The Michigan Department of Community Health has received more than $6 million for HIV prevention from the Centers for Disease Control and Prevention and still has a pending request for $1.2 million in additional funding. And while the money will be used to increase testing and assist those who test positive for HIV to receive medical care sooner, the state declined to request funding for medications that can prevent infections of those exposed to the virus -- something that has been proven to be successful at preventing HIV and has even been recommended by the CDC.
Such prevention methods are called nonoccupational postexposure prophylaxis (n-PEP) and pre-exposure prophylaxis (PrEP). In situations where a person has been exposed to HIV via sex or needle-sharing, physicians can prescribe a 28-day course of anti-retroviral medications called n-PEP. While those medications are powerful, they are also incredibly successful at preventing infection when applied within 72 hours of exposure. But the prescription is costly -- as much as $1,000, depending on the prescription drugs used.
PrEP is the daily use of the anti-HIV drug Truvada by HIV-negative persons. A 2010 study found PrEP had a significant impact on new HIV infections in high risk men who have sex with men. As a result, the CDC issued guidance for the use of PrEP in men who have sex with men.
While n-PEP has been an approved prescription by the CDC since 2005 and the World Health Organization since 2006, MDCH did not adopt policies related to the prescription measures until April 2011. An investigation by our former sister site the Michigan Messenger in 2009 found that access to n-PEP varied based on where a person lived.
The state has not approved PrEP guidance at all.
The Ingham County model
Michigan has a program to assist those living with HIV to access the costly medications, but MDCH does not have any similar program to help those at risk access the medications. In 2011, state health officials said paying for nPEP prescribed under the new policy would be the responsibility of the patient.
In fact, the state could have requested funding for both prescription interventions, but chose not to.
“We did not pursue nPEP or PrEP because we focused our efforts on addressing known gaps in services relative to priority needs and on demonstrably effective interventions which could feasibly be supported within the level of resources for which we were eligible,” said MDCH spokesperson Angela Minicuci.
Minicuci told The American Independent that only Ingham County currently offers n-PEP prescriptions.
Marcus Cheatham, spokesperson for Ingham County Health Department, said the county has begun instituting the CDC guidance from 2011 for the administration of PrEP for high risk, HIV-negative men who have sex with men.
“These are the same dollars we use to support our Prevention for Positives program. The state did receive a decrease in funds,” Vennisha Smith, director of STI programs at Ingham County, told TAI in an email. “The CDC has a push for funding Expanded HIV testing ... and linkage to care (which will probably include PrEP and nPEP [prescriptions]). All [are] programs we currently offer.”
Michigan losing HIV-prevention funding
Meanwhile, Michigan faces a loss of 33 percent of its federal HIV funding by 2014. This is the result of a federal realignment on how the CDC determines where the money is needed most. Before this year, funds were sent to states based on their cumulative number of HIV cases, rather than the current number of HIV cases. As a result, California and New York were consistently getting huge chunks of federal funding, while southern states, where the epidemic has started growing more recently, were unable to fund basic services.
And that funding issue is hitting the state and local departments like Ingham.
“What the state wants to give us for HIV/AIDs is constant,” Cheatham said in a email to TAI. “There have been NO staffing changes or reductions in ability to test, etc. The annualized amount would be equal to a half million dollars per year same as last year. But what has changed is this: We used to get this all at once in an annual allotment. But what the state will get from CDC is uncertain. To cope with this MDCH is now giving us the money quarterly. In other words we are only funded for the next three months. Hopefully CDC pulls a rabbit out of a hat and we get through the year intact.”
In order to pay for nPEP and PrEP for low-income residents of the county, the county has added the prescription intervention to the Ingham Health Plan, a free health discount plan administered by the county. The program has an approved list of prescriptions that it will cover, and participants pay only $5 as a co-pay.
And while there is access to funds and medications for those in Ingham County, which has the highest HIV rate outside Wayne County and Detroit, the rest of the state has not caught up. That has activists expressing concern.
“First of all, with PREP, the number of people for whom that is their *only* option to protect themselves is very, very small. It also is still largely hypothetical, in scale, so not pursuing that doesn't bother me at all,” said Sean Strub, co-chair of the Global Network of People with HIV (GNP+) of North America. “nPEP, on the other hand, is an effective intervention in an emergency situation, when someone thinks they might have unintentionally become exposed.
"It is atrociously callous for the state of Michigan to leave those people to a lifetime of HIV infection--and the incumbent expense on the taxpayers--when it could so easily be avoided, in most circumstances, with readily available nPEP," he continued. "It is penny-wise and pound-foolish to not make nPEP widely and easily available at no charge.”
Michigan in a 'state of denial'
With more than 50 percent of the HIV cases in Michigan found in the men-who-have-sex-with-men category, Emily Dievendorf, policy director for Equality Michigan, also expressed concern.
“Focusing funding on continued care in light of an aging HIV positive population in Michigan is necessary but to do so at the expense of prevention efforts demonstrates an alarming state of denial," Dievendorf said. "Michigan is experiencing increased pressure to educate youth as minimally about HIV, pregnancy, and STD prevention as possible. We are seeing direct results of these omissions in the steady increase in documented new cases of HIV in teens and young adults. Only recently have Michigan health departments received any formal briefing and suggested protocol in relation to life-saving nPEP and PrEP. This means more, not less, of a commitment needs to be made by the Michigan Department of Community Health to increasing familiarity and availability of nPEP and PrEP."
The lack of developing avenues of access for nPEP and PrEP ought not be lost on the state's hardest hit region -- metro Detroit. In Detroit, over half of the zip codes have HIV prevalence rates between 3 and 5 percent; one zip code has a prevalence rate of 6 percent, according to MDCH statistics. The state also reports that nearly two-thirds of all HIV cases in the state are located in Southeast Michigan, including Detroit. And many of those cases are found in African-Americans, the state reports in "The Annual Review of HIV trends in Southeast Michigan (2005-2009)," the most recent review.
The rate of new HIV diagnoses is consistently highest among those of black race. In 2009, the rate of new diagnoses among blacks was 9.7 times higher than that of whites. The rate of new diagnoses for black males was 8.6 times higher than that of white males. The disparity is even more pronounced among females, with the rate among blacks 27 times that of whites.
That report concludes that black men who have sex with men, particularly youth, are significantly more at risk of infection with HIV.
Those numbers and demographics are similar to what is being found throughout the country, particularly in the South. And the research findings related to PrEP led the National Black Gay Men's Advocacy Coalition to issue a white paper in December 2011 calling for more funding for research and more demonstration projects looking at PrEP as a prevention tool.
Such prevention tools will be absent from Michigan's hardest hit communities if the state does not ask for the money to fund them.
Image: AMERICAN INDEPENDENT/Todd Heywood