Pre-exposure prophylaxis (PrEP) is a once-daily oral treatment that, when taken consistently, dramatically reduces the chance of acquiring HIV after exposure from a sexual encounter or injection drug use. However, a 2018 study found that “less than 10% of the 1.2 million individuals indicated for PrEP are potentially receiving protection.” This blog post outlines the complex nature of addressing the underuse of PrEP, and shares findings from an AcademyHealth project that identified Medicaid levers to increase implementation of PrEP-related clinical care services.

Efforts to Address Underuse of PrEP

A recent Centers for Disease Control and Prevention (CDC) report announced that between 2014 and 2017, PrEP use increased from 5.7 percent to 35.1 percent among men who have sex with men (MSM). This rate of progress is encouraging, but is not enough. In particular, there is a need to address disparities in PrEP access and use. For example, while PrEP use increased among all racial groups during this period, rates of use continue to be lower for black and Hispanic/Latino MSM compared to white MSM, despite the higher prevalence of HIV infections in these populations.

Ongoing efforts to increase PrEP use include the recent “A” recommendation from the United States Preventative Services Task Force (USPSTF), which concluded that PrEP is of “substantial benefit in decreasing the risk of HIV infection in persons at high risk of HIV acquisition.” This rating could help address two key barriers to the underuse of PrEP: cost and provider hesitancy. With this designation, insurance plans are required to cover PrEP at zero cost to their beneficiaries. Health care providers have expressed hesitancy to prescribe PrEP due to concerns such as feelings of insufficient evidence for real-world efficacy. The recommendation may therefore increase physicians’ confidence in prescribing the drug.

However, increasing access to the drug itself is not enough. It is also critical to increase the quality of care for patients already using PrEP, as many are not currently receiving the full suite of PrEP-related services in line with the CDC’s clinical guidelines. Many barriers contribute to this gap in care. HIV specialists, the seemingly obvious providers of PrEP care, are less likely to see populations of people at risk of acquiring HIV. While most are aware of PrEP and are comfortable prescribing it, their role in the provision of ongoing care to PrEP patients is less clear. Primary care physicians (PCPs), on the other hand, have the most consistent relationships with patients, but many are unsure how to integrate PrEP screening into their clinical care, or are unaware of the clinical guidelines. That leaves public health and sexually transmitted infection (STI) clinics primarily responsible, but their resources to provide follow-up care are limited.

Finally, there are barriers patients experience to seeking and receiving care. Many do not realize that PrEP is available and could benefit them, or worry about revealing information about sexual orientation and behavior or drug use habits to providers due to stigma. Patients may also have difficulty accessing services due to cost, geography, or time.

The Need for Multi-Stakeholder Collaboration and Policy Levers

Addressing complex health care delivery problems like this one requires collaboration by a variety of stakeholders. It is critical that health systems, payers, providers and policymakers explore ways to coordinate efforts, and to engage patients in the design and evaluation of care delivery to ensure care is responsive to patients’ needs and aligns with patients’ preferences and values.

AcademyHealth led a year-long project under a cooperative agreement with ChangeLab Solutions and the CDC to identify Medicaid levers to increase implementation of PrEP-related clinical care services, specifically considering strategies related to financing and benefit design, as well as patient and provider education and engagement efforts. These strategies were summarized into two white papers and distilled into issue briefs.

The first white paper focuses on state-level financial policies such as:

  • value-based payment mechanisms;
  • benefit design for STI testing, case management, and other relevant services;
  • performance improvement measures and incentives;
  • partnerships with local health departments and community-based organizations (CBOs); and
  • Medicaid reimbursement for services provided by nurse practitioners, registered nurses, and pharmacists.

The second white paper reviews barriers to patient and provider engagement, along with educational and operational support tools as well as:

  • Medicaid strategies at the federal-, state-, Medicaid managed care organization-level;
  • the use of data to target strategies and track progress;
  • leveraging Medicaid benefits to cover engagement tools such as telehealth and services provided by CBOs; and
  • other issues such as cultural competency, enrollment changes, privacy issues, and substance use.  

Lessons from the States

To encourage intra-state collaboration in implementing these strategies, AcademyHealth convened eight states’ Medicaid programs, public health departments and Medicaid managed care organizations to learn how each state is using diverse strategies for PrEP clinical care services based on the unique landscape of the HIV epidemic and the needs of at-risk populations, as well as Medicaid services available, in their state. Additionally, subject matter experts including patient advocates, clinicians, nurses, and actuaries attended to provide guidance and feedback to the state teams.

The AcademyHealth convening hosted both states with established intra-agency collaborations, and other states who were meeting their peer agencies for the first time and exploring what an intra-state agency collaboration might look like. States also identified other stakeholders and assets they could engage in their state’s strategies, including strategies to improve access and education such as scope of practice policies to allow reimbursement for pharmacists and nurses to provide tests and prescribe PrEP, and collaborating with physician associations to establish continuing medical education (CME) credits for PrEP care delivery education. States also considered strategies to improve awareness and reimbursement, from “dear colleague letters” to actuarial toolkits to changing prior authorization policies.

States discussed barriers they anticipated, especially in non-expansion states, and considered forming regional cohorts to continue collaborating across states once the meeting ended. While this meeting was simply a stepping stone in connecting agencies and spurring collaboration, it was incredible to see what happens when motivated stakeholders come together to work on solutions to complex problems.

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