State Legislative Activity Supports Federal Evidence-Based HIV Prevention Initiative

December 15, 2021 | Rachel Scheckman

Across the nation, public health agencies have mounted herculean efforts to stem the COVID-19 pandemic while addressing a pre-existing HIV epidemic and an opioid crisis that is serving as a source for many new HIV outbreaks. Tackling these public health crises simultaneously presents significant challenges as overdose deaths have spiked in the past year while HIV resources have been diverted leading to lower testing rates, fewer prescriptions for as pre-exposure prophylaxis (PrEP) and a decrease in HIV treatment, all of which will are likely to increase the number of acute HIV infections.

Since 2019, federal and state governments have invested significant resources into the Ending the HIV Epidemic (EHE) in the U.S. initiative, a four-pillared approach that includes diagnosis, treatment, prevention, and response. These guidelines and supports offered to jurisdictions through EHE have the potential to counter this unintentional impact of the COVID-19 pandemic. Under the pillar of prevention, the Centers for Disease Control have encouraged participating EHE jurisdictions to design plans that would allow them to scale up evidence-based interventions such as PrEP and syringe services programs (SSPs).

Reducing Stigma will Increase PrEP Uptake

PrEP is a once-daily pill that, when taken consistently, can reduce the risk HIV transmission via sexual activity by 99% and injecting drugs by up to 84%. Despite the benefits of PrEP, barriers—including financial, educational, access to care, stigma, and distrust of medical providers—remain for groups most at risk for infection.

Stigma may prevent people from accessing HIV prevention, care, and treatment. For example, potential PrEP users may fear that others will think they are using PrEP to treat HIV or assume that they are participating in injection drug use or sexual behaviors that put them at higher risk for HIV. Reducing the steps needed to access this essential preventative medication could improve the chances of someone initiating a regimen of PrEP.

States have passed or considered several policy options to overcome these hurdles. In 2020, California and Colorado passed legislation allowing pharmacists to dispense PrEP without a prescription. In 2021, Oregon and Virginia followed suit and enacted similar bills. Other states, including Massachusetts, are also considering legislation reducing steps in initiating PrEP to increase patient follow-through and PrEP uptake. Following revelations that insurers denied coverage to patients who use or have used PrEP in the past, Delaware passed legislation to prevent insurers from discriminating against PrEP users.

In addition to these state policies, CDC has updated its guidance and is recommending that all physicians speak to their sexually active patients about PrEP and prescribe PrEP to any patient that asks.

States Supporting Safe Syringe Exchange

Syringe Service Programs (SSPs) are an effective harm-reduction intervention aimed at reducing the risk of HIV transmission among people who inject drugs. These programs provide a wide range of services, including access to and safe disposal of syringes and other injection equipment, access to substance use disorder treatment, and testing and linkage to care for HIV and other infectious diseases. Estimates show that these programs reduce the incidence of HIV and hepatitis C by approximately 50%.

A significant barrier to SSP uptake is state drug paraphernalia laws that criminalize and stigmatize the possession of syringes. These regulations made it hard to access sterile syringes, increasing the risk of reuse and infection with bloodborne diseases including HIV. Since 2014, states have amended laws to ease the way for SSPs to open. Between 2014 and 2018, 14 states changed their laws to allow for SSPs, and 12 states removed barriers to implementation. By August 2019, 38 states Washington, D.C. enacted legislation removing legal impediments to SSPs, and 33 states had laws allowing people participating in an SSP program to legally possess syringes.

In 2021, states implemented legislation in line with EHE prevention policies to reduce new HIV diagnoses. Arizona enacted a law authorizing SSPs and in Missouri a similar bill passed the senate. A Kentucky law allows the sale of syringes at pharmacies without a prescription, and Connecticut authorized SSPs to dispense up to ten (10) syringes per person per transaction by machine. The New Jersey Assembly is considering several actions around SSPs, including a bill allowing the state Department of Health to establish SSPs and prevent municipalities from closing these programs.

Legislators Proposing Supervised Consumption

Similar to SSPs, supervised consumption sites have the potential to provide many services to reduce the harmful impacts of injection drug use. They allow people who inject drugs to self-administer their substances under medical supervision—a service SSPs currently cannot offer. Studies have demonstrated that supervised consumption sites are an effective strategy in reducing the spread of HIV and other complications as clients have access to clean equipment and medical personnel trained in overdose reversal.

Rhode Island enacted legislation to start a pilot program for two safe consumption sites housed at existing SSPs; the state is working with communities to open the sites but does not expect to do so until 2022. Legislators from six other states (New York, Illinois, California, Massachusetts, New Jersey, and Missouri) have proposed legislation allowing for supervised consumption sites or pilot programs that would allow states to monitor the impacts of the sites before committing to longer-term programming. On Nov. 30, 2021, New York City Mayor Bill di Blasio announced the city had opened the nation’s first safe consumption sites.

Conclusion

Stigma and structural barriers have fed the fire of both the HIV and opioid epidemics. EHE has emphasized a focus on preventative measures. The new National HIV/AIDS Strategy updated for 2022-2025 refocuses these efforts on the disparities and inequities that have resulted in unequal access to HIV prevention, testing, and care with a greater emphasis on harm reduction lending more support to measures that will reduce stigma. States are addressing stigma and acknowledging the importance of HIV prevention strategies, such as SSPs and PrEP, which will help us to continue to address the HIV epidemic, while managing the effects of the COVID-19 pandemic. In the meantime, ASTHO will continue to monitor this important issue.

The development of this blog post is supported by the Health Resources and Services Administration of the U.S. Department of Health and Human Services under grant number 2 UD3OA22890-10-00. Information, content, and conclusions will be those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government.