Maryland’s newly-elected governor Wes Moore (D) ran on a promise to support legislation that would require state Medicaid plans to cover gender-affirming care. Now it looks like he’ll soon get a chance to make good on that promise.
On Monday, the state’s senate approved the Trans Health Equity Act in a 32–14 vote after the bill passed in the Maryland House of Delegates on Saturday. S.B. 460 now goes to Moore’s desk for a signature.
An anti-trans tweet about gender-affirming surgery led trans men to proudly share their scars.
The new law, introduced by Maryland Del. Anne Kaiser (D) last year, requires the Maryland Medical Assistance Program to “provide medically necessary gender-affirming treatment in a nondiscriminatory manner.” It also requires that “gender-affirming treatment be assessed according to nondiscriminatory criteria that are consistent with current clinical standards.” Among the treatments covered are hormone therapies, puberty blockers, and surgeries, as well as voice training, fertility preservation, and permanent hair removal.
“What is being said nationally about trans people are the same lies that were said about gays and lesbians 20 years ago,” said Kaiser, who became one of Maryland’s first openly gay legislators in 2002. “And that’s part of the reason I feel the passion and the connection to our trans brothers and sisters.”
Del. Kris Fair (D), a co-sponsor of the bill and chair of the Maryland Legislative LGBTQ Caucus, pointed to a 2018 Human Rights Campaign study that found that 60 percent of transgender and non-binary youth will attempt suicide by the age of 18 as a reason to make gender-affirming care more accessible.
“Individuals who are trans and nonbinary are struggling because society continues to put unnecessary layers of adversity in their place,” Fair told Baltimore public radio station WYPR. “Eventually, that adversity can become overwhelming for people. And these are simple solutions that we can take out of the way of trans and non-binary people to allow them to live a more authentic life, and to provide them with a sense of hope and optimism for their experience.”
Transgender advocacy organization Trans Maryland cheered the news in an Instagram post.
“This bill came about after we talked to thousands of trans Marylanders about what we need,” the post read. “And then our community and our allies kept pushing until we WON!”
Almost 23% of trans youth in the United States have lost access to gender-affirming care.
A new report from the Human Rights Campaign (HRC) found that of the 300,000 trans youth ages 13 through 17, there are 66,600 living in states that have passed bans on this lifesaving care. And 84,700 more trans youth (28.2%) live in states that are currently considering bans.
The state is the fourth to pass a law prohibiting trans students from using bathrooms that match their gender identity.
According to the Movement Advancement Project, there are currently eight states that fully ban gender-affirming care for minors, along with one state (Arizona) that bans “best practice surgical care” for trans youth.
In the first few months of 2023, alone, gender-affirming care bans have become law in Mississippi, South Dakota, Tennessee, Arkansas, Iowa, and Utah, in addition to five other anti-trans bills.
Over the past few years, Republicans have focused their agenda on attacking equality for transgender youth, with a particularly chilling new Tennessee law requiring youth who have already started gender-affirming care to de-transition. Other states, like Oklahomaand Florida, are considering similar legislation.
These laws go against the best practices of trans-related pediatrics outlined by the American Academy of Pediatrics, the American Medical Association, and the American Psychological Association. Numerous studies have shown that a lack of societal acceptance and access to gender-affirming care contribute to high rates of suicide among trans youth. And other studies have found that gender-affirming care actively lowers the risk of depression and suicide in trans youth.
And it’s more than just trans youth being targeted.
Over 400 anti-LGBTQ+ bills have already been filed this year – more than the total number filed in 2022. The American Civil Liberties Union tracks these hateful bills with a map that allows viewers to search by state, issue, or status. It says 14 have become law, 332 have advanced, 64 have been defeated, and 19 have been introduced.
The Walt Disney Company will host a major conference promoting lesbian, gay, bisexual and transgender rights in the workplace in Central Florida this September, gathering executives and professionals from the world’s largest companies in a defiant display of the limits of Florida Gov. Ron DeSantis’ campaign against diversity training. Michael Chamberlain, chief marketing officer for Out & Equal, confirmed the conference would be held at The Walt Disney World Resort, Sept. 11-14.
Dozens of iconic American companies — including Apple, McDonald’s, Uber, Walmart, Hilton, Amazon, Boeing, Cracker Barrel and John Deere — are sponsoring the Out & Equal Workplace summit, which over 5,000 people are expected to attend. Several agencies, including the State Department and the CIA, are listed as government partners and will have booths at the conference.
Read the full article. Disney has also committed to hosting the same convention next year.
Missouri’s Attorney General Andrew Bailey (R) has announced an “emergency regulation” that restricts gender-affirming medical care for transgender people in his state.
Trans and civil rights advocates have criticized Bailey’s announcement for spreading misinformation and attempting a “power grab” while his state’s legislature considers a bill restricting gender-affirming care. Though Bailey’s announcement mentions “children,” it doesn’t list any age limits for his emergency regulations, meaning that it could apply to people of all ages.
Republicans sneaked a last-minute amendment into a voting rights bill. One Democrat said the genital examinations would happen “over my dead body.”
In a March 20 statement, Bailey announced restrictions including a requirement that individuals must wait 18 months before being given gender-affirming care.
During this waiting period, they must undergo at least 15 hours of therapy, including “a full psychological or psychiatric assessment” to see if they have autism and to ensure that all their “mental health comorbidities” have been “treated and resolved.”
“Comorbidities” is a word for other medical conditions that may be present in a patient, and it has become one of anti-transgender activists’ favorite words as they push the unsubstantiated theory that mental health conditions are regularly mistaken for transgender identity by health care professionals.
In a tweet, out journalist Erin Reed noted that a trans person’s mental health comorbidities could often be resolved by receiving gender-affirming care. However, if trans people are blocked from receiving such care until those comorbidities are resolved, those conditions may never get resolved.
Bailey’s announcement said transitioning individuals must be monitored for 15 years afterward to find any adverse effects of their gender-affirming care. Patients must also undergo an annual check-in to ensure that they’re “not experiencing social contagion with respect to the patient’s gender identity.” “Social contagion” is another anti-transgender buzzword that refers to the idea that people just transition because their transgender friends are pressuring them to do so.
Bailey’s emergency regulation would also require transitioning individuals to sign an informed consent document that says the use of hormone replacement therapy and puberty blockers are “not approved by the Food and Drug Administration (FDA).”
Susan Halla, president of the trans advocacy group Transparent, said that the FDA hasn’t approved of such treatments because “studies involving young people are rarely conducted,” Salt Lake Public Radio reported.
The informed consent document would also contain statistics suggesting that gender-affirming care is dangerous and unnecessary. These statistics have been debunked, Halla said, and also contradict the suggestions for trans-related care issued by major American medical and psychological associations.
In his announcement, Bailey wrote, “Because gender transition interventions are experimental, they are covered by existing Missouri law governing unfair, deceptive, and unconscionable business practices,” suggesting that his office may prosecute any clinics that don’t follow his new regulations. However, such interventions aren’t “experimental.” Medical practitioners have rendered such care for decades.
“Even Europe recognizes that mutilating children for the sake of a woke, leftist agenda has irreversible consequences,” he added, echoing a right-wing lie that gender-affirming surgeries are commonly performed on children. They aren’t.
Halla said of Bailey’s announcement, “There are many things on it that are blatantly false, or impossible to quantify in some way. One of the items was to make sure that this child is not part of a social contagion. Like, how do you do that?”
Tom Bastian, a spokesman for the Missouri American Civil Liberties Union (ACLU) said, “These actions do not protect anyone; rather, they put an already marginalized group of children in greater danger.”
Bailey, who is not a doctor, said his emergency regulations will last 30 legislative days or 180 days, whichever is longer, his statement said.
Reed wrote of the announcement, “This is a de facto ban for many trans youth while the Missouri legislature considers a ban in and of itself. This unilateral action is a power grab by the Attorney General, plain and simple.” Bailey is also up for re-election in 2024 and may be pursuing this crusade to shore up conservative votes.
Meanwhile, Missouri’s Republican-controlled senate approved bans on gender-affirming care and transgender women participating in women’s sports, including at private schools and colleges.
“With [Bailey’s] announcement, I think you’ll see that very few clinicians are willing to risk direct, retaliatory, legal action and or risk to their professional license,” Brandon Barthel, a Kansas City-based endocrinologist who provides care for transgender adults, told The Kansas City Star. “Wouldn’t surprise me if this effectively halts any gender-affirming care on minors in the state of Missouri.”
The world’s most popular gay dating app, Grindr, is participating in a nationwide effort to distribute free at-home HIV testing kits to populations most affected by the virus.
“If you’ve got a way that you are testing, and it’s really working for you, then that’s great, and you should stick with that,” Jack Harrison-Quintana, director of the app’s social justice division, Grindr for Equality, told NBC News. “If you don’t, this is an additional way for you to get tested in a way that’s just about as easy as doing an at-home Covid test.”
Grindr, which reports 12 million monthly active users worldwide, is partnering with the Centers for Disease Control and Prevention, Emory University and several other public health organizations and corporations on the Together TakeMeHome campaign, which launched Tuesday. Supported by a $41 million grant from the CDC, the program will provide up to 1 million HIV self-tests over five years, at no cost for individuals
The program, according to a statement released by Emory, was initiated in response to a decline in the number of HIV testsadministered nationwide during the onset of the Covid-19 pandemic.
Grindr’s primary role in the effort is to allow users in the U.S. and Puerto Rico to easily order an at-home HIV test directly from the app. Starting Tuesday afternoon, Grindr users will see a “Free HIV Home Test” button in the app’s main menu. Those who click will be redirected out of the app to the Together TakeMeHome site, where an at-home HIV test can be ordered.
The test kit consists of an FDA-approved OraQuick device that uses mouth swabs and takes 20 minutes to provide a result. The app will also allow users to set “Testing Reminders” where they can set up a three- or six-month reminder for HIV testing.
Dr. Robyn Neblett, the acting director of the CDC’s Division of HIV Prevention, said these at-home tests give people “the power to test on their own terms.”
“Removing barriers to testing like stigma, discrimination, and access to physical services improves health, advances health equity, and moves our nation closer to ending the HIV epidemic,” Neblett said in a statement.
The CDC recommends those ages 13 to 64 get tested for HIV at least once as part of routine health care. Those with certain risk factors — including men who have sex with men — should get tested at least once a year.
The Together TakeMeHome program is available to anyone in the U.S. and Puerto Rico over the age of 17, and each individual can order up to two kits every 90 days. The focus of the program, however, will be on U.S. populations disproportionately affected by HIV, including cisgender men who have sex with men, transgender people and Black cisgender women.
Men who have sex with men account for 70% of new cases of HIV in the U.S., according to the CDC. Whites in this demographiccomprised 15% of the 34,800 HIV transmissions in 2019, while the much smaller populations of their Black and Latino peers comprised a respective 26% and 23% of new cases.
According to an investigation published in the journal JAMA Internal Medicine in 2019, the distribution of HIV self-tests provides “a worthwhile mechanism to increase awareness of HIV infection” and prevents transmission among men who have sex with men.
Arkansas Gov. Sarah Huckabee Sanders on Tuesday signed a law prohibiting transgender people at public schools from using the restroom that matches their gender identity, the first of several states expected to enact such bans this year amid a flood of bills nationwide targeting the trans community.
The bill signed by the Republican governor makes Arkansas the fourth state to place such restrictions at public schools, and it comes as bills in Idaho and Iowa also await their governor’s signature. And it might be followed by an even stricter Arkansas bill criminalizing transgender adults using public restrooms that match their gender identity.
Arkansas’ law, which won’t take effect until later this summer, applies to multi-person restrooms and locker rooms at public schools and charter schools serving prekindergarten through 12th grade. The majority-Republican Legislature gave final approval to the bill last week.
“The Governor has said she will sign laws that focus on protecting and educating our kids, not indoctrinating them and believes our schools are no place for the radical left’s woke agenda,” Alexa Henning, Sanders’ spokesperson, said in a statement. “Arkansas isn’t going to rewrite the rules of biology just to please a handful of far-left advocates.”
Similar laws have been enacted in Alabama, Oklahoma and Tennessee, although lawsuits have been filed challenging the Oklahoma and Tennessee restrictions.
Proposals to restrict transgender people using the restroom of their choice have seen a resurgence this year, six years after North Carolina repealed its bathroom law in the wake of widespread protests and boycotts. More than two dozen bathroom bills have been filed in 17 states, according to the Human Rights Campaign.
“They’re singling out transgender people for no other reason than dislike, disapproval and misunderstanding of who transgender youth are,” said Paul Castillo, senior counsel and students’ rights strategist for Lambda Legal. “And the entire school population suffers as a result of these types of bills, particularly schools and teachers and administrators who are dealing with real problems and need to focus on creating a welcome environment for every student.”
The proposals are among a record number of bills filed to restrict the rights of transgender people by limiting or banning gender-affirming care for minors, banning transgender girls from school sports and restricting drag shows. Transgender people have also faced increasingly hostile rhetoric at statehouses.
Another bill pending in Arkansas goes even further than the North Carolina law by imposing criminal penalties. That proposal would allow someone to be charged with misdemeanor sexual indecency with a child if they use a public restroom or changing room of the opposite sex when a minor is present.
“It’s a flagrant message from them that they refuse to respect (transgender people’s) rights and humanity, to respect Arkansans’ rights and humanity,” said Holly Dickson, executive director of the American Civil Liberties Union of Arkansas.
The new Arkansas law requires schools to provide reasonable accommodations, including single-person restrooms. Superintendents, principals and teachers who violate the prohibition could face fines of at least $1,000 from a state panel, and parents could also file private lawsuits to enforce the measure.
“Each child in our schools has a right to privacy and to feel safe and to feel comfortable in the bathroom they need to go to,” Republican Rep. Mary Bentley, the bill’s sponsor, told lawmakers earlier this year.
But Clayton Crockett, the father of a transgender child, described to lawmakers earlier this year how a similar policy adopted at his daughter’s school made her feel further marginalized.
“She feels targeted, she feels discriminated against, she feels bullied, she feels singled out,” Crockett said at a House panel hearing on the bill in January.
Opponents have also complained the legislation doesn’t provide funding for schools that may need to build single-person restrooms to provide reasonable accommodations.
At least two federal appeals courts have upheld transgender students’ rights to use the bathroom corresponding with their gender identity. Supporters of the bill, however, have cited a federal appeals court ruling upholding a similar policy at a Florida school district last year.
The Arkansas measure won’t take effect until 90 days after the Legislature adjourns this year’s session, which isn’t expected to happen until next month at the earliest.
Sanders signed the bill a week after she approved legislation making it easier to sue providers of gender-affirming care to minors. That law, which also doesn’t take effect until this summer, is an effort to effectively reinstate a ban on such care for minors that’s been blocked by a federal judge.
Sanders earlier this month also signed a wide-ranging education bill that prohibits classroom instruction on gender identity and sexual orientation before 5th grade. The restriction is similar to a Florida measure that critics have called the “Don’t Say Gay” law.
Lawmakers in Kentucky have passed an expanded anti-trans bill which targets the rights of vulnerable young trans people in the state.
The American Civil Liberties Union of Kentucky denounced the legislation as the “the worst anti-trans bill in the nation”.
On Thursday night (16 March), the state’s legislature passed the bill in a matter of hours, with approval from a committee and both the state House and Senate.
Senate Bill 150 seeks to ban gender-affirming healthcare for trans youth, requires doctors to detransition young trans people and prevents schools from discussing gender identity or sexual orientation with students of any age.
The bill’s original focus was on schools, with provisions to force teachers and students to misgender their own pupils and classmates, and allow parents to opt their children out of any lessons discussing sexuality.
New additions from another anti-trans bill, House Bill 470, were tacked onto SB 150, widening it to include a ban on gender-affirming healthcare for trans young people, and requiring school districts to form policies that “at a minimum” would prevent trans children from using bathrooms and locker rooms consistent with their gender identity.
SB 150 also specifies that doctors must create a timeline to taper off treatment for children currently receiving hormone therapy or puberty blockers – but only if immediately stopping the treatment could physically harm them – in service of the ultimate goal of detransitioning young people.
Additionally, districts and schools will not be permitted to adopt any policies that aim to keep information about students confidential from parents, a move that could put young people in danger at home if they haven’t disclosed their sexuality or gender identity to caregivers.
Kentucky state senator Dr Karen Berg, who lost her trans son to suicide in 2022, spoke out passionately against the bill, describing the vote on Twitter as one to “to remove basic rights from members of the trans community, their parents, and their doctors”.
She added: “Hate has no shame in this state.”
A ‘dangerous’ and ‘unconstitutional’ bill
The Trevor Project condemned the bill, describing it as “appalling” and “dangerous”.
Director of state advocacy campaigns Troy Stevenson said: “It is appalling to see Kentucky lawmakers work so hastily on dangerous legislation that will only put young LGBTQ+ Kentuckians in harm’s way.
“In the last year, nearly half of LGBTQ+ youth in Kentucky seriously considered suicide – alarmingly, nearly one in four transgender and non-binary youth in the state made a suicide attempt.
“Our leaders are pushing political wedge issues and sidestepping the real challenges like addressing the youth mental health crisis,” he continued. “The Kentucky Legislature should not be inserting itself into critical decisions best left to parents and doctors by imposing a blanket ban on best-practice medical care.
“We urge the governor to reject this harmful legislation and send a message to the young LGBTQ+ Kentuckians watching these debates that they belong in this state.”
In a statement, the ACLU of Kentucky dubbed the bill “unconstitutional” and vowed legal action if it becomes law, while blasting it as “the worst anti-trans bill in the nation” on Twitter.
The Human Rights Campaign (HRC) urged the Kentucky governor to veto and warned that SB 150 would “terrorise transgender youth in schools, in doctor’s offices” and could “put them in danger at home”.
The bill is now moving over to Governor Andy Beshear’s desk to be signed into law or vetoed within 10 days.
It is expected that Beshear will veto the bill, but then the veto is likely to be overridden when the Republican-majority legislature returns for the final two days of the session (29 and 30 March).
This comes as part of a wave of homophobic and transphobic legislation sweeping the USthis year. According to the HRC, more than 410 anti-LGBTQ+ bills – around 180 of them specifically targeting the trans community – were introduced in statehouses across the country during the first few months of 2023.
Suicide is preventable. Readers who are affected by the issues raised in this story are encouraged to contact Samaritans on 116 123 (www.samaritans.org), or Mind on 0300 123 3393 (www.mind.org.uk). Readers in the US are encouraged to contact the National Suicide Prevention Line on 1-800-273-8255.
While the country remains in shock after Tennessee’s recent ban on public drag performances, another, more insidious attack on the LGBTQ+ community has been underway in the state.
A coordinated effort by right-wing media and conservative lawmakers has decimated community-based programs addressing healthcare for LGBTQ+ people in Tennessee, including efforts to combat HIV.
In January, Tennessee Gov. Bill Lee (R) announced his administration was rejecting $8.8 million in federal funds provided by the Centers for Disease Control and Prevention (CDC) for HIV prevention and treatment.
Left unsaid was the fact that some of those dollars had made their way to programs run by groups associated with trans healthcare. After a months-long outrage campaign by right-wing media, Gov. Lee finally threw the baby out with the bathwater.
The pressure campaign started in September, when right-wing provocateurs Matt Walsh and Ben Shapiro set their sights on the transgender care program at Nashville’s Vanderbilt University Medical Center, which Walsh described as “barbaric.”
“They now castrate, sterilize, and mutilate minors as well as adults,” Walsh said at the time.
Walsh amplified the accusations with an appearance on Tucker Carlson’s Fox News show on September 21 publicizing his “investigation,” while the Daily Wire co-founder Shapiro promoted the charges on his YouTube channel and podcast, detailing “nonsense garbage that a boy can be a girl and a girl can be a boy.”
The very next day, Gov. Lee issued a statement calling for a “thorough investigation.”
The accusations ignited a social media firestorm and surfaced the existence of the Tennessee Transgender Task Force, a volunteer team at Vanderbilt focused on trans health and HIV prevention, funded in part by those CDC dollars.
Weeks later, in November, the trans program’s director Dr. Pamela Talley told staff that federal dollars funding the task force, as well as Tennessee Planned Parenthood, would cease at year’s end.
Then in mid-January, the Lee administration announced it would not just end funding for those recipients, which totaled $235,000, but also that it would reject entirely a pair of CDC grants directed at HIV prevention, treatment and monitoring in the state worth more than $8.8 million.
“People have been crying all week,” one Tennessee Health Department staffer told NBC News after the announcement on January 20.
Ashley Coffield, the CEO of Planned Parenthood of Tennessee and Northern Mississippi, said the decision “felt like they were punching me in the gut.”
“I couldn’t believe that the governor would take the nuclear option,” she said, adding that she saw the move as a “political vendetta against abortion rights groups and transgender people.”
On Wednesday, newly appointed Tennessee Health Commissioner Ralph Alvarado told a state Senate committee that money from the grants would be replaced with $9 million in state funds.
Alvarado called the federal grants “cumbersome.”
“I think this is going to allow a bit of innovation, a little bit of liberty,” Alvarado testified. “I think it’s going to help vulnerable populations: people who are in human trafficking populations, mothers, children, first responders.”
But those populations, also identified by the governor’s office, are not the ones most affected by the HIV epidemic in Tennessee, experts say.
“Tennessee is preferring to fight a fictitious epidemic rather than their very real HIV epidemic,” Greg Millett, the director of public policy at amfAR, The Foundation for AIDS Research, told NBC News.
“First responders are just not at risk for HIV anywhere in the United States. Sexual trafficking is awful, but it’s not a major contributor for HIV cases in Tennessee or elsewhere.”
He added: “All of this is willful ignorance on the part of the state government.”
When State Sen. Jeff Yarbro (D-Nashville) asked Alvarado if future state funding would focus on the highest-risk groups, including men who have sex with men and intravenous drug users, the health commissioner was less than definitive.
“I imagine that the same populations they’ve been approaching will continue to receive benefits from this.”
Sanders on Monday signed the new law, which won’t take effect until this summer. It would allow anyone who received gender-affirming care as a minor to file a malpractice lawsuit against their doctor for up to 15 years after they turn 18. Under current Arkansas law, medical malpractice claims must be filed within two years of an injury.
Legal experts have said the change could close access to gender-affirming care for children by making it nearly impossible for providers to get malpractice insurance.
“Arkansas infamously passed the first law in the nation to try to ban gender affirming care for trans youth and after hearing extensive evidence, the courts have blocked that ban,” Holly Dickson, executive director of the American Civil Liberties Union of Arkansas, said in a statement. “This bill is an effort to achieve indirectly what the Constitution prohibits the state from doing directly.”
The new law is among a growing number of bills targeting transgender people, who have faced increasingly hostile rhetoric at statehouses. At least 175 bills targeting trans people have been introduced in statehouses so far this year, the most in a single year, according to the Human Rights Campaign.
The bill was signed as a federal judge is considering whether to strike down a 2021 Arkansas law that would prohibit doctors from providing gender-affirming hormone therapy or puberty blockers to anyone under 18 — or referring them to other doctors who can provide that care. No gender-affirming surgery is performed on minors in the state.
Republican Sen. Gary Stubblefield, who sponsored the malpractice law, said he didn’t know if the measure would face a similar court challenge.
“Anything can create a court challenge in the world we live in today,” Stubblefield said. “I know we did what we thought was best for our children.”
U.S. District Judge Jay Moody temporarily blocked the state’s ban on gender-affirming care for minors in 2021. Arkansas was the first state to enact such a ban, and several states have approved similar restrictions. A ban in Alabama has also been blocked by a federal judge.
Opponents of such treatments argue that minors are too young to make decisions about their futures. But every major medical group, including the American Medical Association, supports gender-affirming care for youths and has opposed the bans.
The malpractice legislation includes a “safe harbor” provision that would give doctors a defense against malpractice lawsuits over providing gender-affirming care for children, but only if they follow restrictions that experts have said are inconsistent with the standard of care for the treatments.
The new law won’t take effect until 90 days after the Legislature adjourns this year’s session, which isn’t expected to happen until next month at the earliest.
The bill is among several targeting transgender youth that have been proposed in Arkansas this year.
Others include legislation that would criminalize transgender adults using the bathroom that corresponds with their gender identity. The bill goes even further than a bathroom bill North Carolina repealed following widespread boycotts.
Dickson urged Sanders to hear from trans youth and those who care from them before signing any more bills affecting the LGBTQ community.
A decade into the era of the HIV prevention pill, called PrEP, efforts to leverage its heralded power to curb new infections have stagnated in the United States.
This shortfall is a key reason the nation lags far behind many others in combating HIV, with a national epidemic long plagued by racial inequities and only a modestly declining new infection rate.
“We are reaching a scientific crisis in HIV prevention,” LaRon Nelson, an associate professor of nursing and public health at Yale University, said last month at the Conference on Retroviruses and Opportunistic Infections in Seattle. Nelson lamented the gulf between PrEP’s impressive performance in major studies and its moderate real-world impact.
On the bright side, PrEP, which is short for pre-exposure prophylaxis and involves taking either oral or injectable prescription antiretroviral medications in advance of potential HIV exposure, has indeed achieved substantial popularity — but only among white gay and bisexual men, who have long seen a dropping HIV rate.
Such inequity persists despite the efforts of a nationwide public-health army and countless millions of dollars spent promoting and facilitating PrEP use among Black and Latino gay and bi men. Of all major intersectional demographics, these groups contract HIV at the highest rates, and transmissions among them have flatlined or barely declined in recent years.
And so, even amid the national reckoning over racial inequity, PrEP has only served to widen HIV-transmission racial disparities among men who have sex with men.
According to the Centers for Disease Control and Prevention, gay and bi men account for 70% of new cases of the virus. Whites in this demographiccomprised 15% of the 34,800 HIV transmissions in 2019, while the much smaller populations of their Black and Latino peers comprised a respective 26% and 23% of new cases.
Additionally, more than a year after the approval of a long-acting injectable form of PrEP, ViiV Healthcare’s Apretude, few are receiving it. Insurers have mostly refused to cover the expensive drug. Consequently, even after clinical trials found injectable PrEPwas dramatically superior to oral PrEP at preventing HIV on a public health level, especially among Black gay men, Apretude’s potential will likely remain untapped for the foreseeable future.
Troubling statistics
Gilead Sciences’ two-drug combo pill Truvada was approved as PrEP in 2012 and was followed in 2019 by a similar drug, Descovy. When either drug is taken daily, this lowers the risk of HIV by at least 99% among gay and bi men and transgender women, according to multiple studies.
PrEP has helped drive down HIV rates in cities where it has achieved a critical mass of popularity, such as in New York, San Francisco andSeattle. But nationally, PrEP has failed to move the needle by much.
The CDC estimates annual HIV transmissions declined by only 8%between 2015 and 2019. Cases are even rising in some states where HIV prevention investment is lacking, such as Tennessee, where Republican Gov. Bill Lee recently compounded the factors worsening his state’s epidemic by blocking $8.3 million in annual CDC prevention funding.
Approximately 814,000 gay and bi menin the U.S. are good PrEP candidates, the CDC estimates. Between 2017 and 2022, the number of people using PrEP, who have always overwhelmingly been gay and bi men, at any point during each given year increased from 155,000 to 382,000. However, a CDC study presented in Seattle found that in September 2022, just 187,000 people were on PrEP within that 30-day window, suggesting that many people do not take it for long.
PrEP’s increasing popularity likely could have put a major dent in the national HIV rate had its use more closely reflected viral-transmission demographics, according to HIV prevention experts. Of the CDC’s estimate of 21,900 new HIV cases in 2019 (the most recent year for which the agency has produced a transmission estimate) in the three largest racial groups among gay and bi men, a respective 23%, 41% and 36% were in whites, Blacks and Latinos. But a lopsided 69% percent of PrEP users last year were white, while only a respective 9% and 18% were Black and Latino.
Apretude’s approval promised progress
Approved in December 2021, Apretude requires receiving an injection by a health care worker every two months. Compared with providing trans women and men who have sex with men Truvada as PrEP, giving them Apretude was associated with a 66% lower overall HIV diagnosis rate in a major clinical trial.
Apretude’s superior efficacy was driven by the fact that participants adhered better to the injection schedule than to the daily pill regimen.
Dr. Hyman Scott, an HIV prevention expert at the San Francisco Department of Public Health, reported at the Seattle conference that of the 844 Black American participants in the trial, those randomized to receive the injectable drug had a 72% lower HIV rate than those who got Truvada.
His analysis suggests that if 10,000 similar Black gay and bi men and trans women were followed for one year, approximately 50 would contract HIV if given Apretude, while 200 would test positive if provided Truvada.
Such sobering findings about Truvada’s shortcomings are in keeping with previous studies finding relatively low rates of adherence to the daily PrEP regimen among Black gay men. Such data suggests that even if HIV prevention advocates succeeded in vastly increasing oral PrEP access in this population, it might have only limited impact among them.
Referring to Apretude, Scott told NBC News, “Whether we can get this rolled out in communities is the real question.”
Cost is a major rub. Since 2021, Truvada has been available from multiple generic manufacturers and now often costs as little as $25 to $35 per month, although in some cases up to $600. ViiV lists Apretude at $1,878 per month, and few insurers are covering it.
The recent CDC PrEP-use study presented in Seattle found that only about 1 in 200 PrEP prescriptions were for Apretude in September.
“There are patients who are getting Apretude now, but it’s people who have health care access, who have health care literacy, who call their insurance companies and yell at the right people,” said Dr. Anu Hazra, a physician at the LGBTQ-focused Howard Brown Health in Chicago.
Since 2021, almost all insurers have been obliged under the Affordable Care Act to cover oral PrEP with no out-of-pocket costs for the medications or the quarterly clinic visits and lab tests required to maintain a prescription. This is because in 2019, an advisory body known as the U.S. Preventive Services Task Force gave PrEP an “A” rating for being a worthy preventive tool.
In December, the task forceissued a draft decision granting Apretude its own “A” rating. If this rating is made official this year, insurers will be required to cover Apretude, and with no cost sharing — but not until January 2025.
Apretude updates
In addition to the associated burden of having to come in six times per year for injections, Apretude does have a notable shortcoming: Breakthrough HIV cases are apparently much more likely among those taking injectable versus oral PrEP.
Of the 25 people who contracted HIV in the 2,282-person Apretude arm of the injectable-versus-oral PrEP trial among gay and bi men and trans women, six did so after getting their injections on schedule, according to a presentation in Seattle by Dr. Susan Eshleman, a professor of pathology at Johns Hopkins Medicine.
Eshleman’s team has not yet calculated the per capita Apretude breakthrough infection rate, but when these researchers initially reported last year that the trial saw seven breakthrough infections (before revising this figure down to six), their calculations suggested that if 10,000 similar men and trans women were followed for one year, 15 would contract HIV despite receiving on-schedule Apretude injections.
At the same Seattle conference, Hazra reported the first breakthrough HIV case in an Apretude patient outside of a clinical trial. By comparison, nearly four years passed after Truvada’s approval as PrEP before a breakthrough infection was first documented in someone faithfully taking that drug.
All this suggests that for those with a history of taking daily oral PrEP on schedule, switching to Apretude would actually increase their HIV risk; although the absolute risk of infection would remain low.
Optimism in the pipeline
HIV prevention experts report excitement about the PrEP pipeline and expectations that in the coming decade, more convenient and longer-acting forms will be approved.
“I’m wildly optimistic,” said Sharon Hillier, a prominent HIV prevention researcher at the University of Pittsburgh. “We just have to work through how to deliver these interventions and how to be less burdensome for health care systems.”
The Seattle conference heard promising early stage research findings regarding medication-infused suppositories that could be placed into the rectum or vagina up to 48 hours following sex and likely prevent HIV. And researchers are developing implants that could be placed under the skin and emit preventive medication for many months.
Gilead is also running major PrEP trials of the drug lenacapavir, which requires an injection only every six months. Dr. Jared Baeten, who leads Gilead’s HIV strategy, said the company hopes to provide initial study results by 2025.
But if Apretude’s pacing is any guide, it could be 2030 before lenacapavir is both approved and widely covered by insurers.
In the meantime, PrEP advocates continue to express dedication to work with the options currently on the table, albeit within a complex and fractured health care system that proves alienating to many of those most at risk of HIV.