October 23, 2023
A case currently before the Fifth Circuit Court of Appeals could lead to tens of thousands of new and preventable HIV cases.
HIV PrEP (Pre-Exposure Prophylaxis) is an extraordinary medical breakthrough that reduces the risk of HIV transmission by close to one hundred percent. Under the Affordable Care Act (ACA), insurers are required to cover PrEP and other critical preventive care services without charging copays or deductibles, referred to as cost sharing. Last spring, however, a federal district judge in Texas issued a ruling in Braidwood v. Becerra blocking that requirement.
GLAD, with law firm Mintz, Levin, Cohn, Ferris, Glovsky, and Popeo, P.C., filed a friend-of-the-court brief in the appeal of the Braidwood ruling at the Fifth Circuit on behalf of HIV Medicine Association (HMA) and the National Alliance of State and Territorial AIDS Directors (NASTAD).
HMA and NASTAD represent thousands of healthcare providers, public officials responsible for stopping the epidemic from every state, and policy experts with expertise in the treatment and prevention of HIV and the demographics and dynamics of the epidemic.
In their brief the organizations issue a dire warning: reinstating cost sharing for PrEP will significantly decrease utilization of PrEP, cause tens of thousands of new and preventable HIV cases, with billions of dollars in associated healthcare costs, and reverse the progress our nation has made towards curbing, and ultimately ending, the HIV epidemic.
“As an organization representing thousands of physicians and other health care professionals working on the frontlines of the HIV epidemic in communities across the country, we are deeply concerned about the harmful and far-reaching impacts this decision will have if allowed to stand,” said Michelle Cespedes, MD, MS, Chair, HIVMA.
The brief analyzes the consequences of a recent epidemiological analysis conducted by experts at Harvard and Yale predicting, under the most cautious and conservative estimates, that blocking the ACA’s no cost sharing provision for PrEP will result in an additional 2,057 HIV infections in the first year alone.
Playing out the study’s straightforward assessment of additional first-year HIV diagnoses, an additional predicted 1,892 secondary infections bring that number to 3,949 people with HIV in just the first year, which will cost the healthcare system a staggering $1.66 billion.
Extending that conservative model just five years into the future predicts approximately an additional 20,000 people with HIV and costs to the United States healthcare system of over $8 billion as a result of the reimposition of barriers to accessing PrEP.
The brief also provides the Court of Appeals with important historical and current-day information about the tremendous toll the HIV epidemic has had on millions of lives, as well as the role discrimination and stigma have played in preventing Americans from accessing highly effective prevention and treatment. While the ruling from the Texas court broadly enjoined the cost-sharing mandate for all recommended preventive services, the case began as a challenge specifically to the requirement to cover PrEP without copays or deductibles.
“The Braidwood decision is rooted in stigma and bigotry towards the LGBTQ+ community and people vulnerable to HIV,” said Dr. Stephen Lee, NASTAD Executive Director. “It will cause incalculable harm to our efforts to end the HIV epidemic.”
Urging the Court of Appeals to understand the devastating consequences for HIV prevention if the District Court’s decision stands, the brief also describes the sobering and unacceptable racial/ethnic and geographic disparities in both the epidemic’s impact and access to PrEP. The most recent CDC estimates from 2021 are that only 11% of Black people and 20% of Hispanic/Latino people who could benefit from PrEP were prescribed it, as opposed to 78% of White people.
“Copays and deductibles deter people from accessing healthcare,” said Ben Klein, Senior Director of Litigation and HIV Law at GLBTQ Legal Advocates & Defenders. “PrEP is nearly 100% effective at preventing transmission of HIV, but it is already underutilized, particularly among Black and Latino communities. Allowing the lower court’s ruling in Braidwood v. Becerra to stand will exacerbate racial health disparities, needlessly increase HIV diagnoses, and cost American lives.”
As we await a ruling from the Fifth Circuit Court of Appeals, GLAD is advocating for other approaches to protect and expand access to PrEP. State legislatures have the power to not only codify the ACA’s no cost-sharing requirement under state law, but to go further by ensuring all forms of PrEP, including long-acting injectables, are available to all who can benefit from them. Barriers like co-pays, deductibles, and insurance pre-authorization requirements mean delays in access to PrEP that can lead to avoidable HIV infections with serious health consequences and even death.
PrEP offers us a powerful path to finally end the HIV epidemic. We only need the will, and good health policy, to embrace it.
This story was originally published in the Fall 2023 GLAD Briefs Newsletter. Read more.