Since the start of the HIV epidemic in 1981, more than 700,000 Americans have lost their lives to AIDS. Being infected used to be a death sentence. But now, 40 years later, the United States is on the verge of eradicating HIV.
The US Ending the HIV Epidemic initiative provides a roadmap to reduce new HIV infections by 90% by 2030. A key preventive strategy in this plan is pre-exposure prophylaxis, or PrEP, a drug that is almost 100%. effective in preventing HIV infection when taken as prescribed.
Today, Medicaid and Medicare cover PrEP at no or low cost, and there are assistance programs to support it. This year alone, PrEP was designated as a mandatory preventive service under the Affordable Care Act that almost all insurers are required to cover for free.
But the latest challenge to ACA put those gains at risk.
We are public health researchers studying the effects of ACA on preventive health use and costs, as well as on HIV prevention and LGBTQ health. Since PrEP has only recently been included as a mandatory preventive service, there is little evidence on how expanding PrEP coverage has affected access. But since removing financial barriers has been shown to dramatically increase access to other types of preventive care, eliminating free HIV prevention would be a big step backwards in the goal of eradicate HIV.
Barriers to accessing PrEP
Although the Food and Drug Administration approved the use of PrEP to prevent HIV in 2012, insurance coverage has been slow to grow and has faced regional disparities, primarily in the South. PrEP often required prior approval before it could be prescribed by a health care provider and is often documented in medical records with stigmatizing terms such as âhigh risk sexual behaviorâ. Some states also have public insurance policies such as restrictive HIV testing requirements that create more barriers to accessing PrEP.
Socially and economically vulnerable people face additional access barriers, such as limited knowledge and awareness of PrEP, concerns about costs, and provider reluctance to write a prescription. Fear of stigmatization of the health care system and personal relationships further diminishes its use.
People who face higher financial burdens benefit the most from free preventive care. For example, low-income Medicare patients showed the greatest increase in colorectal cancer screening rates once it was made free compared to higher-income privately insured patients.
These same trends apply to PrEP. A recent study in a large California healthcare system found that younger patients, people of color, and people with low incomes face significant disparities in obtaining and staying on PrEP. Removing the financial barrier to PrEP through ACA has been a huge victory for HIV prevention and the marginalized populations who will benefit the most.
The Affordable Care Act and PrEP
A popular element of the Affordable Care Act is its requirement that preventive care services be covered free of charge under most commercial health insurance plans. While this doesn’t work perfectly, sometimes leaving patients frustrated with unexpected bills, it has made a huge difference in lowering the costs of services like visits to healthy children and mammograms, to name a few. some.
Section 2713 of the law sets out some ways in which a preventive service can benefit from full coverage. Vaccinations, like COVID-19 vaccines, require a recommendation from the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices, while women’s health services require approval from the Health Resources and Services Administration. Most other preventive services require an A or B rating from the US Preventive Services Task Force, an independent body of experts trained in research methods, statistics, and medicine, and supported by the Agency for Research and Research. quality of health care.
The US Task Force on Preventive Services assigns alphabetical ratings to preventive services through a five-step review process that assesses the strength of scientific evidence supporting a service’s net health benefit. An A or B rating indicates a âmoderateâ or âsubstantialâ net benefit in favor of the service provided to patients, if applicable. C ratings mean that there is probably only a small benefit and the service should be considered on a case-by-case basis, while D indicates a recommendation against use. An I rating means there is not enough evidence to make a recommendation.
PrEP was rated A in June 2019. This paved the way for free coverage of PrEP and related services such as clinic visits and lab tests for millions of commercially insured Americans.
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What’s at stake?
This preventative health benefit has become the latest front in the seemingly endless legal battle over the ACA. The complainants in Kelley v. Becerra advocate for the inclusion of religious and moral objections that would directly affect contraception and PrEP coverage. Kelley v. Becerra, who is currently pending in Texas district court with Judge Reed O’Connor, can also strike out ACA Section 2713 altogether, eliminating other free preventive services. A decision is expected early next year.
The case hinges on two legal niceties that have nothing to do with whether PrEP or contraception deserves to be considered on an equal footing with cancer screenings and childhood vaccinations. It focuses on whether Congress needed to be more specific about which services might be covered by law and whether the power to select which services are covered could be delegated to groups like the US Preventive Services Task Force.
In the United States, more than a million people could benefit from PrEP. But if Kelley v. Becerra eliminates free preventive care, more than 170,000 current PrEP users and a million more who need it could be seriously affected. Access to PrEP for Americans with commercial insurance – nearly two-thirds of the population under 65 – has been made easier by the removal of financial barriers. Now these barriers risk being put back in place.
An HIV-free future is possible and within reach of the United States. But widely available PrEP is a big part of how the nation can achieve it. Losing preventative coverage by Kelley v. Becerra would be a huge setback for the goal of ending the HIV epidemic in the United States