The Trump administration says it wants to end the HIV epidemic in the U.S. within the next decade. But major health care policies that the White House has put in place or proposed over the past two years run counter to those goals and create barriers to coverage for the people they are now trying to help, experts say.
The Health and Human Services Department’s new plan, highlighted during President Trump’s State of the Union address, will focus funding on three areas: increasing investments in “geographic hotspots” through existing and new HIV programs; identifying where HIV is spreading most rapidly to address prevention and treatment needs; and creating a local HIV HealthForce in these areas to expand prevention and treatment.
HIV experts and advocates say they are cautiously optimistic about the president’s announcement and the administration's new focus on ending the epidemic. But they say the plan will require more resources than the administration has dedicated to the issue right now.
They also argued that so far the administration has enacted or proposed policies that would make receiving HIV treatment and prevention harder. These include efforts to undermine coverage gains under the Affordable Care Act, immigration policies that make immigrant populations less likely to rely on health care services and Medicare drug-pricing proposals that could potentially make the task of obtaining HIV medications more difficult for patients.
“What Trump has done in trying to dismantle the ACA has been entirely in contrast or in conflict with trying to expand the ability to get these rather expensive medications,” said W. David Hardy, chair of the HIV Medicine Association. “For HIV positive people, we’re talking about lifetime, or at least as we can best think about it now, a lifetime of medications that cost somewhere between $20,000 to $30,000 a year per person.”
Hardy also said that the preventative treatment comes with a high sticker price of about $1,500 a month. Advocates say Truvada, the brand pre-exposure prophylaxis drug, is the only treatment of its kind available in the U.S., thus contributing to its high cost. “These aren’t cheap medications and they are ones that people need insurance to be able to access them,” said Hardy. “How the Trump administration is going to offer expanded health care access in a world where they are trying to pull back on health care access is going to be I think a big question.”
Health and Human Services Secretary Alex Azar has named expanding the use of this treatment as part of the initiative. But the activist group PrEP4All Collaboration said the Trump administration needs to bring access to generic PrEP to the U.S.
“If Trump really wants to eradicate HIV, it’s in his power,” the group wrote in a blog post after Trump announced the initiative. “He can use the existing statutory authority to enable Americans to access generic versions of Truvada and use the savings generated to create programs that get the drug into the hands of communities that desperately need it.”
Significant health coverage gains for people living with HIV were seen under the ACA’s Medicaid expansion, according to a 2017 Kaiser Family Foundation analysis. The report found that nationwide, Medicaid coverage for people with HIV rose from 36 percent in 2012 to 42 percent in 2014.
“To the extent that the administration discourages other states from expanding Medicaid or makes access to Medicaid more difficult, such as through work requirements, those kind of things could cut people off from needed coverage, and would not necessarily support the goals of getting people access to the services and support that they need,” said Jennifer Kates, vice president and director of global health and HIV policy at the Kaiser Family Foundation.
An HHS spokesperson told National Journal that Assistant Secretary for Health Adm. Brett Giroir had expressed to stakeholders that the initiative does take into account whether a particular “hotspot” was in a Medicaid expansion state or not.
But changes to Obamacare are not the only policies that could make ending the HIV epidemic an unattainable goal for the Trump administration. A Homeland Security Department proposal calls for considering whether an immigrant is likely to use Medicaid, Medicare Part D low-income subsidy program and food stamps as a negative factor against the U.S. government’s decision to either allow the immigrant to enter the country or to obtain a green card. The proposal, however, has already scared families away from certain public programs, some observers say.
“It is going to make the job harder if people are feeling like they cannot trust their medical providers or even trust being able to go to the medical providers because ICE agents are staking out the streets around them,” said William McColl, vice president for policy and advocacy at AIDS United. “We already know that to some extent there’s been a drop in the number of undocumented people who are seeking access to health care.”
Even proposed changes to Medicare Part D to lower drug prices and out-of-pocket expenses has drawn concern from HIV experts. A proposed rule would allow Part D sponsors to require prescribers obtain prior authorization to ensure that HIV medications would be covered by the plan. HHS is also considering letting Part D sponsors implement step therapy, where patients start with the cheapest medication and move up to more expensive options if those drugs aren’t effective.
Hardy said implementing prior authorization requirements on physicians for HIV drugs could introduce detrimental delays to treatment for patients.
He also said step therapy is not appropriate for Medicare beneficiaries with HIV. The HIV Medicine Association put together template comments on the rule that states the “consensus strongly supported by the published clinical trial and study data is that starting patients on the most effective, best-tolerated regimen is the best approach to optimizing outcomes.”
Advocates say they need to wait to see how much funding the president's budget requests for the new initiative to determine just how dedicated the Trump administration is to eradicating the HIV epidemic.
“I think that’s the big question mark right now is will there be new resources and how much will they be, because that’s one of the key ingredients here that would make a difference. ... Will they truly be new resources, not taken from some other area or from some other part of HIV because that would defeat the purpose,” said Kates.