Even as US health officials set their sights on eradicating HIV, fills for the revolutionary HIV prevention drug Truvada have sharply declined since 2015 as patients face surging prices, poor coverage, insurance biases and skeptical doctors.
Introduced in 2012, Truvada for PrEP (pre-exposure prophylaxis) is a mixture of two medications, emtricitabine and tenofovir, that prevent the HIV virus from establishing an infection inside the body. When taken once daily, Truvada can reduce the risk of HIV by up to 99%. Since 2008, HIV rates have declined by an estimated 18%, and many attribute this largely to Truvada.
Despite its success, there has been a substantial decline in fills for Truvada over the last couple of years. At its peak in 2015, three years after Truvada was approved, nearly 0.26% of all prescriptions in the United States were for Truvada. However, Truvada fills have declined by 30% since then, and now account for only 0.18% of total fills.
This decline comes as many states and public health departments pledge to make PrEP more affordable for those who need it most. Florida, for example, now offers Truvada for free, and California offers a PrEP Assistance program to help insured and insured patients save. Some of these programs even help patients pay for additional costs for things like lab work and medical visits.
Considering its high efficacy, and support from local governments, Truvada fills should be skyrocketing. So what accounts for this 30% decline?
Truvada’s skyrocketing cost
While it works well, Truvada is expensive. According to a representative sample of US prescription fills, prices for Truvada have increased by 45% since 2013, with cash prices now above $2,000 for a month’s supply. What’s more, prices for Truvada have increased by nearly 10% at the beginning of the past four years. Should this trend continue, the monthly cash price for Truvada could cross $2,200 in 2019.
With such a high price tag, it’s likely that many turn to insurance to cover the cost of Truvada. But insurance may not be as helpful in this case.
Inadequate insurance coverage
In 2014, Truvada was widely covered. In fact, one researcher told Healthline in 2014 that he was “unaware of any private health insurance carrier who is not covering PrEP.” But this may not be the case anymore.
In recent months, LSU First, the largest insurance plan for students and professors of Louisiana State University, opted to restrict coverage for Truvada; Publix supermarket stopped covering Truvada for their employees; and United Healthcare denied a patient coverage for Truvada because he was “too high risk.” These examples point to a larger shift in insurance coverage for Truvada.
The increase in high-deductible plans hasn’t helped either. As of 2017, the average deductible reached nearly $4,000 for some plans, leaving many to pay the full price of Truvada until they reach their plan’s deductible. At over $2,000 per month, few can afford it.
Insurance restrictions and biases
In a likely effort to dissuade patients from filling Truvada, insurance companies and pharmacy benefit managers (PBMs) have restricted the use for Truvada’s manufacturer copay card, which can reduce a patient’s out-of-pocket cost by as much as $7,200 per year. Patients taking Truvada have received letters from insurers indicating that copay cards will no longer count towards a deductible, forcing many to pay nearly $1,600 per month for PrEP. United HealthCare has been specifically called out for this restriction, over concerns that this extra barrier could result in fewer Truvada fills and more HIV transmissions.
Even those who are covered for Truvada might run into an issue. In recent months, life and long-term care insurance companies have been denying coverage to those on PrEP. One doctor was only granted a five-year disability insurance policy because he was taking Truvada.
This isn’t the only report of biased insurance denials. According to LGBT rights advocates, many patients have stopped taking Truvada in order to get approved for a disability or life-insurance policy. These reports have since spurred an investigation by New York and California to determine if insurance companies are discriminating based on sexual orientation.
In addition to the overall expense of Truvada, some clinicians continue to be hesitant, or uneducated, about PrEP, likely leading to a decline in prescriptions. Many healthcare practitioners may believe that PrEP could encourage more risky sexual behaviors and an increase in STD rates. Research has proved these arguments wrong, but some doctors still don’t feel comfortable prescribing PrEP to their patients.
According to Robert Goldstein, the director of the transgender health program at Massachusetts General Hospital, “there is a large number of people who are not comfortable prescribing PrEP or have not been taught how to prescribe PrEP, whether it be in their residency, fellowship, or post-graduate training.”
It’s likely that this perfect storm of high prices, coverage restrictions and biases have turned many away from taking Truvada for HIV prevention. The CDC (Centers for Disease Control and Prevention), estimates that around 1.1 million people should be taking Truvada, but only about 200,000 are actually taking advantage of the pill.
It makes you wonder, if Truvada was affordable, coverage was more attainable, and biases were removed, would more people be taking it? And would we be any closer to eradicating HIV?
Co-contributors: Jeroen van Meijgaard, PhD & Clement B. Feyt, MPH
This analysis is based on a representative sample of US prescription fills (not GoodRx fills) and comes from several sources, including pharmacies and insurers.
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