As we reflect back on Pride Month, and celebrate the Supreme Court’s recent employment rights decision, we must also recognize the unmet needs of Black, Indigenous, and People of Color (BIPOC) LGBTQ individuals, including health care access. A new California law aims to expand access to preventive care for HIV and AIDS, which disproportionately affects BIPOC LGBTQ individuals.
Medications against HIV
Two medications have transformed the fight against HIV. Pre-exposure prophylaxis (PrEP) is a daily medication for people at risk for HIV from sex or injection drug use. PrEP is highly effective; when taken every day, PrEP reduces the risk of contracting HIV by 99 percent. Post-exposure prophylaxis (PEP) is an antiretroviral drug used to prevent HIV after a high-risk event, such as unprotected sex or needle sharing.
CDC reports HIV preventive activities have stalled at high risk communities
Despite these transformative medications, the Centers for Disease Control and Prevention reports that HIV prevention progress has stalled, particularly among communities which are most in need of services. While HIV rates have decreased among White gay and bisexual men, infection numbers have remained stable for Black gay and bisexual men and have increased by 30 percent among Latino gay and bisexual men.
Limited access to health care for at-risk populations
Prevention efforts have been frustrated by limited access to health coverage. Even before the Trump Administration enacted the new rule permitting health care discrimination, members of the LGBTQ community were more likely to be uninsured. Access has also been hindered by barriers such as prescription requirements and limited numbers of LGBTQ-affirming medical providers.
California policy changes address medication availability and cost
Recent California policy changes seek to address two of the biggest barriers to people’s access to these medications: availability and cost. Under California’s new law, Senate Bill 159, pharmacists are authorized to dispense PrEP and PEP without a prescription, permitting them to administer 30 to 60 days of the drugs after testing and counseling.
In addition, the law directs pharmacists to connect individuals to physicians for long-term care. This law was set to go into effect on July 1, following the adoption of regulations by the California Board of Pharmacy. While the regulations have been approved, the program’s rollout and required pharmacist training has been delayed due to the COVID-19 pandemic.
High cost is a barrier for access to PrEP medication
High cost has also been a significant barrier to PrEP for those who need it most. For the uninsured, PrEP can be as high as $2,000/month or $24,000/year. For those with insurance, PrEP can still be prohibitively expensive, with out-of-pocket costs estimated at $6,000/year. These high costs disproportionately affect BIPOC LGBT individuals, who are more likely to be low-income than White individuals.
ACA provides coverage for PrEP medication
Under the ACA, preventive services with an “A” or “B” designation by the U.S. Preventive Services Task Force (USPSTF) must be covered without cost-sharing by most health plans. NHeLP strongly supported USPSTF designating PrEP as an “A” recommended preventive service last year. As a result of the “A” grade, most plans issued or renewed on or after June 11, 2020 must eliminate cost-sharing for PrEP.
This will help make this potentially life-saving prevention tool available to those at risk for HIV. However, the USPSTF should clarify that ancillary services associated with PrEP use, including HIV testing and counseling, are included in the PrEP access without cost-sharing under this recommendation.
California sends guidance to health insurers
California policymakers have taken note of the federal gaps. The California Department of Insurance released a notice earlier this month, reminding state-regulated health insurers of their obligation to cover PrEP under the ACA for all plans. The guidance goes into greater detail than the USPSTF recommendation, and includes a list of services beyond the actual drug that must be covered at no cost to the patient, including testing for HIV, kidney function, sexually transmitted infections, and pregnancy.
The guidance prohibits prior authorization or step therapy for PrEP drugs, as well as discrimination on the basis of gender identity. The California Department of Managed Health Care is expected to release similar guidance for Medi-Cal managed care plans.
California’s new regulations and administrative guidance present an important opportunity to improve access to PEP and PrEP. When these policies center the needs of BIPOC LGBTQ individuals, it brings us closer to ending the HIV and AIDS epidemic. Ensuring that this care is available where people live and at a price they can afford is a step in the right direction.