Truvada payments totaled more than $2B in 2018
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Third-party and out-of-pocket payments for a 30-day supply of Truvada for HIV pre-exposure prophylaxis added up to $2.08 billion in 2018, data show.
This may be an underestimation of national costs, researchers said, because previous findings indicate that more than 80% of individuals who have an indication for HIV pre-exposure prophylaxis (PrEP) did not have insurance coverage in 2018.
Nathan W. Furukawa, MD, MPH, a medical officer at the CDC, and colleagues conducted a review of outpatient retail prescriptions for a 30-day supply of Truvada (emtricitabine/tenofovir disoproxil fumarate; FTC/TDF) between 2014 and 2018. Their analysis showed the following:
- Annual prescriptions of FTC/TDF increased from 73,739 to 1,100,684.
- The average third-party payment increased from $1,350 to $1,638, a 5% compound annual growth rate.
- The average out-of-pocket payment increased from $54 to $94, a 14.9% compound annual growth rate.
- Those with commercial insurance had the highest out-of-pocket costs ($107), followed by Medicare recipients ($80) and those on Medicaid ($3).
President Donald J. Trump launched his “Ending the Epidemic” initiative in February 2019. Among other things, the plan is intended to leverage the Ryan White HIV/AIDS Program to increase viral suppression across the United States to 90% and end the epidemic by 2030.
In an editorial that ran alongside the study by Furukawa and colleagues, Kevin L. Ard, MD, MPH, and Rochelle P. Walensky, MD, MPH, of the infectious diseases department at Massachusetts General Hospital, wrote that “this public health effort must start by releasing the cost noose that is strangling its own success,” considering how effective PrEP is.
To help patients with the costs of PrEP, Gilead Sciences agreed in May 2019 to provide free FTC/TDF for a maximum of 200,000 individuals annually for up to 11 years or until its second-generation HIV preventive medication, Descovy (emtricitabine/tenofovir alafenamide; FTC/TAF), becomes available and FTC/TDF comes off patent.
The U.S. government has also sought to enforce its claim to the patent for HIV PrEP and sue Gilead to lower the price of the preventive treatment.
Furukawa and colleagues said that their findings “should promote action” to lower the cost of PrEP, remove prior authorization requirements and increase PrEP access.
References:
- Ard KL, Walensky RP. Ann Intern Med. 2020;doi:M20-5643.
- Furukawa NW, et al. Ann Intern Med. 2020;doi:doi:10.7326/M20-0786.
Perspective
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W. David Hardy, MD, AAHIVS
The study by Furukawa and colleagues beautifully justifies why we need less expensive medications in the U.S.
The risk vs. benefit ratio analysis regarding PrEP for HIV when compared with other uses of antiviral medications, at least when it comes to cost, is sometimes difficult to estimate. Unlike HIV therapy, which is meant to be taken for the life of the person living with HIV (or until there is a cure), by design, PrEP will be taken discontinuously during “seasons of risk,” but most likely not for the patient’s lifetime.
PrEP users, unlike HIV therapy users, need to be tested for HIV every 3 months, four times a year, to accurately gauge the effectiveness of the PrEP and to know when to discontinue it if the PrEP user becomes HIV positive. They also need to have their kidney function checked every 6 months. And depending on how sexually active they are, many PrEP users undergo testing for STDs, including gonorrhea, chlamydia and syphilis, every 3 to 6 months.
But we also know that PrEP is very, very effective. The CDC has documented that when taken as directed, PrEP provides somewhere between 95% to 98% protection against acquiring HIV, which is a fantastic protection rate that is as good as or even better than most vaccines. In addition, now that the U.S. Preventive Services Task Force recommends PrEP use, patients taking PrEP who have health insurance are fortunate in that health insurance companies follow this directive to cover the medications and the tests I mentioned earlier.
We are also fortunate in that PrEP will soon be available as a generic medication here in the U.S. This means that instead of it costing $1,500 to $2,000 per month in the U.S., it could cost as little as a few dollars a pill, which is what PrEP currently costs in some parts of the world.
Prescribers need to know that Gilead, the manufacturer of FTC/TDF, has been conducting a significant marketing campaign to encourage them to switch their patients to their new version of the drug (FTC/TAF), claiming that it provides superior cellular pharmacodynamic coverage than the older FTC/TDF. However, in a head-to-head trial, the two drugs showed mostly statistically similar results.
No matter how much the price of PrEP goes down, we will likely continue to see lower uptakes of PrEP among African Americans, Latinos and Hispanics — all high-risk groups for contracting HIV — since many people within these underserved populations do not have health insurance. And if they do, their insurance is often not adequate to cover all the costs associated with its use. There are also many members of these populations who have never heard of PrEP. As physicians, we must do what we can to make more patients aware of, and have access to, this life-saving drug.
Editor's note: On Sept. 11, Hardy revised his perspective to correct his thoughts on Gilead's marketing campaign.
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