March 29, 2022

The Honorable Xavier Becerra
Secretary, U.S. Department of Health & Human Services
200 Independence Avenue, S.W. Washington, DC 20201

Dear Secretary Becerra:

We, the undersigned national, local, and state-based health, education, and civil rights organizations, outline our support for a national program to finance and distribute medications that prevent HIV infection, known as pre-exposure prophylaxis, or PrEP.  A key goal of a national program is to scale up access to PrEP substantially in order to help end the HIV epidemic. A national PrEP program should be guided by these principles: accessibility, equity, simplicity, affordability, sustainability, and adaptability. We were pleased to see the historic investment in a national PrEP program included in the President’s 2023 budget. We believe systems-wide reforms and innovative policies are needed to end the HIV epidemic in the U.S., and we look forward to working with the Administration to help make this ambitious proposal a reality.

HIV in the United States (U.S.):
In 2019, nearly 37,000 people in the U.S. were diagnosed with HIV. Black and Latinx/Hispanic individuals comprised 42 percent and 29 percent of new diagnoses, respectively. Every person living with HIV requires a lifetime of treatment at an estimated individual cost of about $501,000, with potential adverse effects that include liver toxicity and insulin resistance. HIV was the underlying cause of death for more than 5,000 people in 2019 in the U.S.

A major gap in U.S. efforts to address HIV is the under-utilization of medications that can virtually eliminate the acquisition of HIV. Fewer than 25 percent of people who could benefit from PrEP actually receive it, with large and growing disparities by race, ethnicity, gender, and geography. In 2019, the CDC found that 63 percent of White Americans recommended for PrEP received a prescription, compared to 14 percent of Latinx/Hispanic Americans and just 8 percent of Black Americans.

The current role of the federal government in HIV prevention:
In 2019, the federal government launched a major new initiative called Ending the HIV Epidemic, investing more than $500 million in HIV prevention, treatment, and research programs. The goal is to reduce new HIV infections in the United States by 90 percent by the year 2030. Though achievable, success will require substantial improvement over the modest 9 percent decline in new infections from 2015 to 2019.

The recently updated National HIV/AIDS Strategy for 2022-2025 recognizes the need for much greater use of PrEP. The major reasons for poor access include high prices, expensive and inaccessible laboratory tests, complex and confusing eligibility requirements to access PrEP services, limited provider availability in many parts of the country, and stigma. The Department of Health and Human Services (HHS)’s Ready, Set, PrEP Program, launched in 2019, aimed to reduce this gap by providing free PrEP medication for those without prescription drug coverage; however, the program does not cover the required associated clinic and lab costs for PrEP. The program also relies on high-cost, brand-name oral medications from a single manufacturer, despite the fact there are currently 12 manufacturers marketing generic PrEP in the U.S as well as a new long-acting injectable form of PrEP approved in December 2021.

Benefits of a national PrEP program:
To scale up PrEP as part of an effective, sustainable strategy to end the HIV epidemic, a national PrEP infrastructure must move away from the current reliance on high-cost, brand-name drugs that have resulted in overly complex, difficult-to-navigate programs for the un- and under-uninsured and a relatively small number of access points in the Medicaid program.  The proposal from Killelea and colleagues provides one potential path for a national PrEP program focused on these populations. A call for a national PrEP program builds off of recent efforts to secure congressional and Administration support for expanded access to PrEP. Any new funding must be strategically invested to ensure that scarce dollars are stretched to help the most amount of people and focused on reversing growing inequities in PrEP access. A multi-pronged approach will be needed to create a system in which individuals and providers can equitably and sustainably access PrEP.
To reduce the growing inequities enabled by our fragmented PrEP financing system, we seek your support for a national PrEP program which:

• Expands access to PrEP medications and lab services for people who are uninsured and on Medicaid
• Allows the federal government to negotiate with manufacturers and labs for fair public health prices
• Scales-up access to generic PrEP medication as a safe, effective, and cost-effective option for the majority of those indicated for PrEP and provides access to other PrEP options when indicated
• Creates an expansive provider network of non-clinical community-based PrEP providers and local health departments serving the uninsured and Medicaid that are paired with clinical providers via telehealth partnerships
• Works in tandem with existing PrEP funding and programs to supplement, not supplant programs and activities that are working
• Creates a platform for the effective and rapid deployment of novel PrEP medications
• Provides new opportunities to effectively raise awareness and combat stigma by enrolling and educating a new, broad network of providers and building community-led campaigns that connect key populations to this new PrEP infrastructure

A national PrEP program would help put the U.S. on track to end the HIV epidemic.
If you have any questions, do not hesitate to reach out to Jeremiah@prep4all.org


Sincerely,

Advocates for Youth
AIDS Alabama
AIDS Foundation of Chicago (AFC)
AIDS United
Amida Care
AVAC
Black AIDS Institute
Callen-Lorde Community Health Center
Center for Health Law and Policy Innovation, Harvard Law School
Community Education Group
COVID Clinic, Inc.
Equality California
Fenway Health
Friends For Life Corp - Memphis, TN
Georgia AIDS Coalition.
Georgia Equality
HealthHIV
HIV Medicine Association (HIVMA)
Housing Works
International Association of Providers of AIDS Care (IAPAC)
John Snow, Inc. (JSI)
Latino Commission on AIDS
NASTAD
National AIDS Housing Coalition (NAHC)
National Association of City and County Health Officials (NACCHO)
National Coalition for LGBTQ Health
National Coalition of STD Directors (NCSD)
NMAC
PrEP4All
San Francisco AIDS Foundation
Silver State Equality-Nevada
Southern AIDS Coalition
The AIDS Institute
The Aliveness Project, Inc.
The Reunion Project
Treatment Action Group
Vivent Health