California's Plan to Improve PrEP Uptake A Model for Other States?: Public Health Watch

To borrow from the 1970s television program “The Six Million Dollar Man,” we can stop HIV transmission—or at least virtually so. “We have the technology,” as the opening of the show, starring Lee Majors, put it.

In the case of preventing HIV transmission, that technology is pre-exposure prophylaxis (PrEP), which comes in the form of 2 drug regimens, branded as Truvada and Descovy, respectively. And it’s been available for a while now; the only challenge has been getting it into the hands of those who should be taking it.

Research has suggested that a fraction of the more than 1.1 million Americans that have indications for PrEP, according to the US Centers for Disease Control and Prevention, are taking the regimens. The reasons for this shortfall are several, and center primarily on issues of access.

There are cost concerns, of course—the regimens are expensive, even with payment-assistance programs in place—and, sadly, there remains a social stigma surrounding HIV, at least in some circles.

Now, new legislation in California may be working to break down some of these barriers to access. According to a commentary published on December 26^th in the New England Journal of Medicine (NEJM), California Senate Bill 159 (“SB159”), passed in September and enacted as of January 1^st, allows pharmacists in the state to dispense a 30-to-60-day supply of PrEP, without a physician’s prescription; requires pharmacists to complete a PrEP certification program; requires insurers to pay for at least 1 formulation of PrEP without prior authorization; and adds PrEP to the pharmacist services covered under the Medi-Cal program.

“We expect SB159 to reduce many of the barriers to PrEP uptake,” Ian W. Holloway, PhD, LCSW, MPH, a licensed clinical social worker and an associate professor of social welfare in the UCLA Luskin School of Public Affairs, told Contagion®.

Holloway also serves as a principal investigator with the California HIV/AIDS Policy Research Centers (CHPRC), and there are 2 recent reports from this group support his statement. In the first, based on “qualitative interviews” with 8 clinicians, the group found that prior authorization requirements (4 out of 11 California insurers require them for Truvada) delay access to PrEP, potentially exposing patients to risk for seroconversion and disrupts patient adherence to PrEP, through delays in prescription refills.

The second, an analysis of PrEP use among Medi-Cal (California’s Medicaid program) beneficiaries, concluded that while use of prophylaxis has increased across most demographic groups, significant gaps remain—particularly among the state’s Hispanic residents, the group with the largest numbers of new HIV diagnoses, and young people between 16 and 24 years of age.

“In many cases, these are the communities most disproportionately affected by HIV in the state,” Holloway noted. According to Holloway, CHPRC will be monitoring “what PrEP uptake will look like” among Medi-Cal beneficiaries in the aftermath of SB159, but he hopes and expects it will increase.

It should be noted here that the legislation augments the state’s PrEP cost-assistance program, which is funded through taxpayer dollars, and Holloway acknowledges that both initiatives likely place California “a bit ahead of the curve compared to other states in terms of PrEP access.” However, like the authors of the NEJM commentary, he is cautiously optimistic that other governments will follow the state’s lead by establishing similar programs and funding research into low-cost alternatives to PrEP as it’s currently constituted—including injectable formulations, which are in the pipeline.

“SB159 was the direct result of hard work and grassroots efforts from groups such as the HIV Alliance and the San Francisco AIDS Foundation, and we’d like to think that some of the work we’ve done helped pushed the bill through as well,” Holloway said. “Improving PrEP uptake will not only save lives. It will reduce overall health care costs. We hope other states will look to California and see the success of these programs and try to replicate them.”

If they do, we’ll not only have the technology, but the wherewithal, to finally end the epidemic.