The Affordable Care Act did a lot to expand HIV/AIDS treatment and prevention for people at highest risk for the disease. Many gay men and other men who have sex with men gained health insurance and new infections went down. The estimated number of annual HIV infections in the United States declined 18 percent among gay and bisexual men between 2008 and 2014, according to the Centers for Disease Control and Prevention.
But if the Republican Obamacare replacement bill becomes law, much of this progress could be reversed, according to epidemiologist Greg Millett. Millet helped craft Obama’s first National HIV/AIDS Strategy and is currently Vice President and Director of Public Policy at the Foundation for Aids Research.
At a recent HIV conference in Indianapolis, Millet shared his concerns about the future of HIV prevention and treatment.. Reporter Emily Forman of Side Effects Public Media spoke to him to find out what’s at stake.
This interview has been edited and condensed.
EF: What has the Affordable Care Act done for men who have sex with men living with HIV?
GM: We know that under the Affordable Care Act that there are definitely more people living with HIV who have been able to receive health insurance funding. That’s something that we definitely saw with CDC data, that in particular under the ACA Medicaid expansion, those states that expanded Medicaid, we saw better outcomes for people living with HIV as compared to those states that did not expand Medicaid. That’s really incredible news and something that we hope policy makers take a good look at.
We also know that essential health benefits under the Affordable Care Act have really been a lifeline for people living with HIV - paying for mental health services, paying for drugs and a variety of other services that people previously did not have coverage for. In particular, with men who have sex with men-- it doesn’t matter what demographic: income level, HIV status, race, or age-- [we find] that between 2008 and 2014 there was a dramatic increase in access to health care and health insurance coverage.
EF: If the Affordable Care Act is repealed, what’s at stake for this population?
GM: What we’re facing right now is the possibility of that being jeopardized by the [American Health Care Act] which would strip essential health benefits, allow discrimination based on pre-existing conditions, and also doesn’t necessarily do much to continue to encourage states to expand Medicaid to cover people living with HIV. So under the current proposal that we have in Congress, it could actually do damage to the really wonderful efforts that we’ve been making in reducing new infections in the United States because it’s going to cover fewer people living with HIV and it’s certainly not going to cover preventative services for people who are at risk for HIV. So, in many ways it would move us backwards.
EF: One of those preventative services is a medication called pre-exposure prophylaxis or PrEP. Anyone at high risk for HIV can take PrEP to lower their chances of infection. What stands in the way of people gaining access to PrEP?
GM: There are several barriers that stand in the way. First is just knowledge of PrEP. Even though PrEP has been available for several years now, there are many individuals that don’t know that there’s actually a pill that you can take to keep you from becoming infected with HIV. There’s also the barrier of cost. People believing that they might not be able to afford PrEP it might not be covered by their insurance. Another issue for PrEP is the fact that PrEP is not necessarily being dispensed at the same rate nationally. So for instance, you find in San Francisco that there’s been an exponential increase in the number of people who are using PrEP. You find the same thing in Washington, DC. But in smaller areas in rural areas you still see very few percentages of men who have sex with men (MSM) who are using PrEP. In some southern cities such as Atlanta where there is a huge HIV/AIDS epidemic among African Americans as well as gay men you’re still seeing that PrEP use is still fairly low.
EF: While there are fewer new HIV infections among men who have sex with men as a whole, African American men continue to have the highest rate of HIV infection. How much does this have to do with access to care?
GM: If you don’t have access to health insurance then you’re less likely to be virally suppressed.We’ve seen in multiple studies now that black gay men are less likely to have health insurance than white gay men and then of course [this] also means that black gay men who are HIV negative won’t have access to pre-exposure prophylaxis the way that white gay men who are HIV negative do.
Even though there’s an explosion of men who have sex with men who are availing themselves of pre-exposure prophylaxis, when you take a look at the demographics of that you find that there’s vanishingly few numbers of African Americans who are a part of that population that’s taking PrEP. And of course that has implications for our epidemic because black gay men are less than 1 percent of the population but constitute nearly 25 percent of new infections that take place each year so if you’re not focusing on the group where most of the infections are taking place in the United States then we’re really not doing much to end the epidemic.
This story was produced by Side Effects Public Media, a news initiative covering public health.