Hill notes that while PrEP intake is trending in the right direction, many obstacles exist to access the treatment.
"We know that young adults in particular are at higher risk of not having health insurance," Hill said. "A lot of our patients are experiencing long wait times to get appointments with their doctor, or they have to see someone new that maybe they don't feel comfortable talking about a sensitive topic, like their sexual health."
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An additional challenge is ensuring patients remain on PrEP by taking it consistently as prescribed, which is often as a single daily dose taken orally.
Dr. Lauren Snyder, a family medicine doctor at Corewell Health in Grand Rapids with a focus on LGBTQ health, said PrEP has become more accessible as costs come down.
"It's really been the affordability that has been the biggest barrier to my patients," she said.
Tenofovir disoproxil fumarate and emtricitabine (TDF/FTC), a PrEP medication originally released by Gilead Sciences as Truvada, came off patent in 2020. Its generic competition helped drive down the medication's price.
"The best kind of PrEP is a PrEP you can get consistently," Snyder said.
To that point, the U-M study found a decline in how long people remain on PrEP after starting the medication.
Hill says there's multiple possibilities to explain that trend, including existing restrictions to access and the expansion of PrEP prescriptions to a broader patient population that may be less likely to acquire HIV. Some patients take PrEP "on-demand" before potential exposure, which can lower the number of pills dispensed.
"We see two potentially positive outcomes, which are rising dispensing and rising initiation. And then that third outcome, the persistence was decreasing," Hill said. "That's the one that raises a little bit of concern for wanting to better understand what's happening there."
Legal challenges to the Affordable Care Act's preventive services requirement could stop employers and insurance companies from fully covering PrEP and other treatments like contraceptives, cancer screenings and HPV vaccines.
A group of businesses and individuals, led by the Christian-owned business Braidwood Management, raise a religious objection to covering PrEP, saying it "encourage[s] homosexual behavior, intravenous drug use, and sexual activity outside of marriage between one man and one woman."
The lawsuit, originally filed in a federal court in Texas in 2020, was argued before the Supreme Court in April. The case focuses on whether the appointment of the US Preventive Services Task Force, the independent panel responsible for recommending PrEP, is constitutional. Plaintiffs argue the task force's recommendations can be overridden by the US Health and Human Services secretary, a job currently held by Robert F. Kennedy Jr.
While a decision on the case is pending, LGBTQ and HIV advocacy groups worry that reducing access to PrEP would jeopardize the safety of Americans.
"The elimination of no-cost preventive care measures like PrEP will force the nation into another HIV outbreak despite the existence of preventive measures proven to minimize communicability," a national alliance of HIV, LGBTQ and health care organizations wrote in a brief for the case.
"While decades of bipartisan efforts to decrease the incidence and prevalence of HIV/AIDS and similar public health crises have monumentally improved public welfare, eradication and continued health promotion are contingent on widespread access to preventive care measures.
Michigan doctors like Lauren Snyder worry how the court case could impact continued coverage for PrEP.
The Preventive Services Task Force "puts out recommendations that we know there are really good cost-benefit analyses for and also really good evidence that our patients benefit from," she said. "My hope is that we're able to continue to follow good science."