New Efforts to End the HIV Epidemic

A bold new initiative, along with proposed funding, seeks to eliminate the spread of HIV in the United States over the next decade. We gathered insight into this public health initiative’s implications for managed care stakeholders.

In recent years we have made remarkable progress in the fight against HIV and AIDS,” President Trump said during his February 5 State of the Union address, as he urged Democratsand Republicans to commit to eliminating the nation’s HIV epidemic by 2030. In March, President Trump followed up with a proposed $291 million in the FY2020  US Department of Health and Human Services (HHS) budget to support this goal. 

It’s a lofty objective, some say, but it is also one that is more possible than ever before thanks to the availability of prevention and treatment tools such as antiretroviral therapy (ART), pre-exposure prophylaxis (PrEP) medication, and epidemiological techniques that make it possible to focus on specific geographic areas. 

The problem, as Alex Azar, JD, secretary of HHS said in a press release, is that “not everyone is benefitting equally from these advances.” 

New infections are highly concentrated among certain populations, including minorities and homosexual men. In addition, some locations are especially hard hit. Over half of new HIV diagnoses in 2016 and 2017 occurred in 48 counties, Washington, DC, and San Juan, Puerto Rico, he pointed out, and certain rural regions, particularly in the south, struggle with this health dilemma. 

The plan is to increase investments in areas of the country with a high burden via existing programs like the Ryan White HIV/AIDS Program—a payer of last resort for low-income, uninsured, and/or underinsured individuals living with HIV—as well as a new program through community health centers that will provide medication to protect high-risk individuals. 

Funding would also be devoted to the use of data to identify where HIV is spreading most rapidly to better address prevention, care, and treatment needs at the local level. The goal is to reduce new infections by 75% over the next 5 years and to bring that rate down by 90% in the next 10 years. 

Mixed Reactions 

Following the State of the Union announcement, a mixture of enthusiasm and skepticism has emerged from stakeholders. 

“Under the President’s proposal, the number of new infections can eventually be reduced to zero,” Carl Schmid, MBA, deputy executive director of The AIDS Institute and co-chair of the President’s Advisory Council on HIV/AIDS, commented in a press release. 

“We applaud Trump’s announced plan to end HIV/AIDS by 2030, and would welcome success,” Richard Seidman, MD, chief medical officer of L.A. Care Health Plan—the largest publicly-operated health plan in the United States.—told First Report Managed Care in an email. However, he added, success with an endeavor like this calls for more than a bold statement. 

“The inconsistency in the administration statements about a desire to end HIV/AIDS, while continuing a full-frontal attack on access to care in repeated efforts to impact the Affordable Care Act [ACA], makes one question whether this can happen,” Dr Seidman explained. “You can’t be successful on one front if we undermine the core delivery system, the insurance system, the drug reimbursement system, and our social support systems on the other side.”

Other critics have pointed to the efforts to cut Medicaid funding, expand insurance plans that do not cover preexisting conditions, and roll back protections for LGBTQ patients as actions that threaten to undermine the fight against HIV.

Why Medicaid Matters

“It is really Medicaid expansion that has made the biggest difference in terms of increasing the insurance coverage for people with HIV,” Jen Kates, PhD, vice president and director of global health & HIV policy at the Kaiser Family Foundation, told First Report Managed Care. The extent to which options expand or contract and the extent to which more states come on board (or not) has big implications for the ability of the initiative to beat its goals, she said.

Before the ACA, those with HIV faced limited access to coverage due to several barriers, including preexisting condition exclusions, high costs, and Medicaid eligibility limitations. The arrival of the ACA changed that. According to a Kaiser Family Foundation report co-authored by Dr Kates, coverage increased significantly for those with HIV as a result of the ACA’s Medicaid expansion. 

She pointed to New York as one example of a state that has developed HIV Special Needs Plans with the intent of better managing care for people living with or at risk for HIV/AIDS. 

On the other hand, the focus on ending the epidemic could put a spotlight on states like Texas that have a significant HIV burden but have not expanded Medicaid, Jeffrey Crowley, MPH, program director of infectious disease initiatives at the O’Neill Institute for National and Global Health Law at Georgetown University, explained. 

“They are leaving so much money on the table with the feds financing so much share, and they are also not reaping the benefits of effective treatment and prevention to lower the burden of HIV in their communities,” said Mr Crowley, who previously served as an AIDS policy advisor to President Obama and led the development of the nation’s first domestic HIV/AIDS strategy.

The Role of PREP

While no cure exists for AIDS, strict adherence to ART can slow the disease’s progress, prevent secondary infections, and prolong life. The single-most thing that can help stop transmission, according to Mr Crowley, is to diagnose everyone living with HIV, get them into treatment, achieve viral suppression, and keep them suppressed. 

But there’s a synergistic effect if more people at high risk of HIV are put onto PrEP, he added. This daily prevention pill approved by the FDA can be taken by individuals at high risk for HIV before being exposed to the virus to reduce the chances of infection. (Mr Crowley disclosed that Gilead Sciences, the manufacturer of Truvada for PrEP, funds much of his work.)

Currently, the best way to get PrEP in the United States is through insurance, such as Medicaid, Marketplace plans, or employer-based coverage, Dr Kates explained. Without coverage, the only way to get this medication right now is through the pharmaceutical company that makes it and its charitable patient assistance program, which she said is not affordable for many. And those who do have insurance coverage can still wind up paying high copays. 

According to Mr Crowley, however, the United States Preventive Services Task Force issued a proposed rule at the end of last year that would essentially give PrEP its highest evidence-based rating and is expected to finalize it soon. This would mean that private insurers would be required to cover PrEP free of charge for all those with an indication for this medication. It would remove a significant barrier, he added, and could have big implications for managed care markets. 

There is another notable issue related to PrEP that could impact the battle against HIV. According to The Washington Post, the Centers for Disease Control and Prevention and drug manufacturer Gilead Sciences are in a standoff over patent rights, which raises a crucial question for the current administration: To what extent should the government try to enforce its patents against an industry partner? 

Medication Adherence

Both PrEP and ART cost money. And it’s not just the medications, Mr Crowley noted. The services cost money, too. But these treatments have, to a certain extent, removed a lot of the big-ticket health expenses, such as hospitalizations, that used to drive the cost of HIV health care. 

The medications do present their own lingering challenge, however. Most Americans are poor adherers to any course of treatment, he said. Many struggle to take a 10-day course of antibiotics, for example, whereas HIV medications come with the expectation of perfect performance every day over the course of a lifetime. Efforts toward improved medication adherence offer an opportunity moving forward.

“Managed care leaders should be thinking about ways they can innovate, and that potentially has the promise of both improving the persistence of PrEP and reducing transmissions but also making their lives easier and saving costs,” he said. Partnerships could be formed with community-based organizations to handle some of the HIV screenings, for example. There are also ideas of using “minute clinic”s or allowing people to handle their own screening and mail in their samples. 

In the future, this may include the delivery of long-acting agents, which several manufacturers are currently developing in the form of pills, injections, and implants. They would act similar to long-acting reversible contraceptives that provide birth control for an extended period of time without requiring any user action on a day-to-day basis, and they could be used with specific populations, such as the homeless, that have been found to struggle with medication adherence.

But there are other considerations for insurers, he added. People stop engaging in care or stop taking their medications for a variety of reasons. “I think managed care leaders need to understand their ownership of this problem,” he added. “It’s hard for people to be perfect, but are we building systems that enable them to be as adherent to their course of treatment as possible?”