Courtesy of Steve Ahlquist

Legislation that will help reduce the spread of HIV transmission by making HIV-prevention and post-exposure medications accessible and covered by insurance, including newer injectable formulations, was signed into law today at Open Door Health in Providence, RI's only LGBTQ+ dedicated primary care and sexual health clinic.

There are two commonly used HIV-prevention medications: pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP). PrEP is taken before exposure to prevent HIV, whereas PEP is taken after potential or known exposure. Together, the treatments have contributed to a dramatic reduction in HIV transmission rates in recent years. But only about 25 percent of individuals at risk of HIV transmission are using these treatments, according to the United States Centers for Disease Control and Prevention (CDC). Advocates point to both out-of-pocket costs and lack of access as barriers.

The legislation (2023-S 0563Aaa) requires the coverage of PrEP and PEP drugs by health insurance plans at no out-of-pocket costs to patients. The bill would also enable pharmacists to prescribe them to eligible patients. The bill outlines clear guidelines for which patients would be eligible.

"I'm old enough to remember when contracting HIV meant an automatic death sentence,said Senator Melissa Murray (Democrat, District 24, Woonsocket, North Smithfield), who sponsored the legislation in the Rhode Island Senate. “When those first cases emerged, very little was known about the disease, and by the time most patients presented with symptoms, they only had months to live. In the United States, when the disease was first seen in already marginalized communities among gay men, intravenous drug users, and sex workers, public policymakers were slow to respond. I have friends who recount stories of attending nonstop funerals during that time. I watched as dozens of their friends, their lovers, and their chosen family members died, one after another.

The history of this epidemic is fraught with stigma, discrimination, and disparity based on sexual orientation, race, and socioeconomic status. But this history is now one of hope. The fact that we have drugs that prevent the transmission of HIV is remarkable, and some people might even call that revolutionary.

"But a cure for a disease cannot be revolutionary unless it is accessible to all people. That's why this legislation is so important because ending the HIV epidemic here in Rhode Island and across the United States is now within our reach. By allowing pharmacists to prescribe these treatments, we are also ensuring that they're easily accessible for all patients. PrEP and PEP treatments are tested, they are safe, and they are highly effective. In fact, these treatments can reduce HIV transmission to nearly zero.

"We should be proud that our state has been a national leader on this front, and we have made amazing progress over a short few years," continued Senator Murray. "What we are celebrating today is a critical step to ensure that no one lacks access to PrEP and PEP because of cost, especially the most at-risk members of our communities. This legislation will ensure that Rhode Islanders have sustainable access to lifesaving preventative tools that will make a difference in everyone's lives. I'm really honored to have sponsored this bill, and I remain committed to the work to end HIV in our state."

The CDC recommends that all adults test at least once for HIV in their lifetime and more frequently if engaging in behaviors that may place a person at ongoing risk of infection.

Prep's been approved since 2012, so it's been over a decade, and this bill is meant to address a lot of the problems that we've been hearing,said Philip A. Chan, MD, an infectious diseases specialist and the Chief Medical Offer at Open Door Health. “We are here today to celebrate a major public health win for the state of Rhode Island. PrEP and PEP are important public health interventions to help people who are HIV-negative stay HIV-negative. They're going to have tremendous benefits, both for our patients here, as well as for the entire LGBTQ community across Rhode Island.

"These bills address things like cost, which is a major barrier, prior authorizations, and I think most excitingly they also cover injectable PrEP, which is one of the big advances for HIV prevention. The cost has been the biggest barrier there. This bill will hopefully ramp up injectable PrEP here in the state.

"This law is one of the most comprehensive in the country. I just don't want to underestimate that. This is really a big step forward.

Several of us started the first PrEP program in the state around 2012, and it's due to the efforts of people in this room. We are one of the top five states, according to the CDC, for PrEP prescribing rates. Due to these efforts, we've had a lot of success in Rhode Island and this bill is building upon that. We are one of the states that is closest to ending the epidemic, and that is exciting. This puts us one step closer."

For people that may be at risk of HIV, PrEP is initiated before and continued throughout periods of potential exposure to HIV. It was first approved by the United States Food and Drug Administration in 2012 and is safe and highly effective when taken as prescribed. PEP is taken after potential exposure, such as a broken condom, shared needle, or sexual assault. If taken within 72 hours of a possible HIV exposure, the drug is highly effective at preventing transmission.

By mandating insurance coverage, limiting prior authorizations, and reducing out-of-pocket costs for PrEP and PEP treatments, this law will expand access to these critical treatments and play a direct, significant role in helping Rhode Islanders proactively protect themselves against HIV,” said Dr. Amy Nunn, executive director, Rhode Island Public Health Institute, in a statement. “This is one of the most progressive public health policies in the country, and we applaud Governor McKee and the General Assembly for their leadership in getting it across the finish line.

Both treatments are considered preventative, and free coverage had been required under the Affordable Care Act. But on March 30, in a case called Braidwood Management Inc. v. Becerra, United States District Judge Reed O’Connor ruled, among other things, that this requirement violated the religious freedom of employers. The case is expected to head to the United States Supreme Court.

A growing list of states, including Maine, Nevada, and Virginia, have passed similar legislation.

The Rhode Island Department of Health (RIDOH) has additional information online about HIV prevention, including PrEP and PEP.