ensure that individuals at risk of HIV infection have access to PrEP and other HIV prevention tools (Killelea et al., 2022).

Access to HIV prevention tools such as PrEP is essential to promote public health equity and reduce HIV transmission rates, particularly among marginalized communities. Unfortunately, denying coverage for PrEP based on religious beliefs can perpetuate health disparities and exacerbate existing inequalities. For example, LGBTQ+ individuals and communities of color are disproportionately impacted by HIV, and denying access to PrEP may further exacerbate these disparities. Moreover, denying coverage for PrEP is inconsistent with the principles of public health equity, which requires that everyone has access to the same opportunities to achieve good health, regardless of their demographic or economic circumstances. In this sense, denying coverage for PrEP is not only discriminatory but also a violation of public health principles that prioritize health equity and the well-being of all individuals and communities. The solutions outlined above may help ensure that individuals at risk of HIV infection have access to PrEP regardless of their employer's religious beliefs or economic status. They may also help reduce the stigma and discrimination associated with HIV and PrEP.

CONCLUSION

In summary, the HIV epidemic in America significantly impacts public health, particularly among vulnerable populations. Therefore, it is crucial to ensure that everyone has access to evidence-based preventive measures and that healthcare decisions are not driven by discriminatory beliefs. A comprehensive approach that prioritizes prevention and access to healthcare for all individuals, regardless of their religious beliefs, can lead to better health outcomes and a more equitable society. It is imperative to create a fair healthcare system that prioritizes all individuals' health and well-being, regardless of their beliefs or identities. PrEP is an effective prevention strategy for individuals at high risk of contracting HIV, and increasing access to PrEP can potentially reduce HIV transmission rates and improve health outcomes. Ensuring everyone can access evidence-based preventive measures and healthcare should not be driven by religious or discriminatory beliefs.

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