Inner Sydney, Australia recently proved for the first time that HIV transmission can almost be entirely eliminated, thanks to increased access to "pre-exposure prophylaxis" or PrEP. PrEP is a medication—either in the form of a pill or more recently an injection—that people without HIV can take to reduce the risk of getting HIV by up to 99 percent. At the same time, Democrats here at home re-introduced the PrEP Access and Coverage Act, which would expand access to HIV prevention medicines. As a researcher studying the health impacts of mass incarceration, any measure to expand PrEP access must prioritize people within our country's prisons and jails.
Carceral facilities have long been environments where infectious diseases like tuberculosis and COVID-19 spread widely and rapidly. Today, the HIV rate is three times higher in prisons than the general U.S. This means that an overwhelming one in seven people with HIV interact with the U.S. carceral system each year. Things may be getting worse. In July, a Baton Rouge jail witnessed a surge in HIV cases, which increased the need for HIV treatment fourfold.
HIV disproportionately impacts two groups of incarcerated people: Black men and Southerners. Seventy-one percent of HIV-related deaths in prisons are Black men. And the states with the highest HIV rates are those in the South, including South Carolina—my home state.
To date, little has been done to address this solvable problem. HIV detection and prevention strategies such as routine HIV testing, access to condoms, and safe injection sites are rarely, if ever, viable options within prisons and jails. Even worse, when people who already have, or are at risk for, HIV are incarcerated, they rarely receive the continuity of care they need to help improve their situation.
Easily accessing PrEP would make a major difference for a huge number of incarcerated people. If someone has been exposed to HIV through sex or needle sharing, PrEP virtually eliminates the possibility of contracting HIV by stopping it from multiplying inside the body. Studies have shown PrEP is incredibly effective, reducing risk of HIV transmission via sex by 99 percent.
Although PreP has been approved by the Food and Drug Administration for over a decade and great strides have been made in its uptake, there are still large racial and ethnic disparities. For example, Black men who have sex with men (MSM)—a group with elevated risk for HIV—are less likely than white MSM to have a provider discuss or prescribe them PrEP. Given the overincarceration of Black and Latinx individuals, prioritizing those currently incarcerated in a national PrEP program could mitigate these disparities.
The PrEP Access and Coverage Act, re-introduced by Senator Tina Smith (D-Minn.) and House Representative Adam Schiff (D-Calif.) in June, was originally introduced by Vice President Kamala Harris when she was a senator in 2019, but has failed to pass in Congress. If passed, the Act would ensure health insurance coverage for PrEP and fund access to PrEP for those without insurance. This would be a critical next step towards HIV elimination. However, the bills make no explicit provisions for those within our prisons and jails—often the people who most need this treatment. Nor does it include strategies to include uptake in this at-risk population—both are necessary to ensuring the Act is successful in reaching its goal.
Ensuring that incarcerated people benefit from this Act isn't simple. The U.S. carceral state includes more than 5,000 facilities ranging from small, rural city jails to large, urban federal prisons, so a one-size-fits-all approach most likely won't work. New approaches will also have to compensate for medical distrust given a long history of medical abuse in carceral facilities. Partnering with individuals currently incarcerated could overcome this lack of trust.
As someone who takes PrEP daily, I know it has personally changed my life for the better. It has improved my mental health by taking away worry about my health and connected me to health care I would have otherwise avoided. As a health researcher, I know eliminating HIV transmission for all is within reach in the U.S. But to get there, we must consider everyone, and especially those within our nation's enormous carceral state.
Tyler Harvey is an MD/PhD (Public Health) student at the Yale School of Medicine and a Public Voices Fellow with TheOpEdProject in partnership with the AcademyHealth.
The views expressed in this article are the writer's own.
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