NEW YORK (Reuters Health) – Cost was likely a big factor for the more than 8% of people who abandoned HIV pre-exposure prophylaxis (PrEP) prescriptions in 2019, according to research from the U.S. Centers for Disease Control and Prevention.
“More than 60% of PrEP patients who did not have health insurance and paid cash did not pick up their PrEP prescription, suggesting that cost is a key barrier to accessing PrEP,” researchers write in Clinical Infectious Diseases.
The effectiveness of PrEP depends on adherence, but the reasons why some people don’t adhere to the therapy are not well understood.
To investigate, Dr. Ya-Lin Huang and her colleagues used the nationwide IQVIA Longitudinal Prescription Data dataset to estimate the percentage of people 16 years or older who did not pick up their PrEP prescription from a retail pharmacy for 12 months.
They found that, in each year between 2016 and 2019, 8.2%, 8.1%, 7.9% and 8.5% of people, respectively, abandoned their PrEP prescriptions. In 2019, that amounted to 20,535 of the 241,965 persons who were prescribed PrEP.
After adjustments for covariates, new PrEP users were significantly more likely than established users to abandon their prescriptions (adjusted relative risk, 2.07). This was also true of women compared with men (aRR, 1.37), of Black compared with white people (aRR=1.20) and of people under 25 (aRR, 1.07) or 65 or older (aRR=1.91) compared with those between 45 and 64.
People who received PrEP through a rural provider versus an urban provider were also more likely to abandon PrEP (aRR, 1.12), as were people prescribed PrEP by a physician versus a nurse practitioner or physician assistant (aRR, 1.33).
PrEP users who paid with cash (aRR, 3.54), and those in drug-assistance programs (aRR, 1.49) were significantly more likely to abandon their prescription than were people who carried commercial insurance. Medicare or Medicaid recipients were less likely to abandon than were commercially insured patients (aRR, 0.88).
Patients with average copayment over $500 per 30 pills were more apt not to pick up their prescription (aRR=4.18) than were those with lower copayments.
Recent reimbursement changes are designed to improve PrEP acceptance. The Ready, Set, PrEP program (getyourprep.com), implemented by the United States Department of Health and Human Services in 2019, provides PrEP at no cost to eligible people. And under the Affordable Care Act, PrEP must be covered by health plans without patient cost sharing. Since January 2021, most health plans have been required to offer PrEP to their beneficiaries without copays.
“Unfortunately, I’m not surprised by the study’s results,” said Christopher B. Fox, a nurse practitioner in the HIV Clinic and an instructor of medicine at Oregon Health & Science University in Portland.
“I frequently see patients in my clinical practice who are eager to start PrEP but never complete lab work or never fill more than the first month’s prescription,” he told Reuters Health by email.
“Writing a prescription is not enough,” said Fox, who was not involved in the study. “We need to think about a PrEP continuum the same way we think about an HIV-care continuum. After identifying who would benefit from PrEP, how do we ensure that they pick up their prescriptions, take their pills, order refills, and continue on PrEP?”
“The authors acknowledged that people of color were under-represented in this study. This is significant because people of color, particularly Black men who have sex with men, have some of the highest rates of new HIV infection,” he explained. “Black men who have sex with men have a 1-in-2 lifetime chance of getting HIV.”
Fox cautioned that, although under the Affordable Care Act no one is required to pay a copay for PrEP, insurance companies may not be up to date on this detail.
“Whenever you prescribe PrEP, consider referring your patient to PrEP navigation services at the same time,” Fox advised. “Most health jurisdictions have some kind of PrEP navigation program (often offered through a local AIDS service organization or the public health department). Utilize this resource to help ensure that patients who are prescribed PrEP are actually able to pay for and start their prescriptions.”
The research team plans to keep monitoring PrEP uptake.
“Future studies will help us better understand the impact of the Affordable Care Act provisions to remove financial barriers and increase access to PrEP,” Dr. Huang told Reuters Health by email. “Using more complete race and ethnicity data will give better insight into differences by race and ethnicity.”
“Our nation will realize the promise of PrEP only if people can access it and use it,” she added.
The study received no external funding, and the authors declare no conflicts of interest.
SOURCE: https://bit.ly/3fYQPgy Clinical Infectious Diseases, online January 8, 2022.
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