The Centers for Disease Control and Prevention (CDC) estimates that 1.2 million Americans over the age of 13 are living with Human Immunodeficiency Virus (HIV), the virus that causes Acquired Immunodeficiency Syndrome (AIDS). Prevention of new HIV transmissions, along with diagnosis, treatment, and quick response to outbreaks, is among the key strategies identified by the Health Resources and Services Administration (HRSA) to end the HIV epidemic in the United States.

As part of the federal government’s goal of reducing new HIV infections by 90% by 2030, two policy approaches that states can employ for HIV prevention are highlighted: provision of Pre-Exposure Prophylaxis (PrEP) medication and availability of Syringe Service/Exchange Programs (SSPs/SEPs). Both interventions are cost-effective and can lead to significant cost-savings for states over time, particularly as Medicaid bears the largest cost-burden for HIV care.

New HIV infections have decreased over the decades since the virus was discovered, but prevention of HIV transmission remains challenging for states. Nationally, 220 counties across 26 states are in the midst of or at risk of an HIV outbreak among people who inject drugs. Forty-eight percent of young people who inject drugs report sharing syringes, which significantly increases the risk of HIV transmission, and people who inject drugs make up about 10% of U.S. HIV diagnoses.

Pre-Exposure Prophylaxis (PrEP) is an oral medication that, when taken consistently and as prescribed, reduces the risk of HIV infection by approximately 74%–84% in people who inject drugs and nearly 99% in HIV-negative men who have sex with men (MSM), heterosexual men, and heterosexual women. Providers are encouraged to prescribe PrEP as a preventive measure to patients who engage in sexual behavior or injection drug use that increases their risk of exposure to HIV infection.

Build Provider Confidence and Capacity: Despite the number of individuals that qualify for PrEP services, there are not enough providers trained in prescribing and administering PrEP to realize the full prevention capacity of this intervention. The regions of the U.S. with higher rates of new HIV diagnoses also have lower rates of PrEP use, and just nineteen percent of federally qualified health centers (FQHCs) operating in the country’s largest metropolitan areas have PrEP services available. Primary care providers (PCPs) are able to prescribe and provide PrEP in primary care settings but frequently report feeling ill-equipped or hesitant to prescribe PrEP. States have a number of strategies to improve provider confidence and increase capacity to prescribe PrEP:

• Use Project Echo to train more providers on PrEP. Project ECHO is an educational model through which a specialist provides clinical guidance via telemonitoring to another clinician rendering services to improve clinical capacity. Beginning in 2015, the Washington State Department of Health, in collaboration with the University of Washington, began incorporating PrEP into an existing HIV-specific Project ECHO program. In the first three years of the PrEP program, the program has held talks on PrEP and hosted case discussions which have supported community providers on PrEP related questions. As part of their prevention efforts, Washington also worked to identify clinicians in the community willing to prescribe PrEP and developed tools and other resources to healthcare systems, including a decision tree on how to pay for PrEP.
• Integrate PrEP into primary care. Recognizing the potential preventive impact of PrEP, New York integrated PrEP statewide within primary care and HIV specialty care The State Department of Health worked with the New York City Department of Health and Mental Hygiene to design a PrEP toolkit for primary care providers and developed a PrEP provider directory. The state’s AIDS Institute published PrEP clinical guidelines on its website, which have since been updated, and NYC developed a PrEP provider FAQ resource and created an email address specifically for questions regarding PrEP. New York’s efforts to raise awareness about and provider confidence in PrEP resulted in a fourfold increase the number of Medicaid recipients receiving the medication.
• Encourage pharmacists to prescribe PrEP. As accessible community providers, pharmacist provision of PrEP can reduce barriers to access and at the same time, reduce stigma associated with the medication. California passed a law that allows pharmacists who have undergone training to provide PrEP without a prescription. The law also prevents health insurers from requiring prior authorization and mandates coverage of pharmacist-prescribed PrEP. Iowa’s telehealth PrEP (telePrEP) program similarly relies upon pharmacists to maximize access to PrEP services through a collaborative practice agreement with the University of Iowa. Colorado and New Jersey also permit pharmacists to prescribe and dispense PrEP.

Leverage TelePrEP: States are supporting telePrEP in order to increase access to HIV prevention services and reduce associated stigma. In Iowa, nearly three quarters of all HIV cases are within 10 of the state’s 99 counties, none of which are near large cities. The state’s Department of Public Health conducted a community assessment to inform the creation of a telePrEP program that mitigates transportation and location-based barriers to access. Louisiana has implemented a similar telePrEP program, and although the state is still working to improve program retention, data show that is has been successful in engaging hard-to-reach individuals; 61% of continuing clients were from rural parts of the state, and all of Louisiana’s nine health care regions were represented.

PrEP services can be cost-prohibitive; medications for PrEP can cost up to $2,000 per month for those without insurance. While most state Medicaid programs cover PrEP medications, the majority of states do not provide payment parity for the provision of telehealth services, although there are some exceptions (e.g., Arizona, Colorado, and New Hampshire). Iowa funds its telePrEP program using savings from HRSA’s 340B Drug Pricing Program. The program also received a four-year $2 million CDC grant in 2018, which has been used to expand the reach of telePrEP services and evaluate the program’s effectiveness and replicability.

Engage Community Health Workers: States are also leveraging community health workers (CHW) to increase access to Medicaid-reimbursable preventive services, including HIV prevention and treatment care. The Centers for Medicare and Medicaid Services (CMS) changed a rule in 2013 to allow non-licensed practitioners, including CHWs, to deliver preventative services that are recommended by a physician. Louisiana and Rhode Island employ CHWs through Medicaid managed care organizations, FQHCs, community organizations, health departments, and others for HIV care.

CHWs fill non-clinical gaps in HIV prevention and treatment by connecting individuals to services community outreach and care coordination. A report prepared by Boston University with support from the Health Resources and Services Administration (HRSA) on integrating CHW into HIV care recommends active engagement between CHW and Ryan White Planning Councils, including through the development of leadership roles and career opportunities on the councils themselves. In Louisiana, HIV/AIDS is the second most common condition that CHW reported addressing in their work.

Other states are utilizing peer navigators to increase access to and comfort with PrEP. Florida relies on HIV peer navigators to connect patients with providers, field patient questions, and assist in connections to health care and social services. Florida’s use of HIV peer navigators has led to improved engagement and re-engagement in HIV care and treatment and more empowered HIV-positive clients. In Louisiana, patients are referred to the state’s telePrEP program through the state’s Health Hub where they can self-enroll or discuss directly with the state’s telePrEP navigator. Once a client is engaged in the program, a provider will e-prescribe PrEP to a client’s pharmacy, and the medication will be mailed directly to the patient. The telePrEP Navigator plays the vital role of keeping patients engaged by connecting with them regularly to ensure medication delivery and adherence, discussing any side effects, and scheduling follow-up appointments.

SSPs provide comprehensive harm reduction services — screening and treatment for communicable diseases, referral to treatment for SUD and OUD, and sterile syringes and other equipment — and are cost-effective and produce cost savings for states. They have played an important role in decreasing HIV transmission among people who inject drugs by providing sterile injection equipment and safe syringe disposal and connecting individuals with needed treatment and other supportive services.

Although states have historically been able to use federal funds to support SSPs, federal rules previously prevented states from using those funds to purchase syringes. States may, however, use the recently announced $30 million appropriated through the American Rescue Plan Act for harm reduction services to purchase sterile syringes for SSPs. Of the 32 states with laws that specifically allow the operation of SSPs, Colorado, Ohio, Georgia, Delaware, and Rhode Island all require SSPs to provide HIV screening services to SSP clients. Other states, such as California, Florida, and New York, include language in their SSP authorizing statutes recognizing the role these programs play in preventing HIV transmission.

New York City realized a four percent annual reduction in new HIV infections among the injection drug user population when it increased its SSP capacity from 250,000 syringes/year to 3,000,000 syringes/year. Five months after Indiana opened SSPs in response to its 2015 HIV outbreak, only 22% of SSP clients reported sharing injection equipment, as opposed to seventy-four percent before the SSP opened. Almost all injection drug users surveyed indicated that they used the SSP; as a result of the uptake of SSP services, Scott County experienced a 96% reduction in new HIV infections by 2018, though the site was recently closed.

SSPs are cost-effective and can help states realize cost-savings over time because of the disease burden they prevent. An analysis of Kentucky Medicaid claims data showed that counties with syringe exchange programs (SEP) have lower rates of disease associated with intravenous drug use, including HIV and hepatitis C, indicating that the state’s SEPs are helping to decrease potentially costly communicable disease burden. Philadelphia’s and Baltimore’s SEPs together prevented over 12,000 new cases of HIV over the span of a decade, which translated into millions of dollars of savings for each city every year. States may use several strategies to maximize the potential of SSPs:

• Increasing legal access to sterile syringes. People who use drugs are frequently hesitant to use SSPs due to perceived risk of interaction with law enforcement, which may contribute to more syringe sharing and unsafe syringe disposal. Syringes, whether or not from SSPs, may be considered paraphernalia under some state statutes. Several states have taken steps to decriminalize possession of drug paraphernalia and personal use amounts of scheduled substances in an effort to reduce drug user interaction with law enforcement. New Mexico decriminalized possession of drug paraphernalia, lowering the penalty for possession with intent to use to a $50 fine and the penalty for possession with intent to deliver to a misdemeanor. Virginia exempts the possession of syringes obtained from a harm reduction program from the definition of illegal drug paraphernalia.
• Funding to support HIV prevention, testing, and referral to treatment. Sustainable funding is a perennial issue for SSPs, as programs must frequently piece together budgets through multiple grant-based funding sources. However, when SSPs receive public funding, communities experience improved syringe distribution and increased access to treatment and prevention services, which results in reduced or maintained low rates of HIV. New York’s drug user health hubs are enhanced SSPs that provide a more comprehensive array of services, including HIV testing and treatment, as well as PrEP services. Drug user health hubs provide a bundle of Medicaid-reimbursable harm reduction services, such as Hepatitis C treatment, mental health services, and SUD services including MOUD.

Looking Ahead

Despite the progress that has been made toward preventing HIV infections and improving outcomes for HIV-positive individuals across states, the U.S. still experiences 38,000 new cases each year and spends $20 billion annually on HIV. One of the four goals of the HIV National Strategic plan is to reduce new HIV infections, but the U.S. will see an estimated 400,000 additional HIV diagnoses over the next decade if action is not taken.

Recent federal actions and resources can support states as they work to implement and expand HIV prevention strategies designed to reduce rates of new HIV infections. Funding allocated to states in the ARPA totals $30 million in new investments for harm reduction, and this renewed support of harm reduction services underscores the effectiveness of these approaches.

States have played a key role in preventing new HIV infections by strengthening and maximizing access to PrEP and harm reduction services, particularly for vulnerable populations. It is more important now than ever that states bolster HIV prevention infrastructure, as the COVID-19 pandemic has significantly disrupted the provision of HIV preventive care. Despite the willingness and capacity to provide HIV care virtually, PrEP prescriptions and the number of new PrEP users both decreased between March and September 2020, and SSPs have had to reduce their in-person services due the pandemic, which has impacted syringe exchange and HIV screening.

Acknowledgments

This toolkit was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award under the National Organizations of State and Local Officials (NOSLO) cooperative agreement totaling $836,859.00. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov. The authors would like to thank HRSA project officer Diba Rab and her colleagues for their guidance and helpful feedback.