With Governor Andrew M. Cuomo’s mid-year announcement of an ambitious plan to end the AIDS epidemic in New York State by 2020, there lies increasing promise in the arena of HIV prevention—the end of an epidemic seems almost possible.
This hope stems, in part, from a relatively new HIV prevention approach called pre-exposure prophylaxis (PrEP), a once-a-day pill to prevent HIV infection in persons who are HIV-negative. That the governor chose to make providing access to PrEP a major goal of his three-point plan further underscores PrEP’s tremendous potential. However, PrEP’s full promise can be realized only if those who need it can get it—and the topic of how women (and particularly women of color) may benefit from PrEP has been largely absent from the national public health and media discourse about this new approach to HIV.
This lack of discussion about how PrEP may benefit women is particularly surprising given that one of the most glaring HIV-related disparities remains in new infections among women: Over 80 percent of new HIV infections among women in the United States occur among Black and Hispanic women. The trend is just as pronounced, if not more so, among transgender women. A confluence of societal and structural factors such as poverty, lack of access to quality health care and gender-based violence contribute to the increased HIV vulnerability of women of color. These factors can create barriers to condom use for many women, leaving them with few tools to protect themselves from HIV infection.
Until the Food and Drug Administration (FDA)’s 2012 approval of Truvada for PrEP, female and male condoms were the only approved HIV prevention method for sexual activity. However, both female and male condoms are very difficult for women to take advantage of without a consenting partner. In comparison, PrEP is a prevention method over which women have far greater control and is undetectable. This is particularly important for women who may not be in a position to negotiate safer sex practices with a male partner. PrEP is also a highly effective option for protecting an uninfected woman with an HIV-positive male partner during conception and pregnancy.
Most importantly, PrEP will work for those women who take it as prescribed. Clinical trials evaluating PrEP in women have had mixed results, primarily due to lack of adherence. If we want PrEP to work for women, we must make it work in the context of their lives.
In the midst of these possibilities, very few women in the U.S. are even aware of PrEP’s existence. And if they are aware, many believe PrEP is only for men who have sex with men.
Certainly, all groups highly impacted by HIV – particularly, young Black and Hispanic men who have sex with men – should have access to PrEP to keep themselves safe and healthy and reduce the number of new HIV infections. However, a focus on women is crucial, given the existing disparities in new infections among women and the lack of female-controlled HIV prevention options. To ensure equitable access to PrEP for women in New York State, a number of steps need to be taken.
First, women at high risk for HIV must be made aware of PrEP through public health awareness campaigns at the local and state levels, with a specific focus on women of color. Health care providers must also be informed and instructed on how to educate women about PrEP, assess PrEP eligibility and readiness and, ultimately, provide PrEP. In particular, health care providers such as primary care providers and obstetrician/gynecologists, along with family planning organizations, are uniquely positioned to both reach women who may be at high risk and to provide PrEP-related services to them.
In addition, community-based organizations that serve neighborhoods highly impacted by HIV can assist in the dissemination of information about PrEP and referral to health care settings that offer it.
Second, remove the cost-sharing for PrEP and PrEP-related care, for private and public insurers, in New York State. PrEP and PrEP-related care should be considered as preventive services and fully covered by insurance plans. While Gilead (the maker of Truvada) has taken steps to increase access to PrEP through drug assistance programs, barriers to affordability remain, including the cost of the medication, clinic visits, and lab tests. Studies have shown that women, especially, are likely to defer health care – including preventive services – due to the cost of care. This barrier must be removed.
Under the Affordable Care Act, there is no cost-sharing (i.e., co-payments, deductibles, or co-insurance) for preventive services in New York, such as HIV testing and FDA-approved methods of birth control such as oral contraceptive pills. While Truvada is covered by the state’s Medicaid program, individuals are asked to provide a co-payment, depending on the Medicaid plan – an additional barrier to accessing PrEP. With one-fifth of women on Medicaid in New York State and most of those being Black and Hispanic, the impact on women of color is undeniable.
Another step to improve access would be to provide PrEP to those who are uninsured. A substantial number of women who are uninsured in New York State are undocumented and, not eligible for Medicaid or a health plan through the state’s health exchange. Persons who are uninsured often forego health care, especially, preventive services. Offering a program similar to Washington State’s PrEP-DAP, a drug assistance program that covers the costs of Truvada for HIV-negative persons at high risk of HIV infection, would help to improve access to PrEP for women.
PrEP is a potentially transformative tool that may help to stem the tide of new HIV infections, especially among women, and women of color, in particular. Removing the barriers to access PrEP in New York State, and beyond, will ensure that all women, can experience PrEP’s potential benefits. Much like oral contraception pills, PrEP has the potential to have a substantial impact not only on women’s lives and sexual health, but, also, on the families and communities they support.