Right-wing politicians are stoking renewed moral panic about HIV

In May, just before Pride Month, the Centers for Disease Control and Prevention released news worth celebrating: 2021 saw the lowest numbers of new HIV diagnoses in decades. New HIV infections were down 12% from 2017 to 2021, thanks to successful prevention efforts, including PrEP. The end of the epidemic may finally be in our grasp. Prevention methods now include a medication called PrEP (for pre-exposure prophylaxis), and uptake has never been higher.

But lawmakers and judges may undo this progress by cashing in on the political capital of renewed moral panic about HIV.

Perhaps the most well-known threat to HIV prevention comes from the case Braidwood Management Inc. v Becerra, in which self-identified Christian business owners challenged their obligation to provide health insurance covering PrEP and other preventive services. They found a friend in Judge Reed O’Connor, who agreed that covering PrEP harms their religious freedoms and, further, that this medication “facilitates and encourages homosexual behavior, intravenous drug use, and sexual activity outside of marriage.”

This contradicts a wealth of evidence showing that an individual’s choice to take PrEP doesn’t define their sexual orientation or relationship status, nor does it influence use of injected drugs. Nevertheless in April, as part of his ruling on Braidwood, O’Connor issued a nationwide injunction on cost-free preventive health care for all Americans. The decision is temporarily stayed amid a national uproar and a robust response from the Department of Justice. But higher courts may affirm this precedent. If his ruling stands, my colleagues and I project that Judge O’Connor will be responsible for 2,000 entirely preventable new HIV infections in the coming year if even a small proportion of private insurers refuse to cover PrEP.

Other threats to HIV prevention have received far less attention. In May, Florida’s governor signed a legislative version of Braidwood. SB 1580 shields healthcare providers and insurance companies who refuse to provide or pay for care that conflicts with “sincerely held religious, moral, or ethical beliefs.” Though not named, HIV prevention clearly hangs in the balance. This overbroad and cruelly inclusive law makes Florida a test case for an ideologically driven approach to health care. Other states may replicate it, which will harm people along the fault lines of race, socioeconomic status, sexual orientation, and gender identity.

Also this year, Tennessee shocked the public health community by refusing $9 million in federal funds for HIV testing, treatment, and prevention. This move grants the state tighter control over nonprofits that serve people with increasingly politicized health needs, such as abortion and gender-affirming care, but infections are more expensive to treat than they are to prevent. Researchers estimate that it will cost $255 million in public funds to treat hundreds of preventable new HIV infections.

All of this is dire because PrEP is 99 percent effective in preventing HIV. Like a vaccine, PrEP prevents the virus from entering cells in the body. It’s uniquely valuable because it does not rely on condom use or partner disclosure to prevent infection. The United States Preventive Services Task Force — an independent, volunteer panel of medical experts — gives it a Grade A recommendation.

Let’s be clear about who needs PrEP most and why. Systemic racism stands between communities of color and state-of-the-art HIV treatment and prevention. But thanks to novel community health approaches, PrEP is breaking through and its benefits are profound. The privacy of PrEP tackles stigma and empowers women in intimate relationships. PrEP protects families, because more than one-third of parents with HIV fear touching or kissing their children. PrEP also dismantles the intolerably high lifetime risks of infection faced by Hispanic/Latino and Black men who have sex with men, which approaches 50% without solid prevention.

For those whose political fates depend on costly victories in the raging culture wars, it makes sense to resurrect the moralism that made HIV a global crisis.

But our public servants have a duty to protect the evidence-based tools and community health networks that are getting us there. The federal government must codify protections for all preventive health care, including PrEP. States in which it is politically feasible must do the same, as an added layer of protection. And higher courts must reject religious beliefs that reek of moral panic and finally establish judicial precedents that protect public health.

Meredithe McNamara is an assistant professor at the Yale School of Medicine, a specialist in adolescent medicine, and co-founder of the Integrity Project, which promotes the use of scientific evidence in health policy.