The Biden-Harris administration has a historic opportunity to help end HIV. New, cutting-edge drugs that prevent HIV are hitting the market, but insurance companies are trying to twist the rules to deny access to these remarkable therapies.

The White House could stop these abuses and put the country on the right course for decades ahead and prevent hundreds of thousands of new HIV transmissions.

Pre-Exposure Prophylaxis (PrEP) drugs represent one of the strongest tools we have to combat HIV. These highly effective therapies can reduce the risk of contracting HIV by up to 99%. So far, the FDA has approved two once-daily PrEP pills, and in 2021 approved the first long-acting version of PrEP. Other groundbreaking PrEP innovations, such as a biannual dosage form, are in active development. 

PrEP is a major reason why new HIV infections dropped 12% from 2018 to 2022. Yet there’s still work to do. Currently, just 36% of people who could benefit from PrEP are using it. Racial and ethnic groups face wide disparities in PrEP uptake. For example, Black individuals constitute 39% of new HIV diagnoses but only 14% of PrEP users. Hispanics make up 31 percent of new HIV diagnoses, but only 18 percent of PrEP users.

A new federal directive, if properly enforced, could help close these gaps. In August 2023, a panel of prevention experts issued an updated recommendation to clinicians, recommending PrEP — including long-acting forms of the drugs — to people who want to prevent HIV acquisition. Under the Affordable Care Act, most newly issued private health plans must cover without patient cost-sharing to comply with this recommendation beginning this month.

Yet many HIV experts and patient advocates have raised concerns that insurers could misinterpret — or downright ignore — the task force’s decision and keep barriers to PrEP in place. 

One top concern is that insurance companies could decide to cover only one kind of PrEP, even though the task force’s recommendation isn’t drug-specific — it applies to all versions. For example, a health plan might refuse to cover long-acting PrEP and force patients to take oral pills instead. 

Yet long-acting PrEP is a critical option for many patients, such as those who struggle to adhere to once-daily drug regimens, are unhoused, or have confidentiality concerns. One study found that patients taking long-acting PrEP had a 66% reduction in HIV infections compared to those using oral pills. Another analysis calculated that long-acting PrEP could help avert 87% more HIV cases than oral pills, and could save over $4 billion over the course of a decade.

Another concern relates to insurers’ increasing use of “prior authorization,” a practice in which health plans refuse to cover certain drugs unless doctors obtain prior permission. Insurers could also force patients to try a number of therapeutic alternatives before agreeing to cover the medicine they and their doctors agreed upon — this is known as “step therapy.” There’s evidence that “prior authorization” policies may disproportionately impact Black and Hispanic individuals, who are already at higher risk of HIV.

Fortunately, these insurer-imposed barriers aren’t inevitable. The Biden-Harris administration, through the Centers for Medicare & Medicaid Services (CMS), has an opportunity to issue clear, detailed guidance that ensures health plans follow through on the legal requirement to cover PrEP for all eligible patients and at no cost.

CMS’s guidance should clarify that insurance companies are obliged to cover all FDA-approved versions of PrEP, including both daily pills and long-acting injectables. When now Vice President Harris was Sen. Harris, she introduced groundbreaking legislation called the PreP Access and Coverage Act, which would require all insurers to cover all forms of PrEP without cost-sharing and prior authorizations. So we know where she stands on the issue. 

A number of states, including New York and California, have already established similar coverage requirements and prohibitions on prior authorization for PrEP. 

A similar requirement already exists for contraception. Plans are required “to cover without cost sharing any contraceptive services and FDA-approved, -cleared, or -granted contraceptive products that an individual’s attending provider determined to be medically appropriate.”  

CMS just needs to adopt language along these lines for PrEP. Doctors — not insurance companies — should decide which drugs best suit patients’ needs.

Thanks to revolutionary research happening every day, people with a reason to be on PrEP have more options available to them than ever before. Yet insurers are intent on restricting access to these innovative therapies. New federal guidance can help combat this and if properly enforced set us on a path toward ending HIV.

Carl Schmid is executive director of the HIV+Hepatitis Policy Institute.

I submitted the column below to the Washington Post as an oped with the above headline, having no real expectations it would be published. They often publish my letters, but never when I criticize them directly. Imagine my surprise when I received an email after five days from Ryan Vogt, in the opinions section of the Post, sharing a version of the oped they had shortened to a 228-word letter, asking if I was OK with that version and saying if I was, they would consider publishing it. I wondered if he did the editing. I gave him an immediate OK to publish it. Then having heard nothing from him for a few days, I contacted him and was told “unfortunately, it is falling out of the mix of letters to be published.” My comment back to him was “no surprise.’ 

Here is the oped as I submitted it to the Post: 

When the publisher of The New York Times, A.G. Sulzberger, is given space in the Washington Post for his oped, ‘How the quiet war against press freedom could come to America’ on the threat to the free press if Trump is elected, it’s time for the free press to speak out. The Washington Post editorial board seems to either be asleep, or willing to let MAGA Republicans win. One would think their slogan ‘Democracy dies in darkness’ would compel them to speak out. 

The Post is the major newspaper for the DMV area, and they have yet to make an editorial endorsement in the presidential race. They didn’t endorse Senator Tim Kaine (D-Va.), running against a MAGA Republican for reelection, until three days after early voting began in Virginia. They have yet to endorse any congressional candidates in Virginia when we know there are a host of MAGA Republicans running who have endorsed Donald Trump and his platform.

I understand newspapers report the news, but then reporting, and editorial content, are two different things and should be separate. Now it would be nice if editors suggested to their reporters, like it seemed they did when writing about Biden and appending his age to every mention of him, that when reporting on Trump they would append the facts he is now the oldest man to ever run for president on a major party ticket, is a convicted felon, and been held liable for sexual assault. All verifiable facts. 

One has to question what is holding the Post back from issuing a presidential endorsement. Are they actually thinking of endorsing a man who their paper wrote tried to stage a coup on January 6, 2021. A candidate who has said he wants to be a dictator on his first day in office, and use federal agencies to get back at his enemies. If they really care about democracy, and freedom of the press, they should be editorializing for Kamala Harris every day in an effort to defeat Trump and his MAGA cult. They should be endorsing against any candidate who supports Trump, and should have done it before voting began. 

Either the editorial board is afraid to speak out, asleep at the switch, or being controlled by the paper’s owner, Jeff Bezos, who might have asked them to hold up endorsements. Are they trying to play both sides in this election in an effort to not lose subscribers? Any of those possibilities is scary, and incredibly sad, for what was once a great major newspaper. A paper owned by the courageous Katherine Graham, who was willing to stand up to a president, no matter the cost to her, or her paper. 

Does the Post’s editorial board lacking diversity have anything to do with holding up endorsements? Why are they seemingly cowering in a corner without any backbone, or willingness to stand up for a free press, and democracy. Is the fear of losing subscribers so paramount the Washington Post continues to publish MAGA Republican opinion columns, and yet won’t endorse? What principles does their editorial board believe in? What do they think will happen if the writers of Project 2025, Trump’s friends, end up in the White House, and have positions throughout the administration? What do they think, if they are thinking at all, will happen when the federal Department of Education, including its Civil Rights division, is closed? If the Federal Deposit Insurance Corp. (FDIC) is closed, and people no longer have insurance when banks go under, do they care? From the editorial board’s lack of action, it would seem they either don’t care, are in favor of those things, or don’t understand the ramification of those possibilities. 

The Washington Post, a once respected paper, owned by Katherine Graham who was willing to stand up for democracy, is now just a ghost of what it once was. If Trump wins because they lack the courage to speak out, they could become totally irrelevant. This is not a time for looking the other way, or thinking they have to be fair to all sides, when one side will destroy what they claim to stand for, a strong democracy and a free press. As early voting continues in Virginia, with no endorsements form the Post, and ballots are sent out in D.C. and Maryland, shortly what the Post editorial board does won’t matter. They will just be another paper, with a big megaphone, they refused to use. 

Peter Rosenstein is a longtime LGBTQ rights and Democratic Party activist.

(Author’s note: The content of this article may be triggering for some readers. If you or someone you know struggles with suicidal ideation, support can be found by calling or texting 988.) 

In becoming a barback, I dove headfirst into the underbelly of fast-paced, homoerotic nightlife, which can be as stressful as it is fun but almost always entertaining. For me, though, the best part has been the camaraderie formed with my staff, in particular the other barbacks, all of whom bust ass behind the scenes while sharing laughs and memes along the way. Among this crew I’ve formed solid, healthy friendships, although it’s Marsel in particular who sees me in a way most in D.C. never has. 

At first, I wasn’t sure if Marsel and I would get along. He’s ripped, tatted, confident, and hot, which is essentially the recipe for intimidating. Then we worked bar shifts together and I finally got to know him. Turns out he’s insanely witty, kind if you’re not an asshole, and overall easy to talk to. As it so happens, he and I are quite similar: two gays in our mid-30s working as barbacks who ended up in D.C. after growing up in rural, ruby-red states. Still, one parallel stands out above the rest: we both also have daddy issues. 

That’s right—it’s a cliché and often a punch line of jokes (which can still be funny, by the way), but the reality for many queers is rejection from one or both parents. For some, including Marsel and me, the traits of a toxic parent warps childhood beyond just conservative thinking. Case in point: both of our dads harbored deeply rooted anger and resentment, making their reaction to learning who we are seemingly inevitable. 

For Marsel, that pivotal moment came when his parents discovered he had a boyfriend in high school. In addition to filling his mind with fears about being gay, “they made me switch schools, severely monitored all my communications, what I would wear to school, and who I could hang out with. I spent the remainder of my high school years alone with no friends, isolated in a rural town outside of Nashville.” 

A few years later, Marsel’s parents kicked him out upon learning he engaged in sexual activity with men. “They expelled me from the family home and, for many years, treated me as though I no longer existed to them. I spent the better part of a year living in my car and the rest of the time couch-surfing, relying on the kindness of friends.” 

As for me: my dad served dual roles as patriarch and specter of my family. He was abusive physically and verbally, though still I tried maintaining a connection to the guy, likely fueling my attraction to mean guys but that’s another story. Despite my efforts, my father abruptly ended our relationship shortly after I came out. In our last phone call, he couldn’t even say the word gay, choosing instead “the way you are.” From there he listed everything he disliked about me, none of which was my homosexuality because these days no one admits so boldly to prejudice. Instead, they gaslight you with every other vulnerability as justification for mistreating you. 

It’s been well over a decade since I’ve spoken to or even seen my father, and at this point I’m certain he’ll happily march to his grave without seeing me again. Losing a parent is always hard. Losing one because they don’t want to love you anymore, well—it’s a searing pain that rips your heart wide open. I wouldn’t wish it on my worst enemy. 

Sadly, stories like these are far from unique among queers, nor are they the sole trauma we experience. From living in shadows and in shame, to schoolyard bullying and alienation, to pressures of religion or toxic masculinity, to a higher likelihood of sexual violence or discrimination in the workplace, we are affronted with so many traumas they’re nearly a marker for our kind. This also doesn’t include intersectionality with other traumas, such as a growing up in America a woman, a person of color, or poor. It’s no wonder, then, that the National Institutes of Health (NIH) published a review last year declaring, “LGBTQ people are at higher risk of PTSD compared with their cisgender/heterosexual peers.”

To most queers, what I just described is neither new nor surprising. In fact, in the face of this collective trauma, queers often come together in the form of fundraisers or Pride events. Yet despite rallying around the common inputs of our trauma, we rarely discuss the outputs. That’s right — emotional trauma has outputs, as neuroscience has proven, and when left untreated those outputs emerge as toxic traits in our adult lives.  

To illustrate, let’s take it back to Marsel. While he hoped to leave his past behind in Tennessee, that wasn’t the case. “For things I hadn’t fully processed or dealt with, my past trauma would bubble up to the surface in the form of emotional triggers, which would inevitably spark my anger. My anger manifested in various ways, and I would often find reasons to justify my behavior. I was angry about my relationships, angry about my body, angry about my career – basically, I was angry about everything. And the root of all that anger was the unresolved trauma I hadn’t properly addressed.”

I couldn’t relate more. I tried to be tough and pretend I didn’t care that my father abandoned me, but the thought still crossed my mind and crushed me every time. Then I took that pain and subconsciously projected my anger everywhere — onto friends, onto other gays, onto myself, but especially onto my relationships, where I’d swing like a pendulum between states of hyperattachment and hyperdetachment with almost no in-between. Steadily, my unresolved trauma chipped away at my self-worth, and once that goes, self-destruction is inevitable. 

Since the path to self-destruction is riddled with more trauma, the downward spiral only gets steeper. “My most impactful and lasting piece of trauma occurred two days before my 25th birthday,” Marsel told me. “The summer of 2013 I had been more than reckless with the frequency of my sexual encounters. I had often done pretty dangerous and wild things in regard to meeting up with guys. Then, on Dec. 10, 2013, I found out I was HIV positive. 

 “At the time it was quite Earth-shattering news because I knew no one who was positive and had no idea what this would mean for me. I was pretty hard on myself for being reckless, and it took a bit to pick myself up, but over time I used it to inspire me to live my life fully and authentically.” 

Often it takes Earth-shattering events to serve as a wakeup call for change. When my PTSD transformed into social anxiety, it was easy to suppress at first with sex, drugs, and most often alcohol, which inevitably led to the occasional outburst, or the loss of a friend. Yet still I’d go out, even more anxious I’d run into newly formed enemies, so I’d drink more, at times pre-gaming by myself before pre-gaming with others before eventually stumbling into the bars. Naturally this facilitated more outbursts, cost me more relationships, and once landed me a night in jail. The further I unraveled, the more I numbed it with heavier drinking, darker sex, harder drugs, until finally — it pains me to write, but for the sake of honesty I must — I was contemplating, threatening, and attempting suicide. 

Sorry to get heavy, but it’s important to dissect why and how queers experience emotional hardship. We don’t struggle simply because we’re queer but rather due to the trauma thrust upon us by a world that still fears queers. As a result, normal events — such as a breakup or losing a job — can feel insurmountable, like proof that those who rejected us were right all along.  

Thankfully, queers can rely on each other for support, right? Sounds nice in theory, but in practice we D.C. gays are pretty fucking mean to each other. Sure, we find our friends, but often our community is itching to judge us at every corner. We throw insults, ostracize those deemed “crazy,” and constantly seek validation from people we (Instagram) deem perfect. And no, I am not above this. I’ve been a narcissist. I’ve burned bridges with glee. Looking back, it was my inner turmoil bursting at my seams.  

Marsel summarized our behavior well: “Everything is a trauma response. That mean gay you see at the bar – trauma response. That gym obsessed muscle queen – trauma response. That career-driven type-A Capitol Hill gay – trauma response. Most of the time I find when people are treating me a certain way, it has little to do with me and everything to do with their own trauma.” 

So, we find ourselves amid a queer trauma cycle in which hurt queer people hurt more queer people. Sounds bleak, but the good news is we also have the power to change that. And we must, for a recent survey by the Trevor Project found a staggering 41 percent of LGBTQ+ youth aged 13 to 24 considered suicide in the last year alone. Queer trauma isn’t going away, so it’s on us to avoid bestowing our trauma to younger queers and instead provide a safe community not only to thrive but to experience inevitable lows as well. That may seem like a tall order, but based on what I’ve learned from Marsel, two measures can move us closer.

First is simple self-reflection, for when trauma goes unnoticed it grows steadily like mold, potentially upending your behavior without you even noticing. “As I moved through different stages of my life,” Marsel explained, “I began to see how this unprocessed trauma and anger influenced so many aspects of who I had become. It colored my reactions to conflict, my relationships with others, and even my relationship with myself.” 

The only way to process trauma is to excavate your mind and dissect underlying memories and feelings, which can be accomplished in many ways including journaling, art, or my personal favorite: therapy. While I didn’t start therapy until my 30s, taking that leap became a life-changing, and potentially lifesaving, decision. “Through therapy,” added Marsel, “I was able to uncover the reasons why this trauma continued to follow me throughout my life and how it manifested.” 

It all sounds so simple: get therapy, and you’ll get better. However, therapy only goes as far as you let it. Progress is never linear and brutal honesty is a must; as a result, not everyone gets there (no judgment though, for I’m not all the way there myself). In fact, my hardest step was admitting I needed therapy at all, for seeing a therapist is often treated like spotting a UFO — no one wants to admit it out of fear of looking insane. However, often the fear of appearing crazy leads to the most toxic behavior, as I’ve witnessed in D.C. time and time again. 

To heal requires dissolving the ego. While tough, it’s truly the first and most important step. 

As for the second measure: we need to cut each other some slack. No, this doesn’t mean excusing terrible behavior, but it does mean holding the belief that others — including and especially your queer enemies — can grow. If not, then tell me: who’s supposed to believe in your growth if you don’t believe in the growth of others? And if your response is you don’t need to grow, you likely have the most growing to do. 

Writing off one of us is writing off all of us, and if we keep burning each other at the stake for every flaw, we’ll grow weaker as a community. Besides, the rest of the world already does that to us. Why do it to each other as well? 

My hope is for more queers to see each other the way Marsel and I do. Not because he and I are perfect — if anything, we’re far from it. Instead, in between inside jokes, we share our mistakes, our hardships, and the work we’re putting in toward self-love and improvement. That feels rare in a city obsessed with perfection, but that’s also why it feels genuine. 

And genuine feels worlds better than perfect ever could. 

Jake Stewart is a D.C.-based writer and barback.