Chapter 4: HIV in Focus: ​Addressing Challenges and Opportunities

Dr Steve Cohen: In this section, I will share some ways that the audience could get involved in ending the epidemic. 64% of those who could benefit from PrEP are not receiving PrEP.  

Therefore, it is critical that barriers to prevention are removed. The IAS-USA, the U.S. Preventive Services Task Force, and the CDC all recommend PrEP to prevent infection with HIV. The Preventive Health Services Act, Section 2713, states that plans and insurers must have an easily accessible, transparent, and sufficiently expedient exceptions process when utilizing reasonable medical management techniques. Health plans can assist in closing the gap of 64% of people who could benefit from PrEP not receiving it by removing barriers in plans that could hinder access. 

The IAS-USA strongly recommends that PrEP be discussed with all sexually active adolescents and adults and any patient who injects non-prescription drugs or who has a substance abuse disorder.  

The USPSTF issued a Grade A recommendation for the prescribing of PrEP to adults and adolescents who may benefit from HIV prevention. And, the CDC has issued guidance recommending PrEP for HIV prevention in adults reporting sexual behaviors that place them at substantial ongoing risk of HIV exposure and acquisition. 

Text Box 23, TextboxThe Affordable Care Act prohibits cost-sharing requirements for prevention services with an “A” rating from the USPSTF for non-grandfathered private health insurance plans, Medicaid expansion plans, and traditional Medicaid and Medicare. This graph demonstrates that with an increase in $0 cost-sharing, there was a decrease in new HIV infections. Health plans can assist with ensuring that people who could benefit from PrEP are receiving it by providing PrEP at $0 cost-sharing. 

The recommendation of HIV testing is every three to six months. However, some plans limit the coverage of HIV testing to once per year. Health plans can assist in ending the epidemic by removing limitations to HIV testing and covering testing per the recommendation. Ensuring adequate HIV testing can assist in people knowing their status, getting the treatment they need, and preventing unintentional transmission of HIV.  

As we saw throughout this presentation, linkage to prevention for people at risk of acquiring HIV and linkage to HIV treatment is a key action to end the epidemic. The HIV Medicine Association conducted a survey in 2023 to document providers' experiences with implementing long-acting injectables. The greatest perceived barriers to implementation of long-acting injectables were health insurance processes, specifically prior authorization approval and appeals, including re-verification of eligibility for continued coverage, and coverage of the medications as a medical rather than a pharmacy benefit, which requires clinics to make upfront investments to cover the costs of LAIs and establish new and more complex processes. The Infectious Diseases Society of America recommends simplifying the prior authorization process by removing redundant approval steps and streamlining prior authorization for LAIs and to collaborate with providers to ensure a clear, efficient, and transparent process that minimizes administrative burdens and delays for everyone. The IDSA also recommends covering long-acting injectables under both the pharmacy and medical benefit. 

I hope that these suggestions provide examples of clear actions that the audience can take in assisting in ending the HIV epidemic.