Problem Statement

Use of HIV pre-exposure prophylaxis among U.S. military service members at high risk for HIV infection remains suboptimal, resulting in preventable new HIV infections and decreased medical readiness among service members. PrEP coverage should be increased to the greatest extent possible to prevent HIV infection and support the Military Health System quadruple aim.¹

Background

HIV infection of service members incurs both high health care costs to the MHS and a detrimental impact on the medical and operational readiness of the command.² While the crude rate of HIV incidence in the U.S. military (21 per 100,000 population) in 2021 was nearly double that of the general U.S. population (11.5 per 100,000),^3,4 military service members actually acquired HIV at a 48% lower rate than in the civilian population after adjusting for age, sex, and race and ethnicity.⁵ HIV incidence rates have also declined rapidly in the U.S. population in recent years,⁶ however, while remaining relatively constant in the U.S. military.³ This consistent rate of incidence in the military population suggests that more intensive efforts are needed to reduce the impact of HIV on the health and readiness of U.S. armed forces and meet U.S. national targets of a 90% reduction in HIV incidence by 2030.⁷ The recent ruling that HIV-infected applicants whose viral load is undetectable cannot be barred from military service⁸ also emphasizes the continued need for the effective use of force health protection strategies to prevent HIV transmission.

The four pillars of the National HIV/AIDS strategy to ending the HIV epidemic are diagnosis, treatment, prevention, and response.⁷ Diagnosis and treatment of HIV are already at high levels in the U.S. military due to testing requirements prior to entry into service, and at least biennially thereafter, two which limit opportunities for further improvement within those two strategy pillars. High-risk sexual behaviors are common among service members because of their age, sex, and other factors,⁹ suggesting that HIV interventions in the U.S. military should be focused on prevention.

Promoting condom use and healthy sexual behaviors is an effective and important method of preventing HIV and other sexually transmitted infections, and the U.S. Preventive Services Task Force recommends routine behavioral counseling for all adults at increased risk for sexually transmitted infections.¹⁰ HIV Pre-Exposure Prophylaxis is also both effective and acceptable to high-risk populations.¹¹ Oral PrEP reduces the risk of HIV infection by at least 54%, and with proper adherence oral PrEP has been shown to be nearly 100% effective.^12,13 Long-acting injectable cabotegravir further reduces risk by 67% when compared to oral PrEP. For these reasons, in August 2023 the U.S. Preventive Services Task Force recommended HIV PrEP as a grade “A” intervention, indicating there is a high certainty of substantial net benefit from its use.¹⁴

Despite universal health care (including HIV PrEP) eligibility at no cost for military service members, use of HIV PrEP among high-risk military service members (31.6%) in 2023 was lower compared to high-risk members of the U.S. civilian population (36.0%) in 2022.¹⁵ As the Affordable Care Act (ACA) requires insurers to cover all USPSTF “A” and “B” recommendations, civilian PrEP coverage is expected to continue to increase.¹⁶ Another reason for optimism in the civilian sector includes targeted funding (rising from $33M in FY2019 to $573M in FY2024)¹⁷ to support robust public health strategies, such as cost coverage and local awareness and persuasion media campaigns.

We used the Centers for Disease Control and Prevention’s Policy Analytical Framework as a basis for developing this health policy analysis.¹⁸ We developed several different policy options based upon the evidence summary and interventions described. We further developed evaluation criteria based on the CDC’s Policy Analytical Framework that incorporated all elements of the MHS quadruple aim, including impact on population health and readiness, impact on the experience of care, and value in terms of cost-effectiveness. An additional criterion of feasibility was also added to account for cultural, societal, and political factors influencing this policy decision.

Our policy analysis suggests that HIV PrEP coverage in the MHS remains suboptimal, while several available interventions could result in substantial increases in PrEP coverage that would, in turn, result in further reductions in new service member HIV infections and increased medical readiness.

Evidence Summary

The lower coverage of HIV PrEP among U.S. military members at risk for HIV when compared to the U.S. population, despite universal health care eligibility, may result from differences in demographics, health behaviors, and health care systemic issues.¹⁵ Several factors most amenable to improving PrEP coverage can be addressed, however, by the military and its health care system. One recent study found that 71% of service members who self-identified as men who have sex with men were interested in accessing PrEP, but only 48% of those individuals reported being able to receive PrEP from their MHS providers.¹⁹

As in the broader U.S. population, MSM service members represent an important risk group for HIV infection in the U.S. military, for whom health disparities should be addressed and mitigated,²⁰ particularly due to the fact they comprise the largest group (66%) with indications for HIV PrEP in the U.S. military.¹⁵ MSM service members have, however, historically noted many barriers to PrEP implementation, including MHS providers’ lack of ability or willingness to provide PrEP; stigma and confidentiality concerns; and lack of codified PrEP services at many MHS facilities.¹⁹ Another report from military PrEP patients and providers reiterated these identified barriers, including a lack of availability of expedited HIV and sexually transmitted infection testing at smaller bases.²¹ These findings suggest several avenues for implementing systemic MHS improvement in PrEP accessibility. These potential interventions are also aligned with and support the quadruple aim—the MHS’s stated goals to collectively transform into an integrated system of readiness and health—with improved readiness, better health, better care, and lower cost.¹

The MHS has several advantages that support HIV PrEP coverage in the U.S. military, including universal eligibility for health care that is free of charge, access to a common electronic health record for optimal continuity of medical care, routine testing for HIV infection, and a very low homeless rate. Despite these advantages, PrEP coverage in the U.S. military remains lower than in the U.S. civilian sector.¹⁵ While several factors are likely responsible for the less-than-optimal PrEP coverage within the MHS, a key factor is trust. Achieving continued increases in PrEP coverage will require reliable provision of culturally competent and confidential care, and outreach by MHS providers who are trustworthy and reliable to those at greatest risk of HIV infection. Any changes to the PrEP implementation program must also be effectively communicated to patients, providers, and the MHS beneficiary community at large to ensure program success.

Many MHS providers, particularly infectious disease physicians, provide excellent care to MSM service members and are well-versed in PrEP and other sexual health topics; other individual providers with an interest in providing these services have developed their own expertise. One recent study found that 93% of MSM service members reported receiving culturally competent care.²² Another study showed that MSM service members expressed a preference for PrEP through the MHS (66%) rather than purchased care off the military installation (58%).²³ Some service members have noted, however, MHS providers with poor knowledge of PrEP, negative beliefs about PrEP, and general discomfort in assessing and discussing the sexual health needs of their MSM patients.^19,24 One study among MHS providers found that 49% self-reported poor knowledge of PrEP and only 29% had ever prescribed it21; a recent U.S. Navy study reported similar findings.²⁵

Service members have reported difficulties in finding a provider willing to prescribe PrEP, with patients often referred to ID specialists, sometimes in the civilian sector because their primary care providers were unfamiliar or uncomfortable with PrEP administration.¹⁹ ID specialists are typically unavailable at smaller health facilities where most service members seek PrEP, and national guidelines specify that sexual health activities such as PrEP should be addressed in the primary care setting.^11,14

Limitations in MHS providers’ capacities to provide PrEP care has placed additional burdens on MSM service members, including the need to advocate for their own acceptance as well as educating their own health care providers, which has led some to seek medical care outside the MHS.²⁶ In the transition period after the 2010 repeal of the “Don’t Ask Don’t Tell” policy, many active duty MSM patients preferred to receive care at civilian health facilities for STI evaluation and treatment due to their fear of reprisal for their sexual orientation.²⁷ Recent studies show that 20% of MSM service members continue to access health care from civilian providers.19 Some MSM service members have experienced these systemic factors and individual MHS providers’ lack of knowledge, experience, and comfort as stigmatizing attitudes and biases.¹⁹ In addition, some MSM service members have concerns that disclosing their sexual orientation to their chain of command may have negative professional implications.²⁶ While such experiences may be the exception, they can result in a lack of trust that inhibits frank communication with MHS providers and impedes PrEP use among service members.^19,26 Further systemic study of HIV prevention and PrEP practices throughout the MHS is needed, along with dissemination of best practices and identification of locations for targeted attention.

In addition to the disparities between HIV risk and PrEP use among MSM, racial and ethnic disparities have been seen in both civilian and military populations, as well as among enlisted and younger service members who may be both at higher risk and less able to access care.²⁰ Although persons of Black race or ethnicity are estimated to account for approximately 40% of those in the U.S. with indications for PrEP, civilian national data indicate that PrEP coverage among White individuals was approximately 7 times higher than among Black individuals and 3.5 times higher among Hispanics.²⁸ Similarly, a previous DOD study suggested that Black MSM service members were less likely to receive PrEP than their White counterparts.²¹ A more recent study, however, found, compared to Whites, that Black and LatinX MSMs in the U.S. military were more than three times more likely to have been prescribed PrEP.²⁹ Other disparities in PrEP use have also been demonstrated, with service members who were enlisted, younger, serving in the National Guard (compared to the active component), and bisexual shown to have lower use of PrEP.²⁹

Several barriers to effective implementation of PrEP services have been recognized within the MHS. Frequent transfers of active duty military providers can lead to fragmented care for a service that then requires development of a comfortable patient-provider relationship to be successful. Significant budget restrictions had historically affected procurement of Truvada and Descovy, but recent availability of generic emtricitabine-tenofovir disoproxil has made this less of a concern. Smaller facilities with limited pharmacy, laboratory and diagnostics capabilities may also struggle to adhere to CDC guidelines regarding PrEP management. While current policy does not specifically restrict deployment of service members who are taking PrEP, ability to re-supply varies based on the location and it is advised that the individual stop taking PrEP, adhere to safe sex practices with condom use, and be re-evaluated for PrEP re-initiation upon redeployment. Current military guidance in Defense Health Agency-Procedural Instruction 6025.29 requires MHS facilities to “offer a pathway for access to PrEP…,” and the link to the DHA PrEP toolkit is found in the glossary (part II).³⁰ The DHA-PI does not, however, mandate that resources be allocated to ensure effective delivery of PrEP at all military treatment facilities in accordance with current CDC guidelines.¹⁹

Policy Options and Anticipated Outcomes

1. Passive PrEP implementation (status quo)

This option is the most feasible because it requires no change, with the least impact on both the care outcomes and population health and readiness. With this option, the slow rate of increase of PrEP coverage in the MHS is expected to persist, and increasingly lag behind the civilian population due to anticipated continued increases in civilian implementation resulting from the ACA requirement for insurers to cover USPSTF “A” recommendations. Service members’ experience of care will continue to be dependent upon resources available at each MHS facility and local provider care preferences. While passive implementation provides the cheapest policy option, a relatively poor value may be realized in comparison to other cost-effective policy options—i.e., relatively inexpensive interventions are expected to make a substantial impact on PrEP use in the U.S. military.

2. Initiate a campaign to improve sexual health, HIV, and PrEP education of service members and providers

With this policy option, the MHS would create a systemic plan for a campaign on sexual health, HIV, and PrEP to educate care providers, service members, and other MHS beneficiaries through social media, websites, brochures, posters and displays, and other printed materials. Effective patient health literacy and provider training on sexual health in general, and HIV and PrEP care specifically, are widely available for immediate use or adaptation and dissemination (see resources below).^11,31,32 The MHS would promote trust among MSM service members by fostering an environment, both physical and cultural, that is welcoming and inclusive for MSM patients, with “gain-based” stigma reduction campaigns.16 The MHS would address disparities in PrEP administration by ensuring culturally competent care, engagement with both MSM communities and communities of color, with education and communication targeted to ensure racial and ethnic inclusion. Provider training would focus on standardizing primary care, and would include on-demand slides for provider training on HIV risk and PrEP guidelines, modifiable materials for patients and providers including decision support tools, infographics and communication tools, along with other resources. The ID, public health, and MSM communities would play a strong supporting role in this effort by advocating for and engaging in this training to ensure all PrEP activities are of high quality and coordinated. This option would be expected to have a substantial impact in reducing stigma, reducing health disparities, and improving the experience of care by promoting an inclusive environment and educating providers. Similar to other “education only” interventions, however, its impact on force health protection and readiness is expected to be small without other concomitant structural changes.³³ For these reasons, while the cost and feasibility are both also relatively good, the value of this option is moderate due to the limited return on investment in readiness.

3. Expansion of standardized PrEP services in primary care, public health, and other settings

Under this option, DHA-PI 6025.29 would be updated to both fully endorse and require implementation of services that promote and affect PrEP use in the MHS, specifically standardizing the requirement to provide it as part of primary care, with support from ID and public health. This option would not just “offer…a pathway” for PrEP services but actively reduce administrative and structural barriers to care by requiring implementation of well-described and recommended services, including provider training; telehealth options; same-day PrEP prescribing; augmented by decision support tools; adherence support; use of health extension workers such as public health nurses, independent duty corpsmen, and pharmacists to increase capacity; and other innovative strategies. Expedited laboratory testing for HIV infection and the 3-site (throat, rectum, urine) gonorrhea and chlamydia nucleic acid amplification testing required for PrEP implementation would have additional benefits for STI control and prevention among military service members. The DHA would create a PrEP implementation checklist establishing expectations for capabilities as well as clear roles and responsibilities at military installations. DHA would further establish a mechanism to ensure accountability for the execution of these requirements and expectations. This option would be expected to have a substantial impact on population health and readiness by greatly expanding PrEP services and access. This option would likely allow greater access to partially address and affect disparities in underserved populations but would not address the underlying stigma they experience, so its impact on the experience of care would be moderate. It would also require a substantial amount of funding and personnel resources, reducing its feasibility and value.

4. Screening and targeted PrEP interventions during the Periodic Health Assessment

Annual screening during the PHA has already been implemented using risk factor questions similar to those described in national PrEP guidelines.¹¹ This mechanism could be linked to offering same-day HIV PrEP to those for whom it is indicated, in addition to informatics tools that would send targeted information via text and email, to promote health literacy as well as PrEP service access. However, this intervention would need oversight from DHA’s public health and privacy offices to ensure that both program objectives and privacy considerations can be met, typically through a case use analysis.³⁴ This option is expected to affect population health and readiness by identifying service members at high risk for HIV acquisition during the PHA and immediately thereafter starting PrEP, as well as providing additional information about PrEP and how to access it. Since service members are often hesitant, however, to respond truthfully about sensitive subject such as sexual behaviors on the PHA, the impact of this option is expected to be moderate. Its impact on the experience of care would likely be minimal, as it may not alter the underlying stigma experienced by service members at highest risk. Its feasibility would be moderate, due to the effort required not only for its inclusion in the PHA, but also in ensuring its implementation by providers and service members. Once implemented, however, it would be a good value, as the incremental resources needed to implement screening as part of the PHA would be minimal but with moderate impact. This strategy could also be further augmented through use of risk prediction tools from data extracted from MHS electronic records, as in civilian populations.¹² More research is needed in PrEP implementation and tools in military populations, including the creation of risk prediction tools by applying machine learning to MHS electronic health records.

5. Phased implementation of all interventions

Under this option, all previously-described interventions would be implemented in a phased approach, beginning with capacity-building for delivery of PrEP services, rapidly followed by initiation of a campaign to improve services, then utilizing those prior phases to expand service implementation during the PHA. As this option includes all the benefits of each assessed intervention, it provides the greatest potential impact for population health, readiness, and the experience of care. Although the most resource-intensive option, it may offer the best value, as the effectiveness of each intervention is expected to be enhanced through concomitant implementation of the other interventions. It is the least feasible of any of the options, however, as it requires a sustained commitment by the MHS and the U.S. military in general to commit resources necessary to both implement the requisite interventions and engender a cultural shift in HIV care.

Recommendation

Phased implementation of all interventions

A coordinated campaign should be implemented using the phased approach described, starting by building capacities for PrEP service delivery, immediately followed by a campaign to improve services, then utilizing the prior phases to expand implementation of those services during the PHA. While it also requires the largest amount of resources and is the most difficult to implement, implementation of a comprehensive program would be expected to have the greatest impact on the MHS quadruple aim, including population health, readiness, and the experience of care. It also provides the best value, due to the enhancement of program efficacy expected when implementing interventions in coordination rather than individually, and it makes the most substantial contribution to the national objective of 90% reduction in HIV incidence by 2030.⁷

Regardless of which policy options are selected, the DHA should ensure accountability for successful, efficient, and effective implementation by continuously evaluating implementation activities and impacts of the policy change, and use these evaluations to guide subsequent interventions and policy development.

Available Resources

Several resources are currently available for PrEP implementation:

• A DHA toolkit that includes information and resources needed to develop a PrEP program is available at: https://www.health.mil/Military-Health-Topics/MHS-Toolkits/Toolkits/HIV-PrEP-Toolkit  
• Military Guidance on Gay and Bisexual Men’s Health Care is available at: https://www.med.navy.mil/Navy-and-Marine-Corps-Force-Health-Protection-Command/Population-Health/Health-Promotion-and-Wellness/Reproductive-and-Sexual-Health/Gay-and-Bisexual-Mens-Sexual-Health   
• CDC’s HIV PrEP toolkit is available at: https://www.cdc.gov/hivnexus/hcp/prep/index.html 
• The CDC has compiled a list of PrEP interventions and best practices at: https://www.cdc.gov/hiv/research/interventionresearch/compendium/prep/complete-list.html 
• The USPSTF has developed a “Let’s Talk About It” guide for clinicians and patients about the use of HIV PrEP: https://www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/inline-files/hiv-prep-prevention-discussion-guide.pdf 
• A digital toolkit is available at: https://www.cdc.gov/stophivtogether/partnerships/toolkit/august-2021-toolkit.html 
• PrEPline: National Clinician’s Consultation Center is found at: https://nccc.ucsf.edu/clinician-consultation/prep-pre-exposure-prophylaxis 
• Integrating HIV Care, Treatment & Prevention Services into Primary Care–A Toolkit for Health Centers can be found at: https://bphc.hrsa.gov/media/p4c-toolkit-2018.pdf 
• The AIDS Education Training Centers National Resource Centers are at: https://aidsetc.org 
• HIV Info is available at: https://hivinfo.nih.gov/home-page

Author Affiliations

Department of Preventive Medicine and Biostatistics, School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD: Dr. Mancuso, Dr. Agan; Department of Medicine, Walter Reed National Military Medical Center, Bethesda: Dr. Blaylock; 20th CBRNE Command, Edgewood, MD: Dr. Robinson; Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda: Dr. Agan

Disclaimer

The opinions and assertions expressed herein are those of the authors and do not reflect the official policy nor position of the Uniformed Services University of the Health Sciences or the Department of Defense.

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