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The Impact of Health Insurance Coverage on How Quickly Young Black MSM Initiate PrEP

OCT 15, 2019 | GRANT M. GALLAGHER
A new study has found that among young black men who have sex with men (YBMSM) in Atlanta, younger individuals and those without health insurance have longer delays in initiating pre-exposure prophylaxis (PrEP) when compared with older or insured peers. According to investigators, this gap of time can lead to an increased risk of HIV transmission.

The research, published in the Journal of the International AIDS Society, noted previous studies have demonstrated that YBMSM have a high incidence of HIV infection but face barriers that result in comparatively low PrEP usage, making the population a high-risk group. As prior reporting by Contagion® has highlighted, clinicians seeking to limit the spread of HIV have a special interest in paying attention to this group’s behaviors around PrEP initiation.

The study investigators, comprised of experts from University of Miami Miller School of Medicine, University of Albany, and Emory University School of Medicine, set out to evaluate whether lack of health insurance and PrEP access through the manufacturer assistance program (MAP) can lead to a delay in initiation of PrEP.

During the study, participants with and without health insurance were assisted in acquiring PrEP, both financially and in preparing their paperwork. Those with insurance were given a copay assistance card, while those without health insurance relied on a MAP. The primary outcome of the research was the number of days between prescription and initiation of PrEP.

Using a Cox proportional hazards model, the investigators evaluated the effect of insurance status on delay in initiation. They found that study participants without insurance had an adjusted median time to PrEP initiation of 21 days, versus just 5 days for those with insurance. Despite theoretically equal access, participants with health insurance had a 1.72 times higher rate of initiation compared to those with no insurance.

Among the age-specific cohorts, 22- to 25‐year-old YBMSM initiated PrEP 1.93 times faster than the 18-21 age group, and 26- to 29‐year-old YBMSM had 2.56 times the 18-21 rate of initiation. 

MAPs are crucial to providing medications like PrEP for those without health insurance, and some clinicians are cautiously optimistic about moves by the Trump administration to expand PrEP access through these programs. Yet even in the beneficial context of expanded access through MAPs, a PrEP initiation disparity among YBMSM presents risk of HIV infections that could be averted.

Why would this disparity occur? Investigators suspected participants, coming from a population that already has limited access and rates of PrEP use, may have been delayed or discouraged by even a relatively streamlined process.

According to investigators, some participants had “difficulty obtaining documents for the MAP or required multiple reminders to return the documents” even if “anecdotally, the actual pharmaceutical company processing time was short once they received a complete application.” In their report, the study team expressed concern that “utilization of the MAP may delay PrEP initiation through the requirement for multiple points of contact with patients between the time of prescription and when the first dose is taken” while noting that “more recent changes to the Gilead MAP may mitigate some of these delays, but were not reflected in the study period.”

To combat the challenges uncovered in their research, the investigators suggested expansion of programs which provide direct same day access to PrEP irrespective of insurance status. Patients could then pursue either insurance assisted or MAP access to PrEP while working through their initial supply. The research pointed to the success of same day PrEP programs in New York City. Previous reporting in Contagion® covered the impact of a same day PrEP study in Colorado, while cautioning that lower income patients still faced major barriers to access.
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