PrEP Policy, Long-Acting Options Expand HIV Prevention Access: Kelsea Aragon, PharmD

Expanding therapies for HIV is shifting how patients access care and helping increase adherence.

At this year’s meeting, the Academy of Managed Care Pharmacy held an education session with an array of panelists discussing the impact HIV treatment delivery has on adherence. Long-acting injectables, when compared with oral pre-exposure prophylaxis (PrEP), make it easier to accommodate patients’ lifestyles, said panelist Kelsea Aragon, PharmD, an associate professor of pharmacy practice at the University of New Mexico College of Pharmacy, in an interview with The American Journal of Managed Care^® (AJMC^®).

In this Q&A, she breaks down how HIV care is delivered and how health care delivery and policy coverage are essential tools to maintaining patient adherence.

This transcript was lightly edited.

AJMC: What recent policy updates are most impactful for improving PrEP access, and how should payers be adapting their strategies in response?

Aragon: Medicare covers PrEP now for under Part B, which is amazing. Medicaid covers PrEP, as well. Commercial payers usually cover, at some point, some type of PrEP. Under the Affordable Care Act, PrEP is one of the pieces that has to be covered. Commercial insurance is where that could vary. So, ensuring that there's no step therapy with PrEP.

It is not like you can cover only oral PrEP until they fail it, right? Because the failure of PrEP would be an HIV diagnosis, which is what we're trying to prevent. I think coming up with strategies to hopefully cover one of the long-acting injectables, or ideally both of them, maybe certain criteria need to be met that are fair, but I think trying to figure out how coverage could possibly work for patient populations from a managed care side. A lot of times, the new diagnoses of people with HIV either don't have access to PrEP because of all of the issues we've talked about, or maybe they just forgot to take something. It takes a lot of wiggle room, and it makes it easier.

AJMC: With more PrEP options available, how should clinicians and payers work together to match patients with the most appropriate regimen based on lifestyle and risk factors?

Aragon: I think working together during the prior authorization process is a great way to communicate, because sometimes there are those implicit factors or things that aren't on paper for a patient. From a payer standpoint, you might not know that they live 100 miles from a clinic and that no one else in their area can provide long-acting injectable PrEP because it's administered by a health care provider.

That is justification to try to get one of these long-acting injectables covered so they only have to come into town every 2 months or every 6 months, vs maybe they can't take an oral daily PrEP for a variety of reasons: drug interactions, comorbidities, family and stigma, and safety concerns.

For people who are unhoused, it might not be feasible to have a daily option that they carry with them, but it might be feasible to try to engage them in care every 2 to 6 months. Hopefully, if we can engage them in care, we can help with other things, too, like the other comorbidities that might be going on.

AJMC: In populations you work with—such as individuals with HIV or those at higher cardiovascular risk—what considerations should guide PrEP selection and management?

Aragon: Thinking through drug interactions, I mean, there's not a ton, and usually we can manage around them, but thinking through HIV independently is a cardiovascular risk factor. My goal is to find ways to prevent it from happening in the first place. All of the PrEP medications, by way of preventing HIV, help potentially lower someone's cardiovascular risk. There's no data on that, but when I think about the risk of contracting HIV and having that baseline low-level inflammation the rest of your life, by preventing HIV from happening, we're helping improve their health outcomes for their entire lives.

The cool thing about PrEP in general is that we also keep track of our patients very closely, making sure that they test negative for HIV. Usually, when a patient's going for labs, it's a great time to also check their lipid panel and all of these other cardiovascular and just primary care monitoring parameters that in states where there isn't a lot of primary care might not happen on a regular basis. By engaging people in PrEP visits, you're able to engage them in the health care system more, which, hopefully, over time will translate to healthier people.

AJMC: Looking ahead, what changes in managed care or clinical practice are needed to fully realize the public health potential of PrEP in the US?

Aragon: I am a big advocate of community-based pharmacists prescribing and managing PrEP and being able to administer PrEP, because I think it's such an important touch point. I think the reimbursement of not only the medication appropriately but also the pharmacist’s time and cognitive services is essential, as I think that would open so many doors. Collaboration with community-based organizations is super important because usually those are the individuals and organizations that have meaningful relationships with the patients we're trying to reach.

If we're talking about a disease state that is very stigmatized, having someone you trust in a community-based organization that can help do a warm handoff to a pharmacist or to a clinic or something like that, where they say, “This is a known, safe person; they're going to take care of you,” is essential, and so I think it’s including the patient voices and the community-based organizations and community health workers; all of those pieces coming together is essential and important.