PrEP in the United States Faces Slow Uptake and Coverage Among Payers

Chris Beyrer, MD, infectious disease epidemiologist and professor at Johns Hopkins Bloomberg School of Public Health, breaks down current rates of HIV across the United States as well as the challenges linked with controlling this epidemic—including the slow uptake of PrEP coverage among payers.

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Welcome back to PopHealth Perspectives, a conversation with the Population Health Learning Network, where we combine expert commentary and exclusive insight into key issues in population health management and more.

Today we are joined by Dr Chris Beyrer, infectious disease epidemiologist and professor at Johns Hopkins Bloomberg School of Public Health. Dr Beyrer breaks down current rates of HIV across the United States as well as the challenges linked with controlling this epidemic—including the slow uptake of PrEP coverage among payers. Dr Beyrer?

I am Chris Beyrer. I'm an infectious disease epidemiologist by training. I am the Desmond Tutu professor in Public Health and Human Rights at the Johns Hopkins Bloomberg School of Public Health.

I've worked on a range of infectious diseases, but primarily HIV/AIDS, viral hepatitis, TB, and now, for the last year, I've been one of the members of the COVPN, the COVID Vaccine Prevention Network, and working on the COVID vaccine trials.

Can you talk a little bit about HIV rates in the US? How have these rates changed over the last few years, and what are some of the challenges with controlling this epidemic?

The US is really alone among the advanced, developed countries, industrialized countries, in being one of the top 10 most affected by HIV/AIDS. We've always had quite a severe epidemic, because, of course, we had an early outbreak here that, for many years, was under-addressed.

We now find ourselves with about 1.2 million estimated people living with HIV in the United States. The epidemic has changed pretty substantially in demography. It began, of course, very much as a bicoastal epidemic, LA, San Francisco, New York, Boston, Washington.

It now very much is concentrated in the South and Southeast of the country, a broad swath that basically goes from Texas across the Deep South, Florida, Georgia, the Carolinas, and all the way up to Baltimore. To give you a feel of how concentrated that epidemic is, there are something like 7,100 counties in the United States, but 48 of them account for half of all new infections.

Most of them are in the South and Southeast. That unfortunately includes Baltimore, where I am based. It also has changed in race/ethnicity, so there is an increasing concentration of HIV in the United States in African American and Latinx communities and populations, particularly concentrated in African American women, who are hugely disproportionately affected by HIV.

Then, among Black and Latinx men, it's really concentrated in men who have sex with men. What we've been seeing now for the last 5 years of the CDC data is that the epidemic among white gay and bisexual men has been coming under nice control and coming down.

The epidemic in African American men who have sex with men has been essentially flat, unfortunately. Very stable, very hard to contain. The epidemic among Latinx gay and bisexual men is increasing. That is the part of the epidemic that's increasing the fastest in the United States.

That's a real challenge. Of course, in addition to the racial, ethnic, sexual orientation, gender identity, higher rates in trans women, particularly trans women of color, we also see a concentration of HIV in those states, particularly in rural areas, where there has not been an expansion of Medicaid through the Affordable Care Act.

That really comes down to, unfortunately, an old issue for the United States, which is unequal access to health care and health insurance.

What should the payer population know about ending or even addressing this HIV epidemic? How can they better adjust their health care plans to help improve that growing number of patients?

I think the thing that has been really challenging in this country in terms of reducing new infections, in terms of addressing the problem of incidence of infections, has been the very low access, uptake, and use of PreP thus far.

That is a real challenge, because, if taken as prescribed, it is remarkably effective for HIV prevention, and it could really help us bend the curve and get out of this epidemic if we could reduce the number of new infections.

The ending the HIV epidemic initiative that the previous administration put forward had a very ambitious goal of a reduction of 75% in new infections in 5 years, and 90% in 10 years. The most recent CDC data suggests that our epidemic is declining at about 2% a year. That is nowhere near enough of a decline to achieve epidemic control.

That means that payers and providers have got to do a better job of helping people access preexposure prophylaxis, use it, stay on it. It's absolutely critical, and many of us would argue that, at this point, particularly with Truvada, which has been generic and freely available in so many countries, and is the backbone of treatment programs, that payers are paying too much for it.

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