PrEP must be available behind bars

IN AN EFFORT to reduce HIV transmission, the Biden administration released new guidance in July mandating that medical insurers provide free access to medication that prevents transmission of HIV. Although the guidance calls for waiving all fees and co-pays associated with medication, clinic visits, and blood work, it’s clear that it’s true purpose is to make pre-exposure prophylaxis (PrEP) more widely available.

PrEP is an antiretroviral medication that blocks HIV from replicating in the body. When it is taken daily, it reduces the risk of becoming HIV positive by more than 90 percent. Between 2015 and 2019, annual new HIV infections in the United States fell eight percent to approximately 34,800. This was after years of seeing approximately 38,000 new HIV infections per year. The breakthrough in prevention is largely attributed to greater use of PrEP among those who are most vulnerable to HIV infection: gay, bisexual, and transgender people, especially those who are also BIPOC, and people who inject drugs.

Despite its efficacy, only 23 percent of people who could benefit from PrEP are prescribed it. That’s why it was so incredibly disappointing to see that the Biden administration’s guidance doesn’t mandate the availability of PrEP to people who are incarcerated.

While I was serving a criminal sentence in the Massachusetts Department of Correction, I witnessed people sharing needles while using injectable drugs, and engaging in consensual sex without the use of condoms. Both behaviors are highly effective at transmitting HIV from one person to another. Yet clinicians in Massachusetts are prohibited from prescribing PrEP to people who are incarcerated. Why? Because we are supposed to pretend that people in prison do not have sex or inject drugs and therefore do not need PrEP. That’s why three percent of all new cases of HIV in the state between 2016 and 2018 were diagnosed among people who are incarcerated in state prisons.

Here in Massachusetts, we like to proclaim being first in so many areas of human rights ranging from being the first state to abolish slavery in 1790 and the first to recognize the marriages of same-sex couples in 2004. But we have a very long way to go in recognizing the humanity, dignity, health, and safety of those the state incarcerates. (Many people, including me, wonder whether that system should be abolished as well.)

Other states have already begun making significant efforts to curb HIV transmission within prisons and jails. In 2014, the California General Assembly passed the Prisoner Protections for Family and Community Health Act, which mandated condoms be made available to incarcerated people. Even though consensual sex is prohibited, policymakers acknowledged that consensual sex happens. For those who choose to take that risk, they should have tools to protect themselves. Since passage of the law, condom dispensing machines have been made available in semi-private areas throughout California correctional facilities. According to one pilot study, after condoms were introduced in California prisons, there was no increase in disciplinary infractions for engaging in consensual sex. This should allay fears that providing PrEP would encourage more such banned activity.

It’s not uncommon for formerly incarcerated people to struggle through the confusing labyrinth of the re-entry process or fall on hard times. The uncomfortable truth is that some of these people will relapse on drugs, engage in unprotected sex, or turn to sex work. We could almost guarantee none of them would be vulnerable to HIV in the period just after release if they left prison or jail PrEP-ed up with a 30-day supply in their hands.

State Rep. Jack Lewis and Sen. Julian Cyr have sponsored a bill called the RIGHTS Act that would make PrEP available to people who are incarcerated and offer a 30-day supply of this life saving medicine upon their release. This is a critical public health measure to ensure that those who have sex or use IV drugs while incarcerated or upon release from custody are protected from HIV.

If we are serious about reducing HIV transmission, then we must make PrEP available to people who are incarcerated. To do otherwise is to say that we value some lives more than others.

Michael Cox, a former prisoner, is the executive director of Black and Pink Massachusetts, a group working for abolition of the criminal legal system. He was appointed by the attorney general to serve on the state’s Special Commission to Study the Health and Safety of LGBTQI+ Prisoners.