Insurers and service-providers have until September to comply with a new federal guidance requiring insurance companies to cover the entire cost of PrEP (pre-exposure prophylaxis) interventions.
Many insurers have been covering the cost of PrEP medication, widely available as the pills Truvada or Descovy, for several years. Truvada became available in a generic formulation in 2020, and U.S. insurers have been prevented from charging co-pays for PrEP since the beginning of 2021.
But one aspect of PrEP has remained daunting for some community members unable to access comprehensive coverage through insurance or assistance programs: Paying for additional lab work or even follow-up medical visitations that a PrEP prescription requires. Those requirements could be "bracing" for some patients, according to activist Jim Pickett, who is at AIDS Foundation of Chicago (AFC).
"If you have insurance, that insurance must cover PrEP in full, and 'PrEP on full' means not just the prescription," said Pickett. "It means the office visits, the lab tests, any kind of counseling—all those things need to be covered completely. So that's a huge win."
PrEP was given a "Grade A" rating by the U.S. Preventive Services Task Force, an independent panel that issues recommendations about clinical preventative services. Under Affordable Care Act guidelines, that rating means insurers have to pay for PrEP services in full. The federal government issued the guidance July 19, and Illinois issued a follow-up about the state's implementation of the rule July 29.
"People often seemed to have everything covered, and then might get a lab bill," Pickett said. "Every insurance plan has different ways that they provide services or refuse services. There's not a lot of plans that up front will say that they will [pay for] a set of labs for you every three months. So people might get a [first] set of labs and it's okay, and then six months in, they get hit with hundreds of dollars in a lab bill."
Care providers generally recommend bloodwork, mainly to monitor kidney functions, every three months for persons using PrEP.
Pickett added, "There are a lot of programs in Chicago that try find support [to avoid financial surprises] so people can still move forward and aren't left hanging, but anything that any kind of friction like that comes up in the system, it's a huge deterrent. Getting an $800 bill is obviously a real deterrent."
PrEP adoption has increased in recent years. PrEP has been a central focus in the state's Getting to Zero initiative, which aims to reduce new HIV transmissions to "virtual zero" by the year 2030. Pickett said that it is too early to determine whether PrEP use has been on an upward- or downward-swing since the COVID-19 pandemic took hold. While some PrEP users might have not seen the point of continuing to use their medication when they were relatively isolated and having less sex, some providers eased access since so much of the work can be done via tele-health visits and with at-home testing.
"We're still in the middle of it all," Pickett added. "We've had waves [of COVID transmissions], but obviously this ain't over. … We'll have a better look at what goes on with COVID and PrEP as time goes on and we have more data. It's just the middle of 2021, and 2020 is when the whole shithouse came down. Oftentimes, we need a year out to see things better."
The PrEP landscape is likely to change even more in the months ahead. Researchers have been looking into administering the drug cabotegravir through injection as a PrEP intervention (as well as an injectable HIV treatment when combined with rilpivirine). Pickett has long spoken of a day when HIV-negative people might choose from a "menu" of PrEP options that best suited their particular situation: Persons who expect difficulty adhering to strict pill regimen might choose a long-lasting injectable option that only needs to be administered every few months, for example. Less sexually active people already can use a "PrEP on demand" protocal to guard against transmission when they anticipate an encounter.
Pickett added, "What I'm really interested in are mult-purpose technologies. Imagine an injection or an implant that also protects against other STI's. Also, this is coming soon: a dual pill that has contraception and HIV-prevention. You take one pill and you don't have to worry about unwanted pregnancy and you don't have to worry about HIV."
He added though, that advocates and providers shouldn't get overly excited about "the new shiny thing," since getting these medications and technologies to the people who need them is where systems tend to fall apart.
"Our health care system is confusing and is filled with friction," Pickett said. "It's filled with challenges. We make people jump through hoops and backflips with their insurance, assistance programs and pharmacy benefits. ... You can have the best technology in the world, but if you make it hard to get, and make people deal with paper, bureaucracy and waiting, guess what? It's not going to happen. We need a system focused on individuals."
