Rising Out-of-Pocket Costs for HIV Prevention Medication Threatens Progress


A new study warns an increase in costs could lead to new infections.

In a recent study led by researchers at the Perelman School of Medicine and John Hopkins Bloomberg School of Public health found that even a modest increase in patient out-of-pocket costs for HIV pre-exposure prophylaxis (PrEP) could result in a sharp increase in prescription abandonment, and a subsequent large increase in the rate of new HIV infections.1

The results from the study published in Health Affairs highlight a concerning scenario that a small rise from $0 to $10 in monthly PrEP out-of-pocket costs would double the rate of PrEP prescription abandonment from 5.6% to 11.1%. Furthermore, an escalation in out-of-pocket costs ranging from $100 to $500 per month could lead to nearly one-third of patients abandoning their PrEP prescriptions at 34.7%.2

With the rate of new HIV infections in the year following the initial prescription being 2 to 3 times higher among those who never filled their prescriptions.

“Our findings suggest that out-of-pocket cost increases for PrEP could upend the progress that has been made towards ending the HIV/AIDS epidemic in the United States,” warns study senior author Jalpa Doshi, PhD.1

PrEP, endorsed by the Centers for Disease Control and Prevention (CDC), is a way of preventing HIV infection among higher-risk individuals and seeks to reduce new HIV infections in the United States by 90% by 2023. However, an ongoing legal challenge, Braidwood Management, Inc v. Becerra, threatens to overturn Affordable Care Act provisions, allowing insurers to impose out-of-pocket costs for PrEP and other preventative therapies.

Researchers estimate while reaching the $500+ category would result in an alarming 42.6% abandonment rate; almost 8 times that of the $0 level.

What You Need to Know

The study reveals that even a modest increase in out-of-pocket costs for PrEP could lead to a significant rise in prescription abandonment, potentially doubling the rate of abandonment with just a $10 increase.

Ongoing legal challenges, particularly the Braidwood Management, Inc v. Becerra case, may undermine Affordable Care Act provisions that currently prevent insurers from imposing out-of-pocket costs for PrEP and other preventative therapies.

Despite the challenges, there are positive developments in HIV prevention, such as the European Commission's authorization of cabotegravir long-acting (LA) injectable and tablets for PrEP. This long-acting option provides an alternative to daily pills, potentially addressing adherence challenges.

Expanding HIV Prevention Options is Crucial in Reducing HIV Transmission

The European Commission authorized cabotegravir long-acting (LA) injectable and tablets (Apretude) for PrEP. Cabotegravir is indicated in combination with safer sex practices for PrEP to reduce the risk of sexually acquired HIV in high-risk adults and adolescents.3

“This authorization marks a pivotal milestone for people across the EU who could benefit from an innovative, long-acting HIV prevention option that may better suit their personal preferences,” Deborah Waterhouse, CEO at ViiV Healthcare, said in a statement. “Long-acting PrEP, alongside other HIV prevention strategies, plays an important role in helping to address some of the challenges that people may have with oral PrEP options.”3

In the US, cabotegravir was approved for PrEP usage in December 2021.

“Today’s approval adds an important tool in the effort to end the HIV epidemic by providing the first option to prevent HIV that does not involve taking a daily pill,” Debra Birnkrant, MD, director of the Division of Antivirals in the FDA’s Center for Drug Evaluation and Research, stated at the time of the approval. “This injection, given every 2 months, will be critical to addressing the HIV epidemic in the US, including helping high-risk individuals and certain groups where adherence to daily medication has been a major challenge or not a realistic option.”3

This study highlights the critical need for federal and state policy makers to identify strategies to ensure no cost or low-cost access to PrEP. The researchers emphasize that the slight increase in costs could trigger a rise in prescription abandonment and the increase in new HIV infections. Ongoing research and monitoring of upcoming policy developments and legal challenges will be needed to assess their effect on access and adherence to PrEP.3


  1. Out-of-pocket Cost Increase Could Put HIV Prevention Medications Out of Reach. Penn Medicine News, January 8, 2024. Accessed January 9, 2024. https://www.pennmedicine.org/news/news-releases/2024/january/out-of-pocket-cost-increase-could-put-hiv-prevention-medications-out-of-reach
  2. Dean LT, Nunn AS, Chang HY, et al. Estimating The Impact Of Out-Of-Pocket Cost Changes On Abandonment Of HIV Pre-Exposure Prophylaxis. Health Aff (Millwood). 2024;43(1):36-45. doi:10.1377/hlthaff.2023.00808.
  3. Parkinson J. Europe Commission Authorizes Cabotegravir for HIV Prevention. Contagion Live, September 22, 2023. January 9, 2024.www.contagionlive.com/view/europe-commission-authorizes-cabotegravir-for-hiv-prevention.
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