PrEP Court Ruling Could Lead to Thousands of Preventable HIV Cases

In September 2022, US District Judge Reed O’Connor ruled that requiring coverage of HIV pre-exposure prophylaxis (PrEP) under the Affordable Care Act (ACA) was unconstitutional and violates a health care employer’s religious beliefs in Texas.

According to new research published in Open Forum Infectious Diseases, the ruling in Braidwood Management v Becerra could result in more than 2000 otherwise-preventable HIV infections within a year, if finalized.

Under current ACA provisions and with 28% PrEP coverage among men who have sex with men (MSM) at high risk of HIV, the CDC estimated that 21,867 new HIV infections will occur annually among MSM in the United States. If ACA provisions are changed and PrEP coverage drops to 10%, the study authors predict 2057 additional HIV infections among MSM in the next year following the change.

These values lie within the range defined by the author’s benchmarking estimates that, in the absence of any PrEP-related prevention, up to 25,064 MSM would contract HIV annually, with 15,234 MSM being indicated for PrEP. At the other extreme, 100% PrEP coverage for all MSM at high risk would reduce new HIV infections in this population to 13,639 annually, with 3808 cases being among MSM indicated for PrEP.

“For every 10% decrease in PrEP coverage resulting from this ruling among US men who have sex with men, we estimate an additional 1,140 HIV infections in the following year in that population,” the authors added.

These findings are based on compiled US data covering HIV epidemiology, current rates of PrEP coverage and effectiveness, and the estimated reduction in PrEP coverage if access to private health insurance benefits were cut back.

The authors also noted that the adverse consequences of the Braidwood Management v Becerra ruling with disproportionately impact racial and ethnic socio-demographic populations with especially high risk of HIV infection.

“Even in our ‘best-case’ scenario, the predominant burden of new restrictions on access to PrEP will likely fall on Black and Latino gay and bisexual men, as well as transgender women, who already face significant barriers to HIV prevention and care,” they said.

There are also federal programs in place supporting access to antiretroviral therapy for individuals with HIV, such as the AIDS Drug Assistance Programs. However, for those without HIV seeking preventative care, federal subsidies for PrEP are currently restricted to individuals without health insurance coverage for prescription drugs, and which may require copays for clinic visits and laboratory testing.

While a final decision has not yet been made, the authors said it is imminent. They also mentioned concerns that the ruling could affect all US health plans.

“In the most worrisome potential outcome, the judge could strike down the USPSTF’s authority to issue binding recommendations on a range of preventive health services far beyond PrEP,” the authors said. “This analysis suggests that by removing the requirement of insurers to cover PrEP – a clinical intervention with the highest level of scientific evidence behind it – the court’s ruling will have dramatic and injurious consequences for both individuals and the public health, undermining years of effort and investment to end the HIV epidemic in the United States.”

Reference

Paltiel AD, Ahmed AR, Jin EY, et al. Increased HIV transmissions with reduced insurance coverage for HIV pre-exposure prophylaxis: potential consequences of Braidwood Management v. Becerra. Open Forum Infect Dis. Published online March 16, 2023. doi:10.1093/ofid/ofad139