repeal and replace

Matthew Limpede takes a pill that gives him protection, peace of mind, and a reassuring sense of community.

That pill is the drug Truvada, more commonly referred to as "PrEP" (Pre-exposure Prophylaxis). And it's been a game-changer in the fight against HIV/AIDS.

"I think for the whole [gay] community and for me personally, [PrEP has] lifted us up to a place of being more responsible for our own health," Limpede explains.

If taken as directed, PrEP is 99% effective in stopping the transmission of HIV. It's mostly used by HIV-negative men and women who are more at risk of exposure to the virus.

From Limpede's own experiences, the drug isn't just about personal protection, either — it has encouraged more gay and bisexual men to have important conversations about staying safe with their sexual partners, building a sense of openness and honesty within the LGBTQ community. Those conversations have helped destigmatize those who are HIV-positive, too, he says — people who can live long and healthy lives while being sexually active.

The only way Limpede was able to get on PrEP was because of an insurance plan provided through the Affordable Care Act in 2014.

And he's definitely not the only one.

Jim Pickett, director of prevention advocacy and gay men's health at the AIDS Foundation of Chicago, says about 110,000 people across the U.S. started using PrEP between 2012 and February 2017. The ACA played a big role in making that happen.

"PrEP is quite a robust intervention," he says. "It's not just a niche thing for gay men."

Making PrEP more accessible has become an increasingly important component of a broader strategy to prevent HIV among groups most vulnerable to the virus, such as transgender women, gay men — particularly gay men of color — and cisgender (non-transgender) black women, according to Pickett.

While PrEP accessibility has grown significantly in the past few years, it's just the tip of the iceberg, Pickett says. About a million more people living at high risk of HIV exposure are good candidates to go on the drug if we can just keep expanding efforts where they're needed most.

Under the current Congress and administration, however, that's shaping up to be quite the tough task.

If the Affordable Care Act is repealed, access to PrEP would take a blow, causing a major setback in our fight against HIV/AIDS.

Without health insurance, the price tag for PrEP is about $1,500 a month. With insurance, most people pay between $0 and $500.

Without significant help from an insurer, most Americans can't afford PrEP. Through the ACA's Medicaid expansion, which mostly helped low-income folks — notably, the same groups most affected by HIV/AIDS — PrEP was made accessible in 31 states plus Washington, D.C. Other patients, like Limpede, found the drug was available for free through their ACA plans.

This progress would be reversed under the American Health Care Act, the GOP's plan to "repeal and replace" the Affordable Care Act (aka Obamacare). In the new proposal — one that would cause an estimated 24 million Americans to lose their health care coverage over the next decade — the ACA's Medicaid expansion would phase out. As a result, thousands of people — again, mostly the at-risk groups who desperately need it — would lose access to PrEP.

New HIV diagnoses fell 19% overall from 2005 to 2014, according to the CDC (although progress has been uneven depending on demographics, with some groups seeing increases). With repealing the ACA, we risk reversing this long-term trend.

"If Trumpcare were to be enacted as written, it would be a devastating blow to all of our HIV efforts, both care and prevention," Pickett says. "It would be absolutely devastating."

"If less people are on PrEP, we'll have more HIV infections," Pickett emphasizes. "HIV is forever — that's a cost forever — and that's an increased burden on a system that's overburdened."

Although living a long and healthy life while being HIV-positive is possible, that's only the case for people with access to ongoing health care and treatments that don't come cheap or easy.

For people like Limpede, who has even contemplated moving from Texas to Massachusetts if it means keeping his health care and PrEP access intact, tossing aside life-changing provisions isn't just politics as usual.

It's deeply personal.

"Repealing something like this — that's going to hurt minorities, that's going to hurt people who are low on the socioeconomic scale. It feels very pointed and purposeful," he says. "That's definitely a concern."

The HIV/AIDS advocacy community is getting ready for a battle because this is a fight they can't afford to lose.

"The community's main focus now is making sure that Trumpcare does not see the light of day and stopping these harmful provisions in the bill from happening," Limpede says. "We're fighting tooth and nail."