Rising out- of- pocket costs for PREP threaten key strategy in ending HIV epidemic
Ipatients’ out of pocket costs for HIV pre- exposure prophylaxis ( PREP), medications, which have been shown to dramatically reduce the risk of HIV infection, could lead to a significant reduction in PREP use and a rise in HIV infection rates, according to a new study co- led by researchers at the Perelman School of Medicine at the University of Pennsylvania and Johns Hopkins Bloomberg School of Public Health.
The study, published in Health Affairs, was designed, in part, to explore the impact that out- of- pocket cost increases could have, depending on the outcome of an ongoing court case challenging certain provisions of the 2010 Affordable Care Act ( ACA).
The researchers used a large, proprietary database of medical and pharmacy claims to determine the rates at which patients failed to fill ( i. e., abandoned) insurer- approved PREP prescriptions at different levels of out- of- pocket costs. Their findings suggest that even a small increase, from $ 0 to $ 10 in monthly PREP out- of- pocket costs, would double the rate of PREP prescription abandonment. Further, an increase in out- of- pocket costs to between $ 100 and $ 500 per month would result in nearly one- third of patients abandoning their PREP prescriptions.
The analysis also highlighted the negative consequences of abandoning PREP: The rate of new HIV infections in the year after the initial PREP prescription was two to three times higher among those who never filled those prescriptions.
“Our findings suggest that out- ofpocket cost increases for PREP could upend the progress that has been made towards ending the HIV/ AIDS epidemic in the United States,” according to Jalpa Doshi, PHD, study senior author, professor of Medicine and the director of
Value- based Insurance Design Initiatives at the Center for Health Incentives and Behavioral Economics at Penn Medicine. To date, the United States FDA has approved two HIV PREP products, each of which combines two standard antiretroviral drugs in a single pill. For the past decade, the U. S. Centers for Disease Control and Prevention ( CDC) has recommended PREP as a way of preventing HIV infection among higher- risk individuals. Expanding access to PREP is also one of the central pillars of the CDC’S Ending the HIV Epidemic in the U. S. ( EHE) initiative, which seeks to reduce new HIV infections in the United States by 90 per cent by 2030. In 2019, the U. S. Preventive Services Task Force ( USPSTF), an independent group of experts on disease prevention, gave PREP an “A” rating. Under a provision of the ACA, that rating has meant that, since 2021, most private insurance plans have been required to provide PREP to policyholders without cost sharing.
However, an ongoing legal challenge ( Braidwood Management, Inc. v. Becerra) may nullify that part of the ACA, allowing insurers to now require out- of- pocket costs for PREP and other preventive therapies. Against this background, Doshi and her colleagues sought to gauge how out- of- pocket cost changes affect PREP use.