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Public health officials are stepping up efforts to put the HIV prevention pill in the hands of those at risk, in a national effort to fight infections. But officials hit the roadblocks – the price of drugs, which has increased in recent years, and insurance coverage changes that impose a heavier financial burden on patients.
Since the approval of the Truvada brand for HIV prevention six years ago. its average wholesale price has risen by about 45%. Now, the drug – which in 1945 billions of dollars in global annual revenues for its manufacturer, Gilead Sciences – brings a sale price of nearly $ 2,000 for a 30-day delivery. 19659002] Most insurers cover the pill, also known as pre-exposure prophylaxis, or PrEP. It has been shown that it is more than 90% effective in preventing HIV when it is taken every day.
But patients can end up with fees that make them unaffordable.
"There is an example of dysfunction in the US pharmaceutical system, it is this case," said James Krellenstein, a member of the ACT UP New York AIDS advocacy group. "We have the most effective tool to end the HIV epidemic, and one of the reasons we can not step up, is because it costs [much] ]
Policymakers and the health system debate drug prices, experts say this case highlights how patients are allowed to hold the bag.
Private health plans make patients responsible for a larger portion of the costs of drugs. In addition, the use of "copay coupons" that pharmaceutical companies have used to protect their patients from personal expenses is limited. Insurers say pharmaceutical companies use vouchers to direct consumers to more expensive drugs. One of the ways used by health plans to limit their use is to no longer allow them to count for patients' deductibles.
"It's one more thing that will push people to get rid of their medications," said Jim Pickett. AIDS Foundation of Chicago
Jared Wile, who lives in Chicago, began taking PrEP about three years ago, while he was dating an HIV-positive person. Wile, who has a $ 2,750 deductible, used a coupon to get the drug. He has never paid anything out of his pocket, he said.
Gilead waives $ 4,800 fee for commercially insured patients
This changed for Wile last May, when Wile learned the coupon no. more counted towards his deductible and that he should pay the full cost of the prescription – $ 1,600 a month – until he has reached his deductible. Wile said he felt "blind" and stopped taking the medication.
Gilead spokesperson Ryan McKeel said the company had made extra efforts to help patients overcome financial hurdles. "We have designed our support programs with the intention that people can benefit from their full value, and we can not control the actions or decisions of health insurers," McKeel said in a letter. electronic.
The Federal Center for Disease Control and Prevention estimates that more than a million people are at high risk of contracting HIV, but Gilead says that only 167,000 people currently take PrEP
. is one of many obstacles – along with the lack of knowledge of patients and the reluctance of doctors to prescribe – that threaten to exacerbate the already marked disparities in the use of PrEP and the HIV infection rate
. The South, for example, accounts for more than half of new HIV diagnoses, but only about 30% of new users of PrEP, according to data from AIDSVu, which maps HIV infection and HIV infection. use of PrEP. HIV rates and the use of PrEP also vary by race and ethnicity
"We do not necessarily see that the people most at risk are those who start PrEP," said Kristin Keglovitz Baker, chief operating officer of Howard Brown Health, a Chicago health center.
Gilead has recently launched advertising to reach people at risk, including print campaigns and the television commercials that will be aired during the summer. Since 2012, he has spent $ 28 million to fund US organizations seeking to raise awareness about HIV, said McKeel, the spokesman for the company.
"We recognize that many people at high risk of Truvada infection for PrEP, and we are in regular dialogue with public health officials, lawyers and doctors to better understand and, if possible, help to meet these challenges, "he added.
But the price is also an obstacle"
"If it were only pennies, we would launch it," said Joey Mattingly, badistant professor at The University of Maryland Pharmacy School "Because of its high cost, we have to control it."
Some states, including California and Florida, have launched programs to help children get better. PrEP help that can help patients cover the cost of the drug, as well as the medical and medical work required.
Beyond these state programs, some public health departments and HIV service organizations are recruiting browsers PrEP to help patients Navigate the labyrinth of copais and franchises and improve the recruitment and retention of new PrEP users. According to Michael Kharfen, deputy director of the department responsible for the administration of HIV / AIDS, hepatitis, STDs and tuberculosis, Truvada is the key to prevention. The programs should fill any financial gaps, he said. But when this is not feasible, the department intervenes by distributing free Truvada Starter Kits to at-risk patients.
Kharfen said the city had spent close to a million dollars in the last three years alone in Truvada pills. at a reduced rate through the federal 340B program, which benefits some health care providers who treat low-income people. And because of new advertising efforts, he expects the department to need to buy and distribute more pills – posing an enigma.
The treatment of more people is net positive, he said. But "how can we support that?"
Medicaid programs typically cover PrEP, so that they are faced with a similar situation. Outreach efforts lead to more beneficiaries taking the drugs, but this, in turn, could subject states' Medicaid budgets to financial difficulties.
States spend millions of dollars on drugs. California's Medicaid program, for example, has spent about $ 50 million in 2017 and expects costs to continue to rise. But officials said the expense is offset by long-term savings to prevent new cases of HIV.
The Mbadachusetts Medicaid program spent about $ 22 million on Truvada the same year – about $ 18,000 per beneficiary, according to a spokesman for Health and Human Services. These figures do not reflect discounts that the state receives from Gilead, which are not disclosed and are considered proprietary information.
A complex and non-competitive solution
PrEP is only part of HIV prevention.
Patients also need HIV testing and regular medical care, which adds to the cost borne by both patients and the health system. Some experts warn that the high price of Truvada could financially harm such prevention efforts
Competition could help.
A generic version of the drug, manufactured by Teva Pharmaceuticals, is available overseas and has been approved for use last year by the Federal Food and Drug Administration. When it becomes available in the United States, it could lower prices, but we do not know when that will happen. Gilead's forecasts reflect this expectation, showing declines in Truvada's future revenues.
"When generics come in, brands lose market share," says David Howard, a health economist and professor at Emory University.
For now, however, Truvada is the only PrEP option available in the United States, he said. "From the point of view of the company … their best strategy is to earn as much money as possible."
KHN's coverage of these topics is supported by Laura and John Arnold Foundation and Blue Shield of California Foundation
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