Legislative Lessons: How Three States Improved Access to HIV Prevention Medications
Our knowledge of how to prevent and treat AIDS—the syndrome caused by untreated HIV—has increased tremendously since 1981, when the virus was first documented in the United States. Once a death sentence, HIV is now a manageable, chronic disease. Options for preventing HIV infection now include highly effective pharmaceuticals that decrease the likelihood of getting HIV by up to 99 percent when used as prescribed. Unfortunately, these medications—pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP)—are underutilized. Uneven access (or complete lack of access) to health care providers authorized to prescribe PrEP and PEP contributes to this problem.
One way policy is addressing this challenge is by implementing legislation that allows pharmacists to prescribe PrEP or PEP to patients. States that allow pharmacists to initiate PrEP and/or PEP are increasing in number, although they accomplish this through different policy mechanisms. It can be useful for lawmakers interested in advancing similar legislation in their state to consider how others have done it. For example, Arkansas, Florida, and Louisiana—three states that have recently expanded access—have comparatively high rates of new HIV diagnoses and lower PrEP use relative to the number of people who could benefit from it. This makes interventions that aim to increase PrEP and PEP use vitally important.
We recently highlighted these states in a series of explainers that summarized each state’s policy process and the strategies they used to pass pharmacist-prescribed PrEP and/or PEP legislation. This analysis synthesizes key takeaways from those explainers.
Key Takeaway #1: Engage Stakeholders Early and Often
It was clear that bill sponsors in all three states had dedicated considerable time to meeting with stakeholders. Generally, more individuals and organizations registered support for the bills than opposition, and what opposition there was decreased as the bill progressed. It was also clear that bill sponsors worked with their fellow legislators to rally support for the bill, as all three passed both chambers unanimously. The behind-the-scenes work of listening to and addressing the concerns of stakeholders and other legislators was key to getting these bills across the finish line.
Key Takeaway #2: Prepare to Compromise
Simply meeting with stakeholders is not enough—policymakers must also respond to their concerns. Florida’s bill is a great example of this, as it underwent several significant changes before its passage. Even though some stakeholders testified that they wanted the bill to be more comprehensive, they did not withdraw their support. Louisiana’s bill also demonstrates the importance of being willing to compromise to address concerns raised by stakeholders and other legislators. Sometimes a bill will end up less comprehensive than when it was filed. It is important to embrace incremental policy change in these cases, as small successes can offer evidence that further action is needed.
Key Takeaway #3: Frame Legislation Strategically
Knowing the audience and considering their perspectives can also improve the legislation’s chance of passing. In Arkansas, the bill sponsor focused on provider shortages that cause access issues and the economic impact of new HIV infections. Florida’s bill sponsors focused on how the bill would improve health care delivery options and public health, emphasizing the short window in which PEP can be started. Louisiana’s bill sponsor often referred to the bill as providing a “framework” that allowed state medical boards and experts to promulgate the specific prescribing rules. All bill sponsors considered their state’s unique circumstances, health care landscape, and legislative environment when framing their bills, which doubtlessly contributed to their success.
Conclusion
With expanded use of medications that prevent HIV, it is possible to decrease the number of people who get the virus. Although no causal link has been established, studies have found that increased PrEP use is associated with fewer new HIV diagnoses. To realize the full potential of these medications in the fight against HIV, it is necessary to implement novel strategies to reach people who can benefit from PrEP or PEP. Legislation that allows access to these medications through pharmacists is one such strategy.
Pharmacist-Prescribed Medications to Prevent HIV
Medicines known as pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP), are underutilized. Learn how these three states passed pharmacist prescribed PrEP and/or PEP legislation.