California Lawmakers Push to Protect Free HIV Prevention Amid Legal Threats

More than 40 years after the national HIV/AIDS epidemic began, San Francisco still holds the reminders — in memorials, in murals, in the stories of survivors and in the voids left by the tens of thousands of deaths — of the deep loss suffered during that time.

“I came of age as a gay man in the late 1980s during the absolute worst period in the AIDS crisis, with gay men and others having a mass die-off,” state Sen. Scott Wiener said. “It was absolutely terrifying.”

That story is not just one of loss but also eventual triumph. Medical advancements mean that people with HIV can live longer with minimal to no risk of transmitting the disease to partners. And highly effective preventative treatments like preexposure prophylaxis, better known as PrEP, help people avoid contracting HIV.

“When PrEP came around, for me and for so many other people, it was a game changer that we actually had a tool to protect our health and to stay negative,” said Wiener, who was the first elected official to publicly acknowledge being on the medication. “PrEP is an absolutely essential part of any strategy to end new HIV infections.”

Public health experts now hope to dramatically reduce the number of HIV transmissions by the end of the decade, but a lawsuit filed by a business in Texas against parts of the Affordable Care Act could derail ambitions.

The lawsuit, currently under review by the Supreme Court, questions the constitutionality of a mandate requiring that health care providers offer some preventative care, including for HIV, at no cost. In response, Bay Area legislators are pushing to enshrine the no-cost mandate for HIV prevention medication in state law.

Wiener and Assemblymember Matt Haney introduced legislation in the state Assembly on Thursday that seeks to protect the no-cost-sharing requirement for existing HIV prevention treatments — and for treatments that could become publicly available in the coming years.

“There are so many people who have lost their lives, who have lost loved ones over a number of decades,” Haney said. “California, I think, has a responsibility — certainly San Francisco does as well, to step up and say this medication needs to be protected. It needs to be made available for all who need it.”

A Promising Future for PrEP

In 1987, San Francisco reported roughly 5,000 new HIV cases per year. In recent years, that figure has fallen below 200 and is trending downward.

Public health experts attribute that drop in large part to the development of preventative treatments like PrEP. The medication most commonly comes in pill form and is taken daily or before sexual activity to reduce transmission risk. Postexposure prophylaxis, known as PEP, is taken in the hours after sexual activity for the same purpose.

The Food and Drug Administration approved PrEP in 2012. In the years since, San Francisco has seen a 67% decline in new HIV diagnoses, according to Susan Buchbinder, director of Bridge HIV, an HIV prevention research unit within the San Francisco Department of Public Health.

“The U.S. Preventive Services Task Force gave PrEP an A rating, which means that there’s really substantial evidence that it makes a dramatic difference in prevention of HIV acquisition,” Buchbinder said. “So it should be covered for everyone, free of charge. That’s not always the case, but it should be the case. And it really would make a huge difference.”

An injectable version of PrEP requires a shot every two months, and a dosage that lasts six months is currently under FDA review. The proposed legislation would require healthcare providers to offer an option for oral medication and different injection cycles.

“What we want to do is not only ensure that insurance providers in California cover this critical preventative care that can help us eliminate HIV transmissions,” Haney said. “But also that we cover these new forms of medication that will be even more effective because they cover people for longer periods of time.”

Buchbinder believes the six-month version of PrEP will be enticing.

“We know that an every-six-month injectable will appeal to some people and could really make a difference in increasing the number of people who are on PrEP because, for some people, taking a daily pill isn’t very practical,” Buchbinder said.

Working Toward Zero HIV Transmissions Eradicating HIV in the United States has been a goal for many since the epidemic first broke out. In 2019, President Donald Trump set a deadline to end the disease within a decade.

“Scientific breakthroughs have brought a once-distant dream within reach. My budget will ask Democrats and Republicans to make the needed commitment to eliminate the HIV epidemic in the United States within 10 years,” Trump said during his State of the Union address.

An initiative led by the U.S. Department of Health and Human Services, Ending the HIV Epidemic in the U.S., set out to decrease transmissions by 75% by 2025 and 90% by 2030. However, 2023 had more than 38,000 cases nationwide, according to preliminary data. That’s up from the more than 36,000 documented cases in 2019, the year Trump made his pledge.

Locally, things look more hopeful. Not only are new yearly transmissions in the low hundreds, but other data points look promising as well. Of the people who have HIV in San Francisco, 95% are estimated to be aware of their status, and more than 90% receive care within one month of diagnosis, according to federal data.

“So many people have not only dreamed but have worked towards this reality that we are now able to actualize,” Haney said. “Because of this medication, we can actually get to zero new transmissions a year, and there are so many people who have lost their lives, who have lost loved ones over a number of decades who have dreamed of this moment.”

Buchbinder acknowledged it is an aggressive target.

“We are really working hard on that goal here in San Francisco … We think that there need to be additional tools that would help get us towards that goal.”

While Buchbinder did not express confidence that new cases could be all but eliminated by the turn of the decade, she was confident that keeping the medication affordable and accessible is key to continuing current trends.

“Cost is always an issue, particularly for preventive treatments,” she said. “People often don’t have the funds to pay for PrEP, and so having government coverage of that and having insurance coverage of that is really a key part of [the] rollout of PrEP.

“We know that when people lose their insurance coverage, they often go off of PrEP, and that’s when they may be vulnerable to acquiring HIV.”