NASTAD PrEP Financing Consultation

On March 2 and 3, 2016, NASTAD convened a consultation to discuss challenges, opportunities, and strategies for financing coverage of PrEP (the medication, as well as clinical and ancillary services). The consultation brought together representatives of state and city health departments, community health centers, evaluation experts, national partners, and federal partners from the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration HIV/AIDS Bureau (HRSA/HAB). The consultation was supported through a CDC cooperative agreement with NASTAD. The consultation topics included strategies to leverage Medicaid, private insurance, and safety net programs to expand access to PrEP.  

Discussion Topics:

Health Insurance Access and Coverage for PrEP

PrEP is an important part of our prevention toolkit; yet financing to secure access to PrEP remains challenging. Gilead Sciences estimates that through the end of 2015, approximately 49,000 individuals had received prescriptions for PrEP, which is only about 4% of the estimated 1.2 million individuals who could be indicated for the intervention.[i] Given restrictions with regard to use of federal funding from CDC and HRSA/HAB to pay for medications for HIV negative individuals, leveraging other payers and health care systems is crucial to expanding access to PrEP. The Affordable Care Act (ACA) in particular presents a significant opportunity to help finance PrEP access. Since January 2014, millions of Americans have gained access to Medicaid and private insurance through the Marketplaces. However, navigating coverage options and choosing plans that are affordable and comprehensive remains a challenge.

Promising Models to Engage Partners in PrEP Access

In addition to increasing the overall uptake of PrEP, some delivery models incorporate strategies that respond to well-known disparities in access to health care services among individuals s at high risk of HIV infection. These models avail program participants of a comprehensive range of services and in some cases facilitate access to PrEP through non-traditional primary care providers, and through non-clinical provider partnerships.

PrEP Assistance Programs

Despite significant progress in health insurance enrollment and coverage, the high cost of utilizing insurance for PrEP is often prohibitive. In addition, CDC restrictions on covering the medication and the cost of labs have created a funding gap for many.

A National PrEP Evaluation Agenda

Evaluation informs resource allocation in public health and it is critical in engaging funders and third-party payers in supporting PrEP initiatives. State and local health departments across the country are at very different stages in their overall evaluation process. Accessing claims data and information on prescriptions filled across payers and providers continues to be a challenge for health departments to be able to evaluate PrEP uptake locally and nationally. In addition to forecasting models currently available, short-term return on investment analysis and a syndemic approach to the impact of the intervention in cost-effectiveness models will be key in enlisting the support of third-party payers.

Influencing State-level Healthcare Systems and Policies

Without leveraging healthcare systems, reaching the 1.2 million people in the United States potentially indicated for PrEP is a daunting – and in many cases impossible – task for health departments. HIV programs have unprecedented opportunities to maximize the jurisdiction-level impact of the intervention by leveraging partnerships with state Medicaid offices and state Insurance commissioners, and individual health plans, among others.