Last month, a District of Columbia-based harm reduction organization announced the launch of a “Harm Reduction Vending Machine Pilot Program.” This program would place three vending machines that offer, free of charge, naloxone nasal spray (the opioid overdose antidote), fentanyl test strips, clean syringes, clean drug snort kits, condoms, water, and other items aimed at reducing drug overdoses and HIV and other infections among sex-workers and people who use drugs.
In 2021, the Biden administration set the goal of ending the HIV/AIDS epidemic by 2030. If the administration is serious about that goal, one action it can take is to reclassify PrEP and PEP (HIV pre-and post-exposure prophylaxis) as over-the-counter and make them accessible in vending machines.
Using vending machines to make harm reduction accessible to people engaging in underground victimless crimes and to remain anonymous is not a new idea. Kentucky’s first naloxone vending machine opened in a rural part of the state in 2022. Louisville opened one in the exit lobby of its metro jail in September 2023 for people leaving the facility to access, and by December, the machine had dispensed 270 units. A CNN analysis earlier this year found 33 states and the District of Columbia stock vending machines with harm reduction tools for people to freely access. Including PrEP and PEP with those harm reduction tools can reduce the risk of HIV exposure in people who don’t have ready access to health care providers.
Research indicates that taking PrEP daily can decrease the risk of HIV transmission from sex by 99 percent and lower the risk of HIV transmission from needle sharing by 74 percent. PEP, on the other hand, effectively prevents HIV transmission, but people must start it within 72 hours of exposure and stay on it for 28 days. It is advisable to undergo repeated HIV testing from a health care provider after PEP treatment. A randomized controlled trial in an East African region where HIV is prevalent found that PrEP reduced new cases of HIV by 40 percent among men and by 76 percent among women.
Doctors recommend that regular users of PrEP get semiannual blood tests to check their kidney function because long-term use harms the kidneys. But that’s no reason to require people to get a doctor’s prescription to have access to this lifesaving drug. Nonsteroidal anti-inflammatory drugs, like ibuprofen and naproxen, can harm the kidneys. People who take them long-term should also periodically check their kidney function. And long‐term acetaminophen can harm the liver. Yet even minors can purchase lethal amounts of these drugs off the pharmacy or supermarket shelf without a prescription.
Many states have created workarounds to make it easier for people to obtain HIV prophylaxis without expending time and money — or risking stigmatization — by going first to a doctor’s office. The FDA decides whether a drug is classified as prescription-only or over-the-counter, but states get to determine the scope of practice of their licensed health care practitioners.
State legislatures have increasingly expanded pharmacists’ scope of practice, allowing them to prescribe prescription-only drugs to work around the federal prescription requirements to improve access and decrease the cost of taking off work and going to the doctor for residents to get the medications they want and need. Today, 29 states and the District of Columbia work around the FDA’s prescription-only requirement for most birth control pills by letting pharmacists prescribe them. And at least ten states — Arkansas, California, Colorado, Illinois, Maine, New Mexico, Nevada, Oregon, Utah and Virginia — let pharmacists prescribe PrEP and PEP.
Plan B, the so-called “morning after pill,” has been available in vending machines on college campuses since at least 2018. People have been able to get naloxone in vending machines in Puerto Rico since 2009 and in the mainland U.S. since 2017.
If the White House wants to meet its goal of ending the HIV epidemic six years from now, it should make PrEP and PEP over-the-counter and get them into vending machines as soon as possible.
Jeffrey A. Singer, MD, practices general surgery in Phoenix and is a senior fellow at the Cato Institute.