Reviewing Recently Approved, First Injectable PrEP Treatment for HIV

Gary Owens, MD, president of Gary Owens Associates, reviews what payers should know about cabotegravir as it hits the market, as well as how future treatment options could impact costs and patient care.

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Welcome back to Pop Health Perspectives, a conversation with the Population Health Learning Network where we combine expert commentary and exclusive insight into key issues in population health management and more.

Today, we are joined by Dr Gary Owens, president of Gary Owens associates. He reviews what payers should know about Apretude as it hits the market, as well as how future treatment options could impact costs and patient care. Gary?

Thanks, Sam. I'm Gary Owens, I'm a former payer, medical director, and prior to that, a former primary care physician. For a decade or so, I've been in the consulting world and have my own consulting organization. It's a pleasure to chat with you this afternoon.

I would like to talk to you about the first injectable PrEP treatment being approved by the FDA in December, what should payers know about Apretude as it hits the market?

First of all, obviously, there are two oral PrEP medications approved by the FDA. Some of the drawbacks of that is patients have to number 1, know that they are at risk and talk to a doctor. Number 2, it's a daily medication. We know from treating active HIV to get to that U equals U or that undetectable equals untransmittable state, medication adherence is the biggest cog in that wheel. Likewise, for PrEP the biggest cog in that wheel is daily adherence to medication. We know that we don't live in a perfect world.

I think one of the most stunning statistics I ever saw was in people who have just received a solid organ transplant, adherence to daily immunosuppression therapy runs about 65%-70%. If that isn't a strong stimulus to adhere to your medication, then certainly, in a case where you're taking something to prevent disease, therefore, you're asymptomatic and you literally don't have the sword of Damocles hanging over your head, it's going to be easy to be non-adherent to the medication.

I think, too, there are probably some educational issues there. Some of the populations that should be targeted for PrEP aren't aware that there's a need for it. There's also demographic differences, we know that the south and the northern and central part of the west probably have the least use of PrEP in the coastal areas the most and that may be due to demographic, ethnic, or even religious biases about the disease.

With that, I think what we have with the cavity revere extended-release injectable suspension is another way to tailor the treatment to those who maybe aren't going to take a daily pill or aren't able to take a daily pill. They can get those first two injections a month apart, and then it's only 6 times a year after that.

The good news on that is it's 6 times a year. The bad news on that, it's 6 times a year because 2 months can pass and they can forget. Now the good news on that side is because providers are in control of that, they can send out reminders, or even payers or their specialty pharmacies can send out reminders.

I think what's most important here, having a choice of how one receives PrEP has the potential to increase uptake. Of course, we're only going to know after a few years of use and more options here. But it does really give a chance to integrate that therapy in one's lifestyle, or perhaps in one's inclination to be adherent to a medication that's given less often. Again, it's a nice addition to the armamentarium. Is it a perfect solution? No, but again, we take baby steps in this disease state.

With that, there is hope for longer-acting treatments that require fewer doses to be approved in the future. How do you think these might impact patient care and HIV costs?

Let's take the patient care issue to start with, I think, again, the more we can alleviate daily treatment, the more likely we are to see improved adherence to medication. I think a good analog to that is, many of us were a little bit skeptical initially of the long-acting antipsychotics for schizophrenia and related disorders, but I think we've seen data now that there's some pretty good success and they enjoy broad coverage by most payers.

I think the same thing may happen with HIV. Although, I will say we're lightyears ahead of where we were. Think about it, when you had HIV 10 years ago, you were on a multi-drug, multi-pill regimen a day. Fast forward to those patients who are basically not the complex ones, in other words, they don't have resistant disease or resistant strains. They can take 1 pill once a day with either a 2 or 3-drug combination and pretty well achieve undetectable levels.

But again, it's the same as for PrEP, the more options we have, the more ability we have to tailor to people's lifestyles and other things. So again, there's optimism. Now, I'd like to think that as we have more treatment options the cost of these treatments may come down. But I think we all know in medicine, it's probably one of the few counterintuitive areas where when you add more options and more competition in the space, usually, the cost of treatment goes up.

I think reasonable payers will expect the cost of treatment to go up north of that $35,000 or $40,000 a year again of which 60% is for drugs. The cost of treating HIV will continue to rise, but that's been the case for decades now and we're seeing the payoff is because we're seeing very few of these patients if they take their treatments, go on to develop full-blown AIDS. These people live with HIV for a very long time now.

With that, I would just like to open it up for you to add anything else that you want to mention. I know you mentioned before that there was some data you wanted to share.

Yes, there is. I think the CDC has established a goal of reducing new HIV infections by 75% by the year 2025, which gosh not that far away anymore, and by 90% by 2030. So, we'll take those new infections from just a nudge under 40,000, maybe down to 4000 or so which would be de minimis. The goal is really 4 prong: diagnose all people with HIV as quickly as possible, get them on treatment as quickly as possible, that's where that broad range of treatments come in, prevent transmission by promoting PrEP, which I think we've talked about.

Then if there are outbreaks much like we respond to outbreaks of other infectious disease, try to react to that. The reason why I bring up those CDC goals, most payers will align with those and do their part to do it because what we've seen is if we do that—there's some data that was published again by the CDC that shows if we can expand all of those 4 goals between now and 2030, we can reduce the total cost for treating HIV, maybe by as much as 30% or 40% on a total cost basis.

Now, we're going to be spending more on treatment and prevention, but we'll be spending less on any complications and fewer cases. So, if you have fewer cases by fewer transmissions that'll ultimately lead to less cost. I think payers will really look at this comprehensive approach and I will encourage them to really adopt some strategies to support that approach. That's probably my closing comment.

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