This commentary uses the terms “queer” and “Hispanic/Latino.” The terms are chosen to encompass a spectrum of non-heterosexual orientations, providing broader perspective on the issues discussed, and to resonate with a wide demographic while acknowledging the diversity within these communities. Additionally, “MSM” (men who have sex with men) is utilized in line with health care research to address specific health dynamics without assuming sexual orientation.

Here in 2024, we have the benefit of highly effective medical regimes for both the prevention and the treatment of HIV. We should be long past the days of HIV-positive individuals suffering from their condition, or of any concern about transmission. And yet, here in 2024, HIV is still a debilitating, even life-threatening matter for many Americans. Queer Hispanic/Latino men are among the most vulnerable.

The disparities that this population face in accessing HIV prevention and treatment are dramatic, and are rooted in socio-economic and systemic factors. In 2019, Latino MSM accounted for more than 75 percent of new HIV infections among all Latino people in the United States. Despite the Affordable Care Act (ACA) expanding access to HIV prevention medications, the gains have been unevenly distributed, disproportionately benefiting white populations and leaving behind queer Hispanic/Latino men and, more broadly, people of color. As such, a significant portion of the Hispanic/Latino community still does not know their HIV status, and even fewer receive the adequate care and treatment necessary for viral suppression.

A significant portion of the Hispanic/Latino community still does not know their HIV status, and even fewer receive the adequate care and treatment necessary for viral suppression.

This is not merely an issue of implementation: for decades, obstruction to access has been an objective for many policymakers, and the challenges persist today. Recently, a series of legal battles has emerged with the intent to curtail the provision of HIV prevention drugs within the framework of the ACA. Central to these legal disputes is the question of whether the essential preventive measures for HIV transmission, including pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) drugs, should continue to be covered by this landmark health care legislation. PrEP is a highly effective medication reducing the risk of contracting HIV via sex by 99 percent, but access disparities exist, particularly for queer Hispanic/Latino men. These legal challenges have instigated a profound debate on the potential repercussions for individuals’ access to these life-saving medications.

This commentary highlights the existing disparities facing queer Hispanic/Latino men in accessing HIV prevention care and treatment. Furthermore, this piece analyzes the potential impact of the Braidwood Management v. Becerra ruling on access to PrEP for HIV prevention, specifically among queer Hispanic/Latino men. Lastly, the commentary ends by providing policy solutions for both the federal and state governments to expand access and uptake of HIV prevention drugs among queer Latino men. It identifies the following as the most impactful policy measures for the current state of the policy landscape:

  • Increase public awareness for individuals at risk of HIV.
  • Strengthen culturally competent care and non-discrimination protections.
  • Expand access to zero-cost PrEP.

Existing Disparities

We can begin to understand, and then to address, the disparities in HIV prevention that the queer Hispanic/Latino community faces by underscoring the intersectionality of their identities, which places them at a unique risk. This community faces a higher incidence of HIV infections due to a confluence of factors, including discrimination, stigma, and systemic barriers, which collectively hinder their access to health care services and HIV prevention and treatment resources.

Before the ACA’s passage, in 2010, the HIV infection rate among Latinos was three times higher than for their white counterparts, with 9,800 new infections reported. At the time, Hispanics/Latinos represented 16 percent of the U.S. population, all the while accounting for 21 percent of new HIV infections. Hispanic/Latino men, particularly Hispanic/Latino MSM, were significantly affected, making up nearly 7 in 10 of new HIV infections among Hispanics/Latinos. Despite a decrease from a peak in the late 1980s, the number of Hispanic/Latinos living with an HIV diagnosis increased by 8 percent between 2008 to 2010. Additionally, HIV-positive patients were charged higher premiums or offered limited coverage.

Since 2010—and so after the passage of the ACA—new estimated HIV infections in the United States have declined by 32 percent since 2010. The ACA also banned charging HIV-positive patients higher premiums. Subsequently, there was an increase in health insurance coverage among HIV-positive individuals, leading to better access to life-saving service and sustained viral suppression. Most importantly, the ACA mandates coverage of preventive services without additional cost-sharing. Despite these strides forward, challenges still remain, and the benefits of the ACA have not been equally distributed. Queer Hispanic/Latino men have been disproportionately excluded from those benefits.

The rates of new HIV infections among the U.S. Hispanic/Latino population remained stable from 2015 to 2019, underscoring that disparities continue to exist and severely impact the Hispanic/Latino population, specifically queer Hispanic/Latino men. According to the Centers for Disease Control and Prevention (CDC), in 2019, Hispanic/Latino MSM accounted for more than 75 percent of new HIV infections among all Hispanic/Latino people in the United States. Further complicating this issue, the CDC highlights that approximately 16 percent of Hispanic/Latino people with HIV in the United States are unaware of their status, significantly higher than their white counterparts, underscoring the gap in diagnosis and access to care. Exacerbating this disparity further, Hispanic/Latino communities face a higher uninsured rate compared to white communities, impacting their access to preventive measures like PrEP. This disparity is also driven in part by stigma among Hispanic/Latino communities, discussed below.

Cultural and Societal Factors

Several factors contribute to the continued heightened HIV risk and rate of infection among queer Latino men. Cultural norms and stigma related to sexuality and HIV status in Hispanic/Latino communities can discourage individuals from seeking testing and treatment. Many of the pressures can start right at home, with one in five HIV-positive Hispanic/Latino gay and bisexual men suffering from stigma within their families and communities.

Cultural norms and stigma related to sexuality and HIV status in Hispanic/Latino communities can discourage individuals from seeking testing and treatment.

Additionally, many queer Hispanic/Latino men grapple with the reality of limited access to health care providers who understand their cultural nuances and specific needs. Even with insurance, language barriers, compounded by economic hardship, further exacerbate these challenges, leaving individuals without the guidance and support necessary to navigate the health care system and access essential preventive measures like PrEP. Moreover, 22 percent of Hispanic/Latino adults lack health insurance compared to 8 percent of white adults, highlighting the significant impact of insurance coverage on access to PrEP and other preventive health care services.

Typically an unspoken factor, but very real and salient to queer Hispanic/Latino men is the concept of machismo. A 2021 study published in the Journal of Sex Research revealed the influence of machismo norms, highlighting how their emphasis on masculinity and their enforced silence about sexuality can create a barrier to open communication about sexual health concerns.

The Dangers Created by Braidwood Management v. Becerra

Despite facing numerous challenges, the queer Hispanic/Latino community can still benefit significantly from advancements in medical treatments and the continuous expansion of health care access, all of which are crucial in combating HIV. PrEP has established itself as a cornerstone of the United States’ “Ending the HIV Epidemic” initiative, playing a crucial role in reducing HIV diagnosis rates in communities with high PrEP use. However, the September 2020 ruling in Braidwood Management v. Becerra casts a long shadow over this vital tool, threatening to exacerbate the HIV/AIDS epidemic and undo years of progress.

If this ruling stands, individuals under the ACA would be subjected to cost-sharing for HIV preventive care and treatment. Imposing cost-sharing on preventive care services, including those that can prevent HIV among queer Hispanic/Latino men, creates significant access barriers. Research indicates that consumer cost-sharing can decrease the use of preventive services, and this trend seems likely to be borne out in the case at hand: as it stands with the ACA, the elimination of cost-sharing has led to increased use of preventive services, especially in HIV prevention.

In 2022, 36 percent of the 1.2 million individuals who could benefit from PrEP were prescribed it, compared to 23 percent in 2019, before PrEP was mandated to be no-cost under the ACA. However, the Braidwood ruling could make this life-saving medication inaccessible to the communities that need it the most. Consequently, this would have ripple effects, potentially impacting the 1.2 million people who could benefit from PrEP and face cost-related barriers to access. In particular, queer Hispanic/Latino men, on top of existing disparities, could face significant barriers to accessing PrEP and other HIV prevention services.

The Braidwood ruling could make this life-saving medication inaccessible to the communities that need it the most.

Studies have projected that such a scenario could lead to the following:

The potential consequences of Braidwood v. Becerra extends far beyond those living with HIV, hamstringing entire care infrastructures and everyone who relies on them. According to a 2015 study, preventing a single case of HIV can save up to $229,800 in lifetime medical costs, underlining the significance of accessible preventive measures in mitigating the financial strain on health care systems as well as on individuals. Indeed, the potential increase in HIV infections would strain health care systems, requiring resources that could be devoted to other pressing medical needs. Subsequently, this increase would also lead to substantial economic costs associated with treatment and long-term care, particularly for marginalized groups who already struggle to cover out-of-pocket health care costs. PrEP cost without insurance is expensive, and could amount between $22,000 and $30,000 out-of-pocket per year. Additionally, the lifetime cost of HIV treatment is estimated at more than $420,000.

Beyond the cost implications, the dismantling of PrEP access would erode public trust in health care institutions and undermine efforts to combat HIV/AIDS stigma and discrimination. Preventing this bleak scenario requires a multi-pronged approach. On the legal front, an appeal of the Braidwood ruling is essential to preserving the current PrEP mandate. Simultaneously, legislative action is needed to codify the zero-cost sharing requirement for PrEP into law, ensuring its long-term survival.

Policy Recommendations

The ACA’s coverage of PrEP without cost-sharing has been a crucial step forward. However, recent legal challenges and ongoing efforts to undermine the ACA threaten this vital access provision. Additionally, insufficient federal funding for HIV prevention programs specifically designed for queer Hispanic/Latino men hinders the development and implementation of culturally tailored interventions.

To effectively address this critical public health issue, a three-pronged approach is necessary. Each of the core elements is discussed below.

Increase Public Awareness

Queer Hispanic/Latino communities experience significant disparities in HIV infection rates, often due to a lack of culturally competent prevention awareness and access to health care. As such, public awareness campaigns should specifically target queer Hispanic/Latino communities, highlighting the effectiveness of PrEP in preventing HIV transmission.

However, to maximize its effectiveness, it’s crucial to consider the needs of men who may not identify as openly gay or bisexual, but who are still at an increased risk for HIV. Many Hispanic/Latino men, due to cultural norms and social stigma surrounding homosexuality, might not readily identify as gay or bisexual. This presents a unique challenge in HIV prevention efforts.

Culturally relevant media channels, such as social media, community events, and trusted community leaders, can play a vital role in engaging diverse audiences. Disseminating information and addressing misinformation through partnerships with health care providers, LGBTQ+ organizations, and HIV/AIDS service providers is crucial. Importantly, campaigns should emphasize the potential legal vulnerabilities faced by queer Hispanic/Latino men in accessing PrEP, highlighting the urgency for strengthened non-discrimination protections.

Strengthen Culturally Competent Care and Non-Discrimination Protections

Discrimination based on sexual orientation in health care settings remains a significant barrier to accessing essential services like PrEP for queer Hispanic/Latino men. Legislative endeavors, like the Biden administration’s move to formalize the Bostock ruling, which reinforces Title VII of the Civil Rights Act of 1964, alongside other measures prohibiting discrimination based on gender identity or sexual orientation, should focus on implementing robust non-discrimination laws that expressly encompass sexual orientation. In this case, the Equality Act, which has been introduced in Congress since 1974 but has yet to be passed, would further secure these protections in the case of another administration rolling them back. The act also serves as a strong model for state action. Additionally, enforcing existing protections, like Section 1557 of the ACA, is crucial. Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age, or disability in certain health programs or activities. The Biden administration’s restoration of the original interpretation of Section 1557 signifies progress, but continued vigilance is necessary, as court cases are still pending against it.

Partnerships with established civil rights organizations can provide invaluable resources and training programs. These organizations offer expertise in legal advocacy and community outreach, equipping health care providers to deliver culturally competent care for LGBTQ+ patients. Training programs should address cultural competency specific to queer Hispanic/Latino men, fostering a welcoming and inclusive health care environment.

Holding health care institutions accountable through legal action and public pressure also plays a critical role. Instances of discrimination should be addressed with legal support from civil rights organizations, and public campaigns and community engagement can expose discriminatory practices and encourage health care systems to prioritize inclusivity. By enacting stronger non-discrimination protections, fostering culturally competent care, and ensuring accountability, we can create a health care system that effectively serves all patients, including queer Hispanic/Latino men at risk for HIV.

Expand Access to Zero-Cost PrEP

Expanding access to zero-cost PrEP is critical, and there are various ways of doing so. One crucial step would be for Congress to fulfill the president’s budget proposal to repurpose $9.8 billion over ten years for the mandatory PrEP Delivery Program. This program would directly provide free PrEP and related services to uninsured and underinsured individuals, ensuring access regardless of insurance status and maintaining access in the event of a harmful court ruling, such as what has happened with Braidwood. This necessitates advocating for targeted funding allocations within the federal budget. Collaboration with public health advocacy groups can strengthen the call for this crucial investment in preventive health care, and the proposed program should serve as a blueprint for states to follow.

While federal action is critical, state-level advocacy plays a vital role. States can enact laws requiring private insurers to cover PrEP with zero cost-sharing, further expanding access and complementing federal efforts, such as a recent Biden administration proposed rule under Medicare. Additionally, streamlining access to HIV prevention medication by allowing pharmacists to dispense PrEP and PEP without requiring a doctor’s visit or prescription is key. Existing laws in California and Illinois serve as models for other states to follow. As such, advocacy efforts should focus on replicating these successes by urging state legislators to introduce and pass similar legislation requiring private insurers to cover PrEP without cost-sharing. Expanding Medicaid and Medicare coverage for PrEP to all states, regardless of expansion status, is also essential to ensure equitable access for low-income individuals, including queer Hispanic/Latino men. Simplifying enrollment processes, eliminating prior authorization requirements, and partnering with state health agencies and community-based organizations can further streamline access to PrEP.

Beyond eliminating cost-sharing, we must mitigate or prevent restrictive practices by insurance companies that hinder PrEP access. Prior authorization, a process requiring pre-approval from insurers before dispensing PrEP, can cause delays and potential denials due to administrative hurdles. Additionally, professional resistance to prescribing PrEP can compromise health and delay prevention.

Ensuring All of Us Can Heal and Thrive

As we look forward, despite significant medical advancements in the fight against HIV/AIDS, such as PrEP, queer Hispanic/Latino men continue to face daunting barriers to assessing the crucial prevention and treatment options they deserve. The core of the issues lies not only in medical practice, but also within the intersectionalities of legal, social, and systemic inequities that disproportionately affect queer Hispanic/Latino men. The most recent case, Braidwood Management v. Becerra, shines a light on these challenges, and serves as a critical reminder of the work that still needs to be done. As a collective, our response must include increasing public awareness, ensuring access to culturally competent care, and mandating zero-cost PrEP in order to dismantle the barriers that stand in the way of a healthier future for all. As such, it is imperative we support policies and initiatives that champion equity and access, rally together to advocate not only for the rights and well-being of queer Hispanic/Latino men but all communities in the margins.