The first time Dallas resident Rafael Ruiz de Velasco heard about PrEP in 2017, it wasn鈥檛 from his doctor. It was from a dating app.
鈥淏ecause people were saying 鈥榦n PrEP鈥�, and I was like, 鈥榃hat is this? What does that mean?鈥欌�� Ruiz de Velasco said. 鈥淚 thought I was just getting old and they're using some kind of new lingo.鈥�
PrEP stands for pre-exposure prophylaxis, a medication that prevents about . There are a few kinds of PrEP: Truvada and Descovy are once-a-day pills, and Apretude is a .
The CDC recommends PrEP for people who are high-risk, like gay and bisexual men, men who have sex with other men, and people who inject drugs. But the CDC recommends have a conversation with their doctor about PrEP.
Ruiz de Velasco didn鈥檛 have health insurance but wanted to get on PrEP 鈥渢o do something proactive.鈥� But when he asked, his doctor had no idea the medication existed.
鈥淚 just assumed all medical professionals would know what this is,鈥� Ruiz de Velasco said. 鈥淚 don't understand how that's not part of their dialogue, especially when you have a gay male client.鈥�
Doug Hardy, a physician with the HIV and sexually transmitted infections (STI) organization , said taking a pill a day to prevent HIV seemed unimaginable back in the 1990s.
鈥淚t used to be people take a handful of pills a few times a day,鈥� Hardy said. 鈥淎nd it was so hard to take the medications. You had to take another handful of pills just to take care of all the side effects. So, it's really, really changed.鈥�
Hardy said one way to think about PrEP is in the context of other kinds of prophylaxis, like travelers getting , or birth control pills to prevent pregnancy.
鈥淲hen someone gets exposed to HIV, either sexually or through IV drug use, then those medications already in their blood system will counteract the HIV infection, and prevent that person from becoming infected with HIV,鈥� Hardy said. 鈥淭he idea is to prevent that person from ever getting HIV in the first place.鈥�
And in a state like Texas, , prevention methods like PrEP are a key part of the . But not everyone who鈥檚 at risk can afford it or find a doctor to prescribe it. Stigma, health insurance, poverty and access all impact people鈥檚 ability to find HIV care in the state.
Doctor education as a barrier to HIV care
Primary care and family providers can be unequipped to have conversations about HIV, because routine STI testing . Hardy said this is common among doctors who haven鈥檛 made this care 鈥減art of their practice.鈥�
鈥淎 lot of people really don't want to, they鈥檙e not comfortable with it,鈥� he said. 鈥淢aybe it's something that they're not comfortable talking to people about. Maybe they have different judgments about it, or some kind of stigma that they're thinking about. But it's not available everywhere.鈥�
In one , researchers found other barriers to discussing PrEP: Doctors weren鈥檛 taking sexual histories; they assumed their patient wasn鈥檛 engaging in sexual behavior that might put them at risk for contracting HIV; their patient wasn鈥檛 comfortable discussing their sexual history; and, they were worried prescribing PrEP would mean a patient would stop using condoms and engaging in safe sex practices.
Jeffrey Campbell is the CEO of Allies in Hope, . The Houston nonprofit helps people with HIV access health services, housing support, and prevention education. He said if doctors don鈥檛 know how to support their patients, it can stop people from getting tested or seeking treatment altogether.
鈥淏y the time a person comes in and asks you, they know they need it,鈥� Campbell said. 鈥淪ometimes they're doing it just as a part of their sexual health screenings, but a lot of times there's a concern.鈥�
But Campbell said he still hears from folks that their doctors will tell them to 鈥済o to an infectious disease specialist if you want a PrEP prescription.鈥�
鈥淚f they get up the nerve to ask the question, and the doctor basically pooh-poohs that, it's already been a struggle to get there and to get those words out,鈥� Campbell said. 鈥淭hey're like, 鈥極K, I don't need it. I'm good because my doctor told me that I don't need it.鈥� Those words carry a lot of weight.鈥�
How affordable is PrEP?
Affordability is another barrier to HIV prevention care. When Ruiz de Velasco鈥檚 doctor finally prescribed him Truvada, he didn鈥檛 realize how expensive it could be without insurance.
Gilead Sciences, the pharmaceutical company that makes Truvada, charges .
鈥淭he pharmacist told me how much it was going to be and he just looked at me like, 鈥楢re you sure you want this?鈥欌�� Ruiz de Velasco said. 鈥淚 didn't know it was going to be that much. I can鈥檛 afford that. So, we had to take it back, and it was disappointing.鈥�
PrEP鈥檚 accessibility has been an issue since the U.S. Food and Drug Administration approved Truvada . The U.S. House of Representatives held a investigating the rising cost of the drug.
Robert Grant, a professor with the University of California who led clinical trials of Truvada, testified that the drug can be but has a 35,000% markup from Gilead.
Rochelle Walensky, who also testified at the hearing, said the cost meant most people who received PrEP were 鈥渨hite gay men in the Northeast and the West Coast,鈥� even though most new HIV infections are in the South among Black and Latinx men.
鈥淭he way that PrEP was initially rolled out, it wasn't covered by insurance,鈥� Campbell said. 鈥淭he people who got on it were rich, white gay men, because they could afford it.鈥�
New data from the CDC shows there鈥檚 still . About 94% of white people who could benefit from PrEP were prescribed it in 2022, in comparison to 13% of Black people and 24% of Latinx people.
Jonathan Mermin, the director of the at the CDC, said while PrEP usage has been increasing, 鈥渢he encouraging results also highlight the gaps.鈥�
鈥淏ringing information about PrEP, and ensuring that there's appropriate resources, and that we all have the access that we need, continues to be an issue,鈥� he said.
A 2020 study from the estimated that HIV care could cost between $420,000 to a little over $1 million for someone鈥檚 entire life. But under the Affordable Care Act (ACA), which means that
A challenged that provision in 2022. A Christian for-profit company argued it shouldn鈥檛 have to cover PrEP for employees under the ACA, because it would 鈥渇acilitate and encourage homosexual behavior.鈥�
Anyone can contract HIV, regardless of sexual orientation, and in 2020, .
A Texas judge ruled that this coverage violated the company鈥檚 religious freedom, but the federal government challenged the lawsuit in May 2023. The lawsuit is on hold for now.
There are programs that help people without insurance afford PrEP, like the federal , along with that offer services on a sliding scale.
Five counties in Texas鈥斺�� are also part of the national Ending the HIV Epidemic initiative, which focuses on places in the United States Those counties receive additional government funding to improve access, education, prevention and treatment for HIV.
Prism Health North Texas also launched a in October for people anywhere in Texas.
HIV funding
After understanding the out-of-pocket cost for one month of PrEP, Ruiz de Velasco thought he just wouldn鈥檛 be able to access it without insurance. A friend told him about Prism Health North Texas, which at the time had a program to help people pay for PrEP and the lab work needed every few months.
When he got to the clinic, he spoke to a doctor who answered all his questions and 鈥渄id a thorough examination鈥� that 鈥渃overed all the bases.鈥� He was even tested and got treatment for an STI he didn鈥檛 know he had.
鈥淲ithout having insurance, I wouldn't ask a doctor to screen me for everything under the sun, but Prism, they did,鈥� Ruiz de Velasco said. 鈥淎nd as a result, I was able to get well again.鈥�
Doug Hardy with Prism Health North Texas said the organization sees patients with and without insurance, but the funding for their work can fluctuate every year.
鈥淪omething that's funded by the county, the state, federally, the CDC, the National Institutes of Health, may be funded one year or may not be funded the next year,鈥� he said. 鈥淭hat makes it a little bit challenging to always provide the same care at all times.鈥�
One of the funding sources clinics used to rely on was Gilead, the maker of Truvada, which provided reimbursements that often paid for services for low-income or uninsured patients. But that program stopped in 2022, which meant clinics across the United States had to cut back on services and .
That鈥檚 what happened at Prism Health North Texas. The organization cut community STI testing and education about HIV treatments due to funding issues. The organization also laid off about earlier this year.
鈥淚t makes a difference to the person that鈥檚 actually being attended to,鈥� Ruiz de Velasco said. 鈥淐utting short on staff, people that have become your rock after a while and then are no longer there鈥t鈥檚 just like, woah, what happened?鈥�
The other funding issue in Texas is the large uninsured population. Almost 17% of Texans are uninsured, , and like Ruiz de Velasco, many people can鈥檛 afford to pay for doctor鈥檚 visits or prescriptions out of pocket.
鈥淭here's things you have to sacrifice,鈥� he said. 鈥淯nfortunately, your health is one of them, when the cost is high.鈥�
Medicaid expansion and HIV in Texas
One reason for Texas鈥� high uninsured population is because it鈥檚 one of 10 states that has . Nationally a , which covers HIV treatment, care and testing.
It鈥檚 the 鈥渓argest source of insurance coverage for non-elderly adults with HIV,鈥� according to the . The federal government spent about $13 billion on Medicaid services for people with HIV in 2022. But in Texas, many of those people don鈥檛 qualify because of the .
鈥淚f I can't, as a patient, afford [PrEP], I just can't afford it,鈥� Jeffrey Campbell with Allies in Hope said. 鈥淎nd we're talking about every month. Some of this continues to happen鈥here there's lack of Medicaid expansion.鈥�
Guillermo Chac贸n, the president of the , said 鈥渓ack of access to health care is still a fundamental issue鈥� with trying to end the HIV epidemic in the United States.
鈥淚 can tell you that people will be in a better place if they have access to health care and get the benefit of the coverage,鈥� Chac贸n said.
Since Medicaid makes up almost , but since Texas hasn鈥檛 expanded the program, that means clinics like Prism Health North Texas are unable to access millions of dollars of funding.
That bothers Ruiz de Velasco. He鈥檚 helped friends and family get tested for HIV and educated others from what he learned at the clinic.
鈥淚 don't understand the delay with wanting to fund a program [that] prevents any kind of disease from wreaking havoc upon your life,鈥� he said. 鈥淚 just wish there was more funding for the people that are trying to make a good difference in someone's life.鈥�
In the meantime, Ruiz de Velasco is doing what he can to take care of his sexual health. PrEP is just another part of his 鈥渘ightly routine.鈥�
鈥淚t's right there next to my toothpaste,鈥� he said. 鈥淚 brush my teeth, I take my pill, and then I go to bed. I can sleep at night easy, knowing that my body's being taken care of.鈥�
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