Increase PrEP Prescribing and Adoption to End the HIV Epidemic

As of July 2022, pre-exposure prophylaxis, or PrEP, has been available for a decade in the United States.Marcus JL, Killelea A, and Krakower DS. Perverse Incentives—HIV Prevention and the 340B Drug Pricing Program. New England Journal of Medicine, June 2, 2022. DOI: 10.1056/NEJMp2200601 PrEP is used to prevent the transmission of HIV. In 1995, when annual HIV-related deaths reached 50,000,https://www.kff.org/hivaids/fact-sheet/the-hivaids-epidemic-in-the-united-states-the-basics/ this would have been unthinkable. Now, we have access to a therapy that reduces the risk of contracting HIV from sexual intercourse by up to 99 percent when taken as prescribed, and by at least 74 percent for people who inject drugs.https://www.cdc.gov/hiv/basics/prep/prep-effectiveness.html Available therapies for PrEP include Truvada, Descovy,https://www.fda.gov/news-events/press-announcements/fda-approves-second-drug-prevent-hiv-infection-part-ongoing-efforts-end-hiv-epidemic and Apretude.https://www.fda.gov/news-events/press-announcements/fda-approves-first-injectable-treatment-hiv-pre-exposure-prevention Truvada and Descovy are prescription medications that are taken daily, while Apretude, recently approved by the FDA, is a long-acting injectable medication that is administered every other month by a health care provider.

With up to a 99 percent success rate, one would think that the United States is well on its way to meeting its goal of eliminating new HIV infections by 2030 and ending the epidemic. But the success of PrEP has been muted by an ongoing problem: insufficient adoption. According to some sources, less than a quarter of people who could benefit from PrEP are taking it.Marcus et al PrEPWatch, an online information clearinghouse, estimates that over 1.2 million Americans are eligible, but only about 18 percent have been prescribed PrEP.https://www.prepwatch.org/countries/united-states/

PrEP adoption appears to vary across racial and ethnic lines. Of those who are on PrEP, 42 percent are White, 31 percent are Hispanic, and 27 percent are Black.https://www.cdc.gov/nchhstp/newsroom/2021/2021-HIV-vital-signs.html

Barriers to PrEP adoption

There are significant and persistent barriers to access and adoption of PrEP. These include stigma, lack of patient knowledge, and insufficient physician education – including misconceptions about who and what PrEP is for.https://www.ajmc.com/view/barriers-to-access-for-hiv-prep

Unfortunately, stigma continues to surround HIV and the use of PrEP. There’s a misconception that, as opposed to trying to protect themselves and others, PrEP users are irresponsible or promiscuous.

Misunderstanding among the potential patient community can fuel that stigma, making it a persistent barrier. Some prospective users may also perceive that frequent HIV testing is a less expensive alternative to PrEPhttps://www.mdpi.com/2414-6366/7/5/74/htm, highlighting the need for increased, culturally competent patient education.

Insufficient physician education is another barrier to the use of PrEP. While health care providers can play a key role in providing patient education, increasing awareness, and helping to reduce stigma, they may need additional training to play this role effectively. Although many if not most primary care providers are aware of HIV PrEP, fewer than one in five physicians has ever prescribed it.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5500978/

Dismantling the barriers

Significant steps have been taken to remove cost as a barrier to PrEP, which must be available free of charge under almost all health insurance plans as legislated by the Affordable Care Act.https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-47.pdf

There are ways to encourage more widespread adoption of HIV PrEP by dismantling the other barriers, including educating patients and providers, increasing access, and combating stigma by normalizing PrEP.

Experts in the space recommend greater integration of PrEP within health care,https://link.springer.com/article/10.1007/s11904-020-00533-y suggesting that education efforts should be directed at primary care providers. A key part of increasing awareness is sharing clinical insights with providers, including PrEP’s high rate of efficacy in prevention.

Education is critical to equipping primary care providers with the information they need to adopt HIV risk assessment as a standard of care and improve their ability to identify PrEP candidates. Beginning this education in medical school would prepare new primary care providers to encourage PrEP adoption from the beginning of their careers.Cooper RL, Juarez PD, Morris MC, et al. Recommendations for Increasing Physician Provision of Pre-Exposure Prophylaxis: Implications for Medical Student Training. INQUIRY: The Journal of Health Care Organization, Provision, and Financing. January 2021. doi:10.1177/00469580211017666

Partnering with patient advocacy groups could potentially facilitate these education efforts.

Retail pharmacies can play a key role in making PrEP accessible to more people. In some states including California, Colorado, and Oregon, pharmacists can prescribe PrEP for patients with a negative HIV test and baseline testing for sexually transmitted infections. Most state laws limit pharmacist-prescribed PrEP to a 60- or 90-day supply.ttps://alto.com/blog/post/expanded-prep-access-at-pharmacies More than 90 percent of the US population lives within five miles of a pharmacy, and pharmacists are members of their communities – familiar faces to many; they may be perceived as more approachable by those who distrust the health care system.https://www.beckershospitalreview.com/pharmacy/90-of-americans-live-close-to-a-pharmacy-analysis-finds.html

However, for patients for whom geography or transportation present barriers, there are solutions in the form of virtual care and new types of therapy. At one point, two rural counties had the highest county-level HIV infection rates in the country.https://www.ruralhealthinfo.org/

Apretude, the recently approved long-acting injectable, can improve access to care for members in rural areas or with transportation challenges. It requires a provider visit only every other month and eliminates the burden of taking a daily pill.

Addressing stigma around PrEP is critical to increasing adoption. The health care community can combat stigma by normalizing PrEP. Working with thought leaders, advocates, and government agencies, we can spread and reinforce the message that HIV prevention works.

Virtual PrEP Care

Solving for stigma, geography, and transportation, virtual models help improve access to care while reducing costs for plan sponsors.Plan sponsors can save up to $11K annually or $700 for a 30-day fill for members on generic medications as opposed to brand-name therapy. Providers can use telehealth to facilitate the initiation of therapy without requiring an in-person office visit. CVS Health recently introduced our new Virtual PrEP Care program, part of our Virtual Specialist Network offerings, that provides ease and convenience as well as privacy. Even labs and testing can be done at home, and medication can be delivered directly to the patient by any pharmacy of the patient’s choice. 

Increasing PrEP adoption among populations is critical. The nation’s health care system could save the lives of tens of thousands of individuals as well as avoid estimated lifetime HIV-related medical costs averaging $400,000 per patient.

CVS Health has a long history of providing PrEP through our retail pharmacies and MinuteClinic locations. With our unique capabilities, we are well positioned to translate this offering to the virtual space. CVS Health is committed to partnering with stakeholders including clients, health plans, and manufacturers to improve health outcomes by reducing barriers and improving access to PrEP.