Viral Signs: Understanding HIV Medication Use
As we approach the observance of World AIDS Day on December 1, there is no better time to share the findings of our latest research endeavor, Viral Signs: U.S. Trends in HIV Medication Use, Care and Cost, and add to the global conversation around improving the prevention and treatment of HIV.
The CDC estimates that nearly 1.1 million Americans are living with HIV. That’s approximately 33 out of every 10,000 Americans. In 2017, our data show approximately 15 of every 10,000 Americans with commercial health insurance received drug treatment for HIV. Extrapolated to the U.S. population, we estimate that nearly 488,000 commercially insured Americans are being treated for HIV.
Examining de-identified pharmacy data from nearly 42 million individuals covered under commercial, Medicare, Medicaid and Public Health Exchange plans between 2014 and 2017, and with a novel and more sophisticated methodology that we created to better measure adherence in this unique population, we uncovered several important opportunities for providers, policymakers and payers with regard to medication use, quality and affordability.
Improve Affordable Access to Single-Tablet Regimens
Successful HIV treatment requires regimens that include multiple antiretroviral drugs in the right combinations to suppress viral replication and allow people living with HIV to live healthier, longer lives. Treatment can take the form of Multi-Drug Regimens (MTRs) or newer Single-Tablet Regimens (STRs) that combine up to four HIV drugs, allowing a patient to take just one tablet/capsule once a day instead of multiple medications, several times a day.
When looking at differences in adherence and cost between MTRs and STRs, our research suggests single-tablet regimens are associated with better adherence and lower costs compared to multi-tablet regimens.
Nearly 75% of people who use STRs are adherent to therapy compared to nearly 65% of people on MTRs. Staying adherent to HIV treatments is critical since interruption in therapy can result in the emergence of resistance to medication.
Additionally, pharmacy costs for HIV medications were $4,332 less for people using STRs compared to people using MTRs. The difference in cost is even greater -- $6,108 -- among people who are adherent to therapy.
Improving affordable access to STRs, especially lower-cost STRs, when clinically appropriate can help people living with HIV achieve higher adherence and lower overall costs.
Improve Affordable Access to PrEP
Emtricitabine/tenofovir disoproxil fumarate (Truvada®) is the only antiretroviral medication available in the U.S. for pre-exposure prophylaxis (PrEP), or prevention, of HIV in individuals with an increased risk of HIV exposure. A recent report from the U.S. Preventive Services Task Force recommends that clinicians offer PrEP to all persons who are at high risk of acquiring HIV.
Our research shows use of PrEP has increased across all plan types between 2014 and 2017, including a 6‑fold increase among commercial plans, which means more people at risk of acquiring HIV are taking effective steps to prevent infection.
Yet, PrEP use varies significantly by geographic location. There are U.S. regions that have high HIV treatment rates but very low rates of PrEP use; and likely the greatest exposure risk. For example, in the Southeast, only one person uses PrEP for every four people being treated for HIV (1:4), compared to the Northeast (1:1) and West/Midwest (about 1:2).
Cost for PrEP remains a barrier to coverage and affordability in the U.S. as the list price for a 30-day supply of PrEP is nearly $1,676. Meanwhile, in nations such as France, where generic versions of PrEP are available, the cost is €180, nearly 89% less.
The FDA approved generics for PrEP in 2017; however, a confidential settlement between the brand and generic manufacturers removed a patent challenge, effectively extending the brand manufacturer’s monopoly on the emtricitabine component of the regimen in the U.S. until 2021. Accelerating the availability of generic competition, or reducing prices to be more in line with other countries, can help improve affordability for people and payers, and deliver a significant public health benefit by increasing access to preventive treatment.
Payers with a high-deductible or consumer-directed plan design can consider adding PrEP to their preventive drug list -- as Express Scripts will do for qualifying high deductible plans using its CDHC Preventive Drugs List beginning January 2019 -- to provide more affordable coverage for people at high risk of becoming infected with HIV.
In our broader look at medication adherence among people being treated for HIV, we had to improve on existing methodologies for calculating medication adherence, because industry-standard methodologies, such as medication possession ratio and percent days covered, do not adequately address situations in which people need to be on specific combinations of multiple active ingredients to suppress the virus. Instead, we based our measurement on the percent of days that patients had a complete and effective combination of antiretroviral therapies in their possession during their time on therapy. We considered a person adherent if they had their complete therapy on hand for at least 90% of their doses.
We found, across all plan types, approximately 71% of people met this definition for adherence to their HIV medication last year.
Even though people are more adherent to STR therapy compared to MTR therapy, we found that the negative effect of pill burden on adherence does not extend to people who are living with HIV and other chronic conditions for which they are also taking medication, as adherence to HIV therapy is higher among those people living with multiple chronic conditions.
However, there is a significant opportunity to improve adherence among younger people living with HIV – just 61% of people aged 18-25 are adherent to their medication.
Every person living with or trying to prevent HIV should have access to the drugs they need, at prices they and their plans can afford, so they can live their lives to their fullest potential. These opportunities to increase adherence, optimize treatment, and improve access to prevention medication are three ways to fight back against this epidemic.