What's Preventing PrEP?
Pre-exposure prophylaxis (PrEP) is effective, but underutilized by many
Daily PrEP has been available for nearly a decade, yet fewer than 25% of the approximately 1 million Americans who could benefit from it are using it.1,2
The estimated population indicated for PrEP includes more than 800,000 men who have sex with men (MSM); however, less than 10% of the total MSM population who could benefit from PrEP are receiving prescriptions for it.4
The large gap between indicated users of PrEP and those who are prescribed it suggests a need for more equitable implementation.3
When daily PrEP is taken as directed, users can reduce their chances of acquiring HIV infection up to 99%.5 One modeling study, based on guidelines from the Centers for Disease Control and Prevention (CDC), determined that if 40% of MSM used PrEP and 62% were well-adherent, approximately one-third of new HIV transmissions could be prevented over the next 10 years.6
Significant barriers to PrEP uptake include low PrEP awareness, fear of stigma and/or side effects, provider bias, distrust of the healthcare system, and lack of access to care or financial assistance.7
PrEP has inconsistent coverage, which has implications for users and payers
A key strategy of the Ending the HIV Epidemic Initiative is preventing the transmission of HIV with PrEP.8 In fact, the US Preventive Services Task Force issued a grade A recommendation for PrEP, and the Affordable Care Act requires most private health insurance plans to cover these recommended medicines with no patient cost-sharing.4
Medicaid is the single-most important source of insurance coverage for medications like PrEP.9 However, some state Medicaid policies implement strict utilization management (UM) criteria, including prior authorization (PA), step therapy, preferred drug lists, and quantity limits. While these tools can reduce spending, they may create access barriers for users and result in reduced utilization of essential medications and new HIV transmissions.10
As of now, there is state-to-state inconsistency through other channels:
Medicare Part D covers PrEP9
Employer-based and individual private commercial plans generally cover PrEP and other prevention services9
Users who do not have coverage can be expected to pay approximately $8000 annually4
Prevention services are generally not provided through the Ryan White HIV/AIDS program, which is primarily for people living with HIV9
The total cost of PrEP therapy is less than $23,743 per patient per year.8 In comparison, the annual average costs of HIV treatment range from $35,300 in the Northeast to $41,528 in the South.11 When comparing these estimates of annual HIV treatment costs to PrEP costs, the average annual HIV treatment costs range from $11,557 to $17,785 higher than the average annual cost of PrEP therapy.8 When looked at over the course of a lifetime, costs to treat HIV could add up to ~$850,000, all of which could be avoided with PrEP.12
This cost benefit is only possible if users can afford PrEP. The CDC recognizes that there is an issue with PrEP costs for users and put together a guide to help navigate the challenges.4
Low PrEP awareness has obstructed uptake for some populations
According to the American Men’s Internet Survey from December 2013 through November 2017, in a sample of 37,476 HIV-negative/unknown status MSM, PrEP awareness increased significantly over the study period. However, Black and Hispanic groups were less likely to be aware of PrEP compared with White MSM.14
Similarly, according to the CDC and National HIV Behavioral Surveillance data, Black and Hispanic MSM were less likely than White MSM to15:
Be aware of PrEP,
Discuss PrEP with their healthcare provider, or
Have used PrEP in the past year
Raising awareness around PrEP use in vulnerable communities may lead to increased PrEP uptake and lower HIV prevalence16
HIV prevalence by geographic region highlights inequitable PrEP use
In 2016, more than half of new HIV diagnoses occurred in the southern United States, but only 30% of PrEP users were found there.17
.png?auto=format)
The connection between PrEP use to HIV epidemic impact has been defined as the PrEP-to-need ratio (PNR), which is calculated as the number of PrEP users divided by the number of new diagnoses in a period. Lower numbers in the PNR indicate inequitable PrEP uptake. For example, in 2017, the PNR in the southern United States was 1.5 compared with the higher PNRs in the West (3.0), Midwest (3.4), and Northeast (4.7).17
Currently, 89% of people in the United States who have a coverage gap live in the southern United States and, thus, face financial barriers to initiate or continue PrEP use.17
PrEP is underutilized in the southern United States because of challenges such as low rates of health insurance coverage, geography, low health literacy, low healthcare system capacity, low HIV vulnerability perception, and stigma17
There is stigma surrounding PrEP
For example, MSM in Jackson, Mississippi, reported that taking PrEP would raise suspicion among friends that a person had male partners, or may lead others to believe that a person was living with HIV and taking medications for treatment.17
To address stigma in the southern United States, 2 meta-analyses of prevention messaging found that emphasizing the benefits of PrEP was more effective than focusing on the negative impact of HIV acquisition.17-19
Savings of more than $40K per patient
In the southern United States, messages targeting highly impacted communities that emphasize the benefits of PrEP may be a key to altering the current stigma around PrEP, and alleviating HIV treatment costs of $41,528 per patient per year in that region.11,17
.png?auto=format)
PrEP is a key strategy in the Ending the HIV Epidemic initiative, but the disproportionate prevalence of HIV among racial and ethnic communities can be attributed, in part, to inequitable PrEP distribution.8,15
Stay tuned for the next white paper in this series that examines the disparity in PrEP use among Black and Latino MSM and women.*
*Including transgender women.
References:
1. CDC statement on FDA approval of drug for HIV prevention. News release CDC NCHHSTP Newsroom. July 16, 2012. Accessed May 10, 2021. https://www.cdc.gov/nchhstp/newsroom/2012/fda-approvesdrugstatement.html 2. Centers for Disease Control and Prevention. Prevent new HIV transmissions by using proven interventions, including pre-exposure prophylaxis (PrEP) and syringe services programs (SSPs). Accessed June 7, 2021. https://www.cdc.gov/endhiv/prevent.html 3. Huang YA, Zhu W, Smith DK, Harris N, Hoover KW. HIV preexposure prophylaxis, by race and ethnicity – United States, 2014-2016. MMWR Morb Mortal Wkly Rep. 2018;67(41):1147-1150. 4. Kay ES, Pinto RM. Is insurance a barrier to HIV preexposure prophylaxis? Clarifying the issue. Am J Public Health. 2020;110(1):61-64. 5. Anderson PL, Glidden DV, Liu A, et al; iPrEx Study Team. Emtricitabine-tenofovir exposure and pre-exposure prophylaxis efficacy in men who have sex with men. Sci Transl Med. 2012;4(151):151ra125. 6. Jenness SM, Goodreau SM, Rosenberg E, et al. Impact of the Centers for Disease Control’s HIV Preexposure Prophylaxis Guidelines for men who have sex with men in the United States. J Infect Dis. 2016;214(12):1800-1807. 7. Mayer KH, Agwu A, Malebranche D. Barriers to the wider use of pre-exposure prophylaxis in the United States: a narrative review. Adv Ther. 2020;37(5):1778-1811. 8. Oderda G, Biskupiak J, Brixner D. Access restrictions to HIV pre-exposure prophylaxis (PrEP) may lead to unintended consequences. First Report Managed Care. Published 2021. Accessed April 7, 2021. https://www.managedhealthcareconnect.com/articles/access-restrictions-hiv-pre-exposure-prophylaxis-prep-may-lead-unintended-consequences 9. Kates J, Dawson L, Horn TH, et al. Insurance coverage and financing landscape for HIV treatment and prevention in the USA. Lancet. 2021;397(10279):1127-1138. 10. Dawson L, Dolan R. State Medicaid management of prescription drugs for HIV treatment and prevention. Kaiser Family Foundation website. Published June 4, 2020. Accessed April 7, 2021. https://www.kff.org/hivaids/issue-brief/state-medicaid-management-of-prescription-drugs-for-hiv-treatment-and-prevention/ 11. Enns B, Krebs E, Mathews WC, Moore RD, Gebo KA, Nosyk B; HIV Research Network. Heterogeneity in the costs of medical care among people living with HIV/AIDS in the United States. AIDS. 2019;33(9):1491-1500. 12. Cohen JP, Beaubrun A, Ding Y, Wade RL, Hines DM. Estimation of the incremental cumulative cost of HIV compared with a non-HIV population. Pharmacoecon Open. 2020;4(4):687-696. 13. Nunn AS, Brinkley-Rubinstein L, Oldenburg CE, et al. Defining the HIV pre-exposure prophylaxis care continuum. AIDS. 2017;31(5):731-734. 14. Sullivan PS, Sanchez TH, Zlotorzynska M, et al. National trends in HIV pre-exposure prophylaxis awareness, willingness and use among United States men who have sex with men recruited online, 2013 through 2017. J Int AIDS Soc. 2020;23(3):e25461. 15. Kanny D, Jeffries WL 4th, Chapin-Bardales J, et al; National HIV Behavioral Surveillance Study Group. Racial/ethnic disparities in HIV preexposure prophylaxis among men who have sex with men - 23 urban areas, 2017. MMWR Morb Mortal Wkly Rep. 2019;68(37):801-806. 16. Goedel WC, King MRF, Lurie MN, Nunn AS, Chan PA, Marshall BDL. Effect of racial inequities in pre-exposure prophylaxis use on racial disparities in HIV incidence among men who have sex with men: a modeling study. J Acquir Immune Defic Syndr. 2018;79(3):323-329. |
17. Sullivan PS, Mena L, Elopre L, Siegler AJ. Implementation strategies to increase PrEP uptake in the South. Curr HIV/AIDS Rep. 2019;16(4):259-269.
18. Gallagher KM, Updegraff JA. Health message framing effects on attitudes, intentions, and behavior: a meta-analytic review. Ann Behav Med. 2012;43(1):101–116.
19. O’Keefe DJ, Jensen JD. The relative persuasiveness of gain-framed and loss-framed messages for encouraging disease prevention behaviors: a meta-analytic review. J Health Commun. 2007;12(7):623–644.
20. Centers for Disease Control and Prevention. PrEP effectiveness. Centers for Disease Control and Prevention website. Updated November 3, 2020. Accessed April 16, 2021. https://www.cdc.gov/hiv/basics/prep/prep-effectiveness.html
21. Krakower DS, Mayer KH. The role of healthcare providers in the roll-out of PrEP. Curr Opin HIV/AIDS. 2016;11(1)41-48.
HVUWCNT210010 June 2021
