Contributor: Tim Horn is a director of the Health Care Access team and oversees NASTAD’s (National Alliance of State & Territorial AIDS Directors) medication access and pricing portfolio. He works across teams to ensure fair pricing and equitable access to drugs and biologics critical to the prevention and care needs of people living with and vulnerable to HIV and hepatitis C virus (HCV). Horn was interviewed to gain further insight on the access of PrEP.
What is PrEP? And who is it for?
According to the Centers of Disease Control, pre-exposure prophylaxis (or PrEP) is a daily pill for people who do not have HIV but are at very high risk of getting HIV to prevent HIV infection. Truvada is the prescription medication for PrEP.
PrEP may be a good option for you if:
You’re in an ongoing sexual relationship with a partner living with HIV who does not have an undetectable viral load.
You’re a gay or bisexual man who has multiple sexual partners and you don't always use condoms.
You’re a gay or bisexual man in a new sexual relationship but not yet aware of your partner’s HIV status and don’t always use condoms.
You’re not using condoms with partners of the opposite sex whose HIV status is unknown and who are at high risk of HIV infection (for example, they inject drugs, have multiple partners, or have bisexual male partners)
You have sex for money, or receive gifts for sex
You’ve shared injecting equipment or have been in a treatment programme for injecting drug use.
When taken correctly (once per day), PrEP is shown to be very effective at preventing HIV. There are studies that demonstrate that PrEP reduces the risk of getting HIV from sex by 99% when taken daily. It is important to note that PrEP does not protect against other STDs and only protects against HIV.
What does PrEP do to your body?
According to the CDC, you must take PrEP on a daily basis in order for it to be effective. The medications in PrEP prevent HIV from spreading within the body; however, if you do not take PrEP daily there may not be enough medication in your bloodstream to work properly.
Truvada, the brand name for PrEP, contains two active medications: tenofovir and emtricitabine. These medications temporarily occupy the body’s T cells, which are part of the adaptive immune system. HIV attacks human T cells, so if there is enough PrEP in the body at time of infection, the spread of HIV can be stopped from establishing a permanent infection.
How much is PrEP? Why is PrEP so expensive?
The makers of Truvada (or PrEP), Gilead Sciences, increased the price of the drug by 45% since its approval. The out of pocket expense for PrEP is currently $2,000 per month. Nearly 40,000 people contract HIV per year, yet from 2012-2014, just 3,200 people filled prescriptions for the drug despite its effectiveness.
According to NPR, private health plans are making patients responsible for a larger share of drug costs. And more are restricting use of the copay coupons pharmaceutical companies have used to shield patients from out-of-pocket expenses. Insurers say the drug companies use coupons to steer consumers toward pricier meds. One way health plans are limiting their use is by no longer allowing them to count toward patients' deductibles.
How can I get PrEP without insurance?
Tim Horn, Director of Medication Access at National Alliance of State & Territorial AIDS Directors (NASTAD), says there are implementations in order to make the drug more affordable such as Ready, Set, PrEP, in which the U.S. Department of Health and Human Services is leading a program for thousands of individuals to access PrEP for no cost.
Horn also added that Gilead Sciences has a Gilead Advancing Access program that is committed to helping patients to afford the medication. There are also co-pay assistance programs that patients can apply for if they’re eligible.
In New York City, the ADAP Plus and PrEP-AP can help cover the doctor visit and lab tests for eligible uninsured patients. You can enroll in these programs via Federal Qualified Health Centers like Housing Works.
How can I get PrEP with private insurance?
Although it is not certain that every private insurance plan will cover PrEP, prepfacts.org indicates that there are currently no reports of people having trouble getting coverage for this medication. Cost of PrEP will vary depending on your plan, but should be consistent with your co-pay for other prescription medications. If your co-pay is too high, there are programs that can help cover these costs.
Do I need a prescription for PrEP?
Yes, you need a prescription to get Truvada. Although it can be tempting, it is strongly recommended that you do not share a prescription for PrEP with friends or family.
It is highly important that a doctor evaluates your current medications, medical history, and comes up with a personalized HIV prevention plan for you. Don’t let the cost of PrEP discourage you, there are several organizations that will give discounted or free prescriptions for Truvada. These programs include but are not limited to: Gilead’s prescription assistance programs, clinical trials, Medicaid in some states, and Healthy San Francisco.
Does Medicaid cover PrEP?
Medicaid is covering PrEP in states like New York and Florida, but actual Medicaid coverage varies from state to state, so check with your benefits counselor. It is in the hands of Public policy advocates as they will have to ensure PrEP is accessible to everyone in the coming months and years. My PrEP Experience monitors the insurance and Medicaid coverage of Truvada for PrEP. If you have trouble getting a prescription for Truvada as PrEP, or getting a PrEP prescription covered by insurance or Medicaid or Gilead, you can email [email protected]
How do I ask my doctor about PrEP and set up a plan?
Although talking about the need for PrEP with a health care provider can be difficult, it can ultimately help you practice safer sex and reduce your risk of contracting HIV. Before seeing your doctor, do some research on PrEP and put together a list of your current medications and past medical history. During your visit, you can tell your doctor that you are interested in exploring if PrEP would be a good fit for you. It is important that you be honest and transparent with your doctor regarding your current behavior and history that may put you at an elevated risk for HIV.
This will help your doctor make the best decision regarding a specific HIV prevention plan for you. Don’t be afraid to ask your doctor questions during or after your visit - they’re here to help you!
If your doctor decides it is best to prescribe PrEP, they may want to see you more regularly to monitor your health and any side effects. Most doctors will likely want to see their patients every two or three months. Additionally, there may be a need for increased HIV testing. A membership with Mira will get you affordable HIV testing, as low as $25.
The disparity of HIV treatment for minority groups
About 3 out of 4 new HIV diagnoses are among racial and ethnic minorities. In 2017, African Americans accounted for 43% (16,694) of HIV diagnoses and 13% of the population. And Hispanics/Latinos accounted for 26% (9,908) of HIV diagnoses and 18% of the population. While all people living with HIV should have access to and be on treatment that suppresses their viral load of HIV; only 58% of racial and ethnic minorities and 48% of American Indians/Alaska Natives living with HIV in the U.S. have a suppressed or undetectable viral load.
Horn noted that for the disparity to be broken, the barriers and structural issues (such as finances and actual engagement with the healthcare system) must be noted and addressed in order for everyone to have equal access to PrEP.