Member Education, Follow-Up Is Key in Preventive HIV Care

Preventive HIV care has been shown to be incredibly effective at reducing risk of infection and managing exposure but Gary Owens, MD, emphasizes that payers must do more in terms of member education and improving adherence to achieve meaningful, long-term change. 

Gary Owens, MD, president of Gary Owens Associates, spent more than 15 years in primary care, and has more than 30 years of experience in the payer consulting space of health care. He previously served as a medical director for a large Blue Cross plan, as well as managed the plan’s pharmacy benefit management subsidiary. Dr Owens has worked in the consulting world for the past 10+ years of his career with a focus on payer value, payer review, and data requirements for new technology.

In an interview with First Report Managed Care, Dr Owens explores some of the common barriers in treating at-risk populations, comments on preventive HIV care education, and emphasizes the important role payers must play in caring for members at risk. 

What are some of the common challenges in providing preventive HIV care to patients and health plan members?

It is an interesting subject that has to start with some thoughts and data on HIV. The good news is HIV is a controllable disease. We do not yet have a cure, but we can certainly keep people who are compliant and adherent to their medication regimens at a state of virtually undetectable virus.

That being said, we have not necessarily seen a decrease in the prevalence of HIV. If you look at Centers for Disease Control and Prevention (CDC) data between 2014 and 2018, the number of prevalent cases both diagnosed and undiagnosed has been hovering around 1 to 1.1 million. If you break that out, about 1 million persons were diagnosed—which is an estimate because you cannot get data on the undiagnosed of about 150,000 or 160,000.

Why is that important? It’s that latter portion of the patient population who have HIV and do not know that are spreading the disease. Even if you are well intended partner of one of those people, you are not going to be taking pre-exposure prophylaxis (PrEP) because you don’t know your partner is infected. That is a big issue.

The second big issue, for payers, is that there is still significant public unawareness of the value of PrEP for HIV, as well as some partners taking the comfort level that if the HIV positive person has achieved a viral load titer under 400 or what is virtually undetectable, they reach the state of what we call U=U which is undetectable and untransmittable. Therefore, those partners may not even think about PrEP. 

A third issue we see is some regional variations regarding awareness and PrEP. I reviewed some data and areas of high need in terms of PrEP, which are prevalent in the South and some portions of the Midwest where there probably are more undiagnosed and undetected cases, or at least more high risk individuals.

That leads me to my final point, which is a number of high-risk individuals may not have been tested and therefore remain undiagnosed. Those are all issues for payers.

Can you comment on the US Preventive Services Task Force’s recommendation in support of preventive HIV care which led to increased access via an ACA mandate for health plans?

Ever since the combination of tenofovir/emtricitabine (TDF/FTC), or Truvada, received the indication, the US Preventive Health Services Task Force began looking at the data. They originally made a recommendation for PrEP based on level 1 evidence. That is what it takes for health plans to adopt a coverage policy. 

If it is truly preventive care under the conditions of the ACA, it needs to be made available; and not only made available, but made available at no out-of-pocket cost to the recipient.

What the recommendation did, especially based on level 1 or level A evidence, was create a situation where health plans need to cover PrEP. Now, having said that, there are two agents for PrEP, TDF/FTC that I mentioned, and emtricitabine/tenofovir alafenamide (TAF/FTC) or Descovy, which has a more limited indication.

Payers can choose to cover one or both on the formulary. They can choose to have prior authorization criteria in place to ensure the proper patient population is being served. The sum is that PrEP is a valid approach to preventing the spread of HIV and dovetails nicely with the CDC goals of reducing HIV infections by 75% in 2025 and 90% by 2030.

It is not the only way they’re going to do it, but it helps. It all fits together and is served to reduce some, but not necessarily all of the barriers to access for PrEP.

How can payers better approach the education of members on available resources and preventive therapies like PrEP?

Clinical payers play a wonderful role. This is one where literally it takes a village. Payers certainly have a role in educating people about where PrEP is appropriate and where it is not appropriate.

Even once they educate people about where it is appropriate and where it is not appropriate, they need to educate people on whether they need to be on continuous PrEP or what is known as intermittent PrEP based on risk of exposure. Even then, we also know that your risk of contracting HIV from your partner if you are not well adherent to your PrEP regimen increases relatively quickly.

Another component the payers need to engage is adherence to therapy—maybe with a medication therapy management program that contacts these patients regularly to be sure they are adherent to therapy.

From a payer’s standpoint, there is probably nothing more inefficient than spending upwards of $25,000 to $30,000 a year to prevent a disease, only to find out the patient is not taking it properly and gets the disease anyway, which the payer will have to cover treatment for. 

Another area payers can focus on is educating people that taking PrEP is not the only preventive measure. There must also be regular blood work monitoring, both because they are on the medication and because they are still at risk. If an at risk person gets a new partner, there may be new risks, especially the potential to transmit a resistant strain.

There are a number of educational initiatives that I think payers can pursue, but they are only part of the team. Public health is as well. It has to be social media. The CDC plays a role. It takes a multi-pronged approach of which payers are an important, but not the sole, cog in the wheel.

Another thing payers can do is if they have newly diagnosed HIV patients is make sure they are getting care, and if they do have a partner to make sure they are educated about the importance of PrEP for the partner. 

Is there something that payers or health plans should be doing differently regarding prevention by HIV care? 

I don’t know that payers have been actively promoting the use of PrEP sufficiently. There is a four-pronged approach to reducing prevalence and meeting the CDC’s goal I mentioned earlier—75% reduction in incident cases by 2025 and 90% by 2030.

In the four-pronged approach, one is increasing PrEP use by education and making sure that there are not unintended barriers like the cost of monitoring or access. The second action payers can do is promote increased use of testing of individuals, especially in the high-risk populations.

If you look at the risk populations out there, Black and Latino men who have sex with men are at the highest risk, and so on. Once the testing is done, making sure that those patients do get connected for treatment and follow-up with monitoring.

Finally, again, not only for treatment, but for PrEP, making sure that these people are adherent to therapy. The goal there is to minimize dropouts in not only active therapy for HIV but minimize dropouts to PrEP if you are exposed. We need to get payers to look at and engage with that four-pronged approach.

Is there anything I haven’t asked you about or anything that you’d like to add?

The only other thing that I would like to add is we currently have two agents available. They are both relatively expensive. Those agents have come under a bit of fire for the cost per year. In a PrEP situation, we’re talking about $25,000 to $30,000 per patient per year.

I understand that payers may want to manage this class, especially when we are likely to have generic equivalents of the TDF/FTC combination in the near future. Payers who traditionally have not done a lot to accepting Medicaid to manage this space may be looking and probably should appropriately be looking.

Now we have a new category of patients to manage, how we can manage it most efficiently and still get the results we want to get in terms of outcomes in preventing a lifelong disease.