The 2019 National HIV Prevention Conference: What We Learned, Part 2

On day two of the conference, experts in their fields debated the cost-effectiveness of PrEP. How did they come to their conclusions, and how can states leverage that cost without the patients paying the price?


By Barrett White

According to the CDC’s website, PrEP, or pre-exposure prophylaxis, is a medication regimen that “when taken consistently, has been shown to reduce the risk of HIV infection in people who are at high risk by up to 92%.” In the effort to prevent the spread of HIV, getting this tool into the hands of the people who need it is especially important, so why is it so difficult? Health centers like Legacy that utilize Ryan White funding provide PrEP to their patients at a fraction of the cost.

Dr. Dázon Dixon Diallo, founder of SisterLove, Inc., was the moderator of “The Good, The Bad, and The Future” at a morning plenary session of the CDC’s National HIV Prevention Conference. Flanking her were Dr. Judith Aberg, and Michael Saag, MD. The two specialists were gathered to debate PrEP and its accessibility to the public. To begin the debate, the moderator set the scene with introductions: Dr. Aberg would be advocating for PrEP, and afterward Dr. Saag would try to convince the CDC that “PrEP was not the greatest thing since sliced bread.” Diallo said.

Prior to the debate, a live poll was conducted via the convention app with the following questions;

  • How important do you think PrEP is to ending the HIV epidemic in America?
    • Critically important, Very helpful, Somewhat helpful, or Not at all helpful
  • PrEP supports sexual health by opening up conversations, identifying undiagnosed STIs, providing STI treatment, and engaging people in ongoing care.
    • Agree, Disagree, or Don’t know
  • Until the cost of PrEP is reduced, it is too expensive for broad scale-up.
    • Agree, Disagree, or Don’t know.

At the onset of the debate, the audience—comprised mostly of health care providers, journalists, infectious disease specialists, and researchers—was in agreement that PrEP is critically important and supports sexual health, but there was some confusion over the price of the treatment.

Dr. Aberg took the floor first. “We cannot afford to not offer PrEP,” she began. Her argument was grounded in morality and responsibility, calling the treatment “essential” to ending the epidemic, agreeing that it promotes overall sexual health, and urging that due to this, it “cannot be deemed too expensive” to produce the drugs, nor can it be distributed at a price too high for the patients trying to access them.

“PrEP is a key component in ending the HIV epidemic,” she said, “We need PrEP to achieve fewer HIV diagnoses.”

Dr. Saag then had the floor. “It’s not about ‘cons’, it’s about barriers.” The main barrier, he says, is cost. It’s too high for PrEP, he argued. Dr. Saag said that in the U.S., without insurance the medications are just too far out of reach for many people who need them.

Rebuttals were swift, but they left Diallo—and the audience—wondering the same thing. “So, essentially you’re both arguing in favor of PrEP, then?” Diallo asked. Drs. Aberg and Saag illustrated that from the perspective of a health provider, PrEP is the best and most effective way to prevent the spread of HIV. The problem, the doctors outlined, was how to pay for it.

The drug market is not a free market, Dr. Saag argued, because in a free market, there is a seller and a buyer, but the buyer doesn’t need to buy, and the seller doesn’t need to sell. You walk into any store, you can decide not to buy a product based on the price and value. The seller can charge what they want. In health care, Saag said, that is not the case—buyers need to buy. With drug prices soaring, the question becomes, how can communities focus on getting treatments like PrEP to the people who need it?

One answer came from Craig Pulsipher, MPP, MSW is the State Affairs Specialist at APLA Health in Los Angeles. Pulsipher works with Los Angeles County on the intersection of health care and affordability, with a focus on health care policy and legislation. Pulsipher outlined how measures are being taken that can more easily get PrEP into the hands of at-risk populations in LA County, the most populous county in the nation with a staggering 10 million residents, more than double the size of Harris County’s 4.6 million. According to the most recent surveillance data, over 51,400 people are living with HIV in LA County. In Harris County, that number is just over 25,600. How is Los Angeles tackling the issue, and what might other cities learn from them?

California Medicaid—MediCal—pays for PrEP-AP, the PrEP Assistance Program. Anyone in California who earns less 500% of the federal poverty line has access to MediCal, and can access PrEP inexpensively, or for free. Additionally, if you have your own insurance, either through your employer or the Marketplace, you qualify for the Gilead copay card. These solutions are not too different from what is offered in Texas. The problem, Pulsiver says, is how LA County is tackling the insurance gap. Those who make more than 500% of the poverty line, but too little to afford an insurance premium (the coverage gap, also called “the donut hole”), which makes them ineligible for the Gilead copay assistance card.

For now, the conference did not offer a solution to the issue of affordability for people who fall within “the donut hole.” What it did provide however, was an explanation of costs, and the promise for a pursuit of a resolution that could put PrEP medications within reach for all at-risk populations.