This special edition of JLME centers on a novel proposal for a national PrEP access program with the potential to break through a failed status quo.

The U.S. has the tools to end the HIV epidemic, but progress has stagnated. A major gap in U.S. efforts to address HIV is the under-utilization of medications that can virtually eliminate acquisition of the virus, known as pre-exposure prophylaxis (PrEP). This document proposes a financing and delivery system to unlock broad access to PrEP for those most vulnerable to HIV acquisition and bring an end to the HIV epidemic.

The efficacy of pre-exposure prophylaxis, PrEP, with antiviral agents for prevention of HIV infection has been demonstrated in multiple randomized controlled trials and demonstration projects. These trials have studied prevention at the individual level. The effectiveness of PrEP as a public health intervention to reduce HIV incidence at community and population levels is being actively evaluated but is less well described. In reviewing the available data on PrEP as a public health intervention, three significant examples have demonstrated success, and all have been among communities of gay, bisexual and other men who have sex with men (MSM).

The complexity and inefficiency of the U.S. health care system complicates the distribution of life-saving medical technologies. When the public health is at stake, however, there are alternatives. The proposal for a national PrEP program published in this issue of the Journal applies some of the lessons of the national COVID vaccine campaign to HIV prevention. In doing so, it draws on other examples of public health approaches to the financing of medical technology, from vaccines for children to hepatitis C treatment.

Antiretroviral pre-exposure prophylaxis (PrEP) is protective against HIV. Low utilization rates amongst HIV vulnerable populations are due in part to the high cost of PrEP. Generic PrEP offers the potential to improve health at significantly reduced costs. In this study, we examine early utilization patterns and prices for generic PrEP. We discuss the opportunities and challenges for generic PrEP to improve health among HIV vulnerable populations.

Using an implementation science framework, we detail how a national system for covering both standard and telemedicine laboratory testing would support a national PrEP program. Implementation strategies that will facilitate success include minimizing provider burden through uncomplicated billing systems and minimizing patient burden through centralized, online access systems. We anticipate that providing telemedicine and in-person laboratory testing options will optimize PrEP care by making it less burdensome, leading to cost-effective healthcare and improved population health.

Prior to the recent introduction of generic TDF/FTC in the U.S., access to pre-exposure prophylaxis (PrEP) for HIV was greatly limited due to the downstream effects of the high cost of the medication. This article argues that despite drug copay cards and patient assistance programs, the promise of drastically reduced HIV diagnoses has never been fully realized, and more policy reforms on drug pricing are needed to make ending the HIV epidemic a reality.

Inequities in HIV pre-exposure prophylaxis (PrEP) use persist in the United States. Although scientific advancement in delivery options and social acceptance of PrEP has occurred in the past decade, gaps remain in ensuring that this sexual health program is available to all. Components of what a national PrEP program for all would look like are discussed.

Transgender and gender diverse (TGD), Black, and Latinx communities have long borne a disproportionate share of the U.S. HIV epidemic, yet these same key demographics are continually underrepresented in national PrEP prescriptions. Black, Latinx, and TGD individuals are also more likely to be uninsured, meaning that a proposed federal program to cover PrEP for people without insurance could provide significant benefit to potential PrEP users from these populations. However, coverage of PrEP costs alone will not end disparities in uptake. This commentary provides additional context and recommendations to maximize effectiveness of a national PrEP program for TGD, Black, and Latinx populations in the US.

The proposed national PrEP program would serve people who are uninsured as well as those enrolled in Medicaid. In this article, the authors propose a set of recommendations for the proposed program’s implementers as well as state Medicaid agencies and Medicaid managed care organizations to ensure PrEP access for people enrolled in Medicaid, addressing gaps without undermining the important role of the Medicaid program in covering and promoting PrEP.

The paper identifies common barriers and challenges to Pre-Exposure Prophylaxis (PrEP) uptake and offers considerations for state and local public health departments to address barriers and retool infrastructure to increase access to PrEP to new users. Authors identify synergistic opportunities with federal agencies and funders to advance PrEP-related HIV prevention efforts, that prioritize strategies and investments to provide PrEP to people who could benefit from the intervention but are unaware of PrEP or struggle to access it. Barriers discussed and examined include financing strategies to reduce financial burden of PrEP medication, expanding PrEP access and outreach beyond clinical settings, and increasing the network and reach of the provider community to serve people we oppress through policy choices and discourses of racial and socioeconomic inferiority.