A person in a sheer black shirt rests their arm on the shoulder of another person who is looking forward. Both are looking in opposite directions.

Ensuring the Access to PrEP

On September 7, a federal judge in Texas ruled that a requirement of the Affordable Care Act that mandates insurers and employers to offer free coverage of drugs that prevent HIV infections violates the Religious Freedom Restoration Act and infringes on the rights of employers (Texas Tribune). The ruling could threaten access to preventative medicine like PrEP, which is shown to decrease the rate of new infections with increased access and use (Aidsmap). Such a move would greatly impact Black and Brown people in the South, especially in Texas, which has the second highest number of new HIV diagnoses, where access to the medicine is already inaccessible (CDC).

The first HIV/AIDS case was officially reported by the CDC more than 40 years ago (NBC News). Since then, there have been incredible advancements in HIV treatment options. Today, antiretroviral therapies can suppress HIV enough to help HIV-positive people live with undetectable amounts of the virus.

HIV prevention options have greatly expanded as well. Pre-Exposure Prophylaxis (PrEP) medication can reduce a person’s risk of contracting HIV through sex by 99% and their risk of contracting it through intravenous drug use by 74% (CDC).


• Support the Transinclusive Group, a Black trans-led group offering HIV services in South Florida.

• Educate yourself about AIDS history and Black efforts to address historical inequities.

• If you need PrEP, the Ready, Set, PrEP program provides access to the medication at a low or no cost.

But communities with the highest rates of HIV actually use PrEP the least. Men who have sex with men (MSM) – including gay and bisexual men and those who don’t identify as either – are at higher risk of contracting HIV. Though Black and Latinx MSM are five to ten times more likely to contract HIV than white MSM, white MSM both know about and use PrEP at higher rates than men of color (CDC). One reason for this discrepancy is the barriers people of color face in accessing care.

PrEP medication access is hardest for patients in the South, where 56% of Black Americans live (Pew Research). Thirty-eight percent of Affordable Care Act Marketplace health plans in southern states require prior authorization before individuals receive PrEP, a rate significantly higher than anywhere else in the country (JAMA). Requiring prior authorization means the insurance company will only cover treatment if the company approves it before the treatment is prescribed (TikTok). This increases the burden on doctors’ offices and causes delays in treatment. “Prior authorizations have been cited by clinicians as being one of the biggest barriers for PrEP uptake,” according to Dr. Kathleen McManus, who researched the subject (UVA). Ninety percent of physicians stated prior authorizations delayed patients’ access to care, and 75% said that can cause patients to abandon treatments (AMA).

Each year, 50% of new HIV cases occur in the South (CDC). Out of those new HIV cases in Southern states, Black women comprise 67% of cases in women, Black men are 70% of cases in men, and out of men who have sex with men, 50% of new cases are Black men (CDC). Insurance company policies create unnecessary hurdles for accessing crucial HIV prevention measures in a high-risk region where Black people are at disproportionate risk. This constitutes a deadly form of structural racism.

The government and medical establishment’s approach to HIV/AIDS has always been rooted in discrimination. Ronald Reagan’s administration refused to prioritize AIDS research and treatment in the 1980s since it was viewed as a “gay plague” (NBC News). It took years of activism and pressure from groups like ACT UP for the passage of the Ryan White Cares Act in 1990 to mandate serious federal funding and attention to HIV care and treatment (HornetHistory). Despite the historical framing of HIV as a virus that primarily affected gay white men, Black and Brown people have consistently been overrepresented in the HIV-positive population. They have also long been central to AIDS activism and resistance (Drain).

In the words of Raniyah Copeland of the Black AIDS Institute, “HIV is a disease that affects the most marginalized: Black and brown people, LGBTQ+ people, people living in poverty, people who don’t have housing, people experiencing substance addiction, and so many others who aren’t able to thrive simply because of who they are, who they love, or where they live” (Black Aids Institute) The prior authorizations that delay access to HIV prevention medication are the product of healthcare corporations and government policies that place little emphasis on HIV and other health conditions that disproportionately affect Black and Brown people and members of other oppressed and marginalized communities.

Southern state governments have the power to create laws that require their state healthcare plans on the exchange to include coverage of PrEP medications without requiring prior authorization. They must act. In the meantime, organizations like South Florida’s Transinclusive Group are working to ensure HIV prevention isn’t pushed to the side for Black and Brown folks (Instagram). We must fix a system where discriminatory barriers block entire communities from life-changing treatments.


• PrEP dramatically reduces the risk of HIV-negative people contracting HIV.

• Black people in the South are at high risk of contracting HIV, but many ACA insurance plans in southern states require an additional step, prior authorization, before getting PrEP.

• The government has long neglected HIV research and HIV-positive people because of systemic discrimination against queer people, people of color, poor people, and drug users.

*This piece was originally published on 6/16/21. It was updated and edited by The ARD on 9/26/22.

3456 2592 Tiffany Onyejiaka

Tiffany Onyejiaka

Tiffany Onyejiaka is a storyteller interested in educating and enlightening the world about topics ranging from Black history and culture to science and public health (and how diverse topics intersect. She is also passionate about helping to craft dynamic social justice and change in her local community. Tiffany is currently studying Environmental Health at Johns Hopkins Bloomberg School of Public Health. You can follow her on twitter @TEOnyejiaka or read her writing at tiffanyonyejiaka.com.

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