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Study Raises Concerns Over Insurance Barriers to HIV Prevention Medications

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Despite its efficacy, PrEP remains underutilized compared to the need for it. High costs are among the barriers to PrEP use, along with limited knowledge among clinicians, lack of health insurance, stigma, and underestimation of personal HIV risk.

HIV preexposure prophylaxis (PrEP) refers to taking antiretroviral medication to prevent HIV. In October 2019, Descovy (emtricitabine/tenofovir alafenamide) became the second FDA-approved drug for PrEP, following Truvada (emtricitabine/tenofovir disoproxil fumarate) which was approved for PrEP in 2012.

When taken regularly as prescribed, PrEP is highly effective at preventing HIV, reducing the risk of sexual transmission of HIV by nearly 99% and 74% risk reduction for IV drug use. Despite its efficacy, PrEP remains underutilized compared to the need for it. High costs are among the barriers to PrEP use, along with limited knowledge among clinicians, lack of health insurance, stigma, and underestimation of personal HIV risk.

Access to PrEP is a crucial component of the Ending the HIV Epidemic (EHE) Initiative in the US. However, differences in health plan coverage may limit access to HIV PrEP medication in various areas of the country, despite the addition of another approved drug.

Researchers at the University of Virginia conducted a cross-sectional study to understand plan coverage, prior authorization, and specialty tiers for Truvada and Descovy across the US. The study results were published November 10th in JAMA Network Open.

The researchers, led by Kathleen A. McManus, M.D., analyzed more than 58,000 qualified health plans that were compliant with the Patient Protection and Affordable Care Act from 2018 to 2020. Plans were categorized by region and EHE priority areas. Data analysis was completed between March 2022 and March 2023.

“Our study demonstrates that there are increased prior authorization requirements for PrEP in areas with higher rates of HIV diagnoses, which is in direct opposition to the United States’ Ending the HIV Epidemic initiative,” McManus stated in an email to Managed Healthcare Executive.

Results showed that the majority of qualified health plans covered Truvada at a higher rate (98.1% in 2018, 99.8% in 2019, and 94.8% in 2020) compared to Descovy (91.9% in 2018, 92.7% in 2019, and 87.4% in 2020). In the southern region, plans required prior authorizations for PrEP at the highest rates in all three years. Also, in the South, the prior authorization rate for Truvada increased significantly, from 10% in 2018 to 46.8% in 2020.

The analysis also found that health plans with an exclusive prior auth requirement for Truvada were more prevalent in jurisdictions with EHE initiatives compared to non-EHE jurisdictions. Furthermore, health plans were more likely to place Truvada on a specialty tier compared to Descovy.

The study found that although health plans were more likely to cover Truvada, the drug was also more likely to require prior authorization and/or be placed on a specialty copay tier than Descovy. In their paper, the authors described this difference as “notable,” considering the broader clinical indication for Truvada, its generic availability, and the similar list prices of Truvada and Descovy.

“To end the HIV epidemic, the United States must align its health policies in ways that make HIV care and prevention affordable, sustainable, and accessible. Currently, the involvement of for-profit health insurance companies, for-profit pharmaceutical companies, and other for-profit entities leads to commercial determinants of health, which are causing barriers to a unified approach to ending the HIV epidemic in the United States,” McManus stated.

Regarding steps to improve access to PrEP, she explained: “Insurance reforms, increased action from state department of insurance regulators, and a national PrEP program could be actions to provide equal access to communities and individuals who would most benefit from PrEP.”

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