Low-Income State Residents Will Have Coverage For PrEP

By Todd Heywood

Low-income residents of Michigan receiving Medicaid will have prescription coverage for Truvada, an anti-HIV drug proven to prevent HIV infections for those who are HIV-negative. The Michigan Department of Community Health confirms the drug will be covered for Medicaid patients.

"HIV drug therapies are covered, without prior authorization, as a Fee-For-Service pharmacy benefit for both Fee-For-Service and Health Plan enrolled Medicaid beneficiaries," Angela Minicuci, spokesperson for MDCH, tells BTL in an email. "Coverage is unrestricted and available when a medical practitioner evaluates the Medicaid beneficiary and determines a prescription for HIV drug therapy is medically necessary. Ultimately, HIV drug therapy is covered regardless of whether the particular prescription is to treat a Medicaid beneficiary with HIV diagnosis or for exposure prophylaxis, etc."

In 2011, the federal Health Resources and Services Administration (HRSA) reported that 17.4 percent of the state's populations were covered by Medicaid, the state issued low-income insurance program. Another 16.8 percent of the state's residents were covered by Medicare, the federal low-income insurance program. In that same year, nearly 34 percent of Michigan residents lived below 200 percent of poverty.

Using Truvada as a prevention method was approved by the FDA in July of 2012. It has been shown to be extremely effective when taken daily, but it is also expensive. The average 30 day supply costs a Michigan resident about $1,200. Taking the drug for prevention is called pre-exposure prophylaxis, or PrEP.

Despite its effectiveness in preventing infection with HIV, the drug has been at the center of a national controversy. Michael Weinstein the head of the largest AIDS Service Organization in the country - AIDS Healthcare Foundation - came under withering criticism and calls for his resignation in April when he called the drug a "party drug" and rejected it. Many anti-PrEP advocates worry the new intervention will result in gay men in particular throwing caution to the wind and increasing their risk behaviors. However, studies show there is no risk compensation related to taking PrEP, and in fact, participants in some studies showed a decreased number of unplanned sexual encounters.

For its part, MDCH officials have not yet endorsed or promoted PrEP as an effective and safe risk reduction intervention. In December, officials at MDCH told BTL the science was "promising," but they were waiting for more information before embracing the intervention. That lack of embrace means the state has not issued formal guidance to the state's health care providers and that could result in a lack of access to PrEP for many at risk persons.

A similar situation arose in 2010 when it was reported that the state had no official policy or guidance related to non-occupational post-exposure prophylaxis (n-PEP). In that intervention, a person who believes he or she has been exposed to HIV can obtain a prescription for a 28-day course of anti-HIV drugs. The intervention is time sensitive, however, in that a person must start the drugs within 72 hours of exposure, or they will not work. The later one starts the drugs, the less effective they are. Because the state did not have a comprehensive policy and guidance on n-PEP, a person in need could be denied access to the drugs, and an investigation by Michigan Messenger found that access often relied on where a person was in the state. It took the state 18 months to issue its n-PEP guidance, which mirrored the 2005 CDC guidance.

That refusal by MDCH to issue guidance or endorse PrEP as a prevention option is not sitting well with some Michigan activists.

"This is literally a drug that you can take to reduce your risk of contracting HIV. Why isn't this available to everyone, everywhere?" asks Katelyn Tonge, an Albion College student leader. "Attempts to marginalize PrEP, some going so far as to frame it as a 'party drug,' go along with the historical narrative that HIV is a punishment for risk behaviors. It is a blatant example of how active the stigma surrounding HIV really is. PrEP is a tool, and it's an important one. PrEP offers individuals a chance to be active and empowered about their sexual health, a chance that shouldn't be contingent on socio-economic status or stigma."

Stevi Atkins, executive director of Wellness AIDS Services in Flint, says the lack of support from the state will continue to be a roadblock to access for the intervention in Genessee County.

"That's great it will be covered," Atkins says. "Too bad no one in Genesee County is prescribing it."

She says the intervention isn't on "anyone's radar" without the state guidance.

Equality Michigan Victim Advocate Bryan Victor was hired late last year to specifically assist the organization in addressing HIV-related issues.

"Pre-exposure prophylaxis (PrEP) is an incredibly important tool in our efforts to curb the ongoing epidemic of HIV infections among transgender women, gay men and bisexual men in Michigan," Victor said. "Equality Michigan is extremely pleased to learn that the Michigan Department of Community Health has confirmed that PrEP will be covered by Medicaid. Access for poor and working class folks, and in particular for young transgender women, gay men and bisexual men, has always been a leading concern when it comes to PrEP. This decision by MDCH moves Michigan a large step forward in removing the many barriers that limit its use by these groups. However, without a significant number of primary care providers who are willing and able to both prescribe PrEP and monitor its use, this coverage decision alone will have little impact. The next important step is for MDCH to issue recommendations and guidance on the use of PrEP to prevent HIV transmission to HIV/AIDS service organizations and primary health care providers, similar to what was released earlier this year by New York State Department of Health. Equality Michigan considers MDCH's work on this matter to be incomplete until these steps are taken."


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Low-Income State Residents Will Have Coverage For PrEP

"This is literally a drug that you can take to reduce your risk of contracting HIV. Why isn't this available to everyone, everywhere?" - Katelyn Tonge, an Albion College student leader

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