Out-Of-Pocket Costs Hinder PrEP Use Among Young MSM in the Private Health Care System

If taken consistently, research has shown that pre-exposure prophylaxis (PrEP) can reduce the risk of HIV infection by up to a whopping 92%. However, the cost of the medication isn’t cheap, and out-of-pocket (OOP) costs can affect the use of PrEP.

Although it is known that these costs can potentially affect adherence to PrEP, the extent to which these costs can impede PrEP use have not been previously quantified.

Until now.

At the 25th Annual Conference on Retroviruses and Opportunistic Infections (CROI), Rupa Rajesh Patel, MD, MPH, DTM&H, director of the Global Health Pathway in Internal Medicine within the Division of Medical Education at the Institute for Public Health at the Washington University in St. Louis (WUSTL), Missouri, shared the results of a recent study that assessed individual OOP costs and how they affect PrEP utilization in a population that is at particularly high risk for HIV infection: men who have sex with men (MSM).

For the study, the investigators reviewed intake demographic, behavioral, and billing data collected between June 2014 and July 2017 among MSM between 18 and 35 years of age who were receiving PrEP for 3 months or longer at the WUSTL Infectious Diseases Clinic.

The following charges were included in billing data assessed in the study:

• Office visit charges to individuals and insurance companies (copayments, coinsurance);
• Costs individuals were responsible to cover after insurance reimbursement;
• The amount of money paid by individuals; and
• The debt accrued by individuals (what the individual was responsible for paying vs what they actually were able to pay).

“The primary outcome was PrEP utilization, defined as self-report of continuing PrEP at 3-month follow-up,” the study authors wrote.

A total of 149 MSM with a median age of 26 years were included in the study. Half of the participants were white, 30% were black, and 4% were Latino. More than half of the participants (67%) graduated from college and had an annual income of $25,300. Eighty-three percent of the study participants had private insurance, 8% had public insurance, and 9% were not covered by insurance at all.

The median OOP total for the initial office visit for PrEP was $40, payment was $20, and accrued debt was $0. According to the study, “When adjusting for race and insurance, young adult MSM with any debt (>$0) were less likely to continue PrEP compared to those with no debt; adjusting for the same factors, MSM with a debt of $25 or more were less likely to continue PrEP.”

Furthermore, the investigators noted that median OOP payments and median accrued debt among those participants who were black and those who were not, “significantly differed” (payments: $0 and $25; P<0.001, respectively; accrued debt: $31 and $0; P<0.001), according to the study abstract.

Similarly, and perhaps not surprisingly, median OOP charges and median accrued debt among those who were insured and those who were not, also differed (charges: $36 and $212; P<0.001, respectively; accrued debt: $0 and $92; P=0.001.

“This study quantified amounts (>$0, and $25 or more) at which individual OOP costs impede PrEP utilization among young adult MSM, regardless of insurance coverage, who are accessing care within the US private health care system,” the study authors concluded. “Black MSM were disproportionately affected. Public sector financing to cover individual medical costs is needed to reach population-level benefit of PrEP.”