Trump-Bobby Jr. AIDS policy makes no sense
Increasing out-of-pocket costs, copayments
Led by Emory University researchers and published yesterday
in JAMA Network Open,
the first study explored the likely changes in HIV transmission and
healthcare costs if policy changes result in decreased HIV pre-exposure
prophylaxis (PrEP) use in the United States.
The team used population-based data, PrEP prescription
information from 2012 to 2022, estimates from a previously published clinical
model, and parameters from a previously published ecological model to describe
population-level PrEP use and new diagnoses under different hypothetical
changes in PrEP coverage sparked by federal policy changes.
PrEP, when taken as directed, reduces the risk of
acquiring HIV by as much as 99%.
Scenario 1 was based on an assumption that the increases in
PrEP coverage observed during the past decade would be reversed over the
following decade. The other two scenarios took the same approach but at
alternative levels of 10% (scenario 2) and 2% (scenario 3) absolute annual
decreases.
Discounted analyses indicate the present value, reflecting
the time value of money, while undiscounted analyses represent the total
projected cash flows linked to the scenario.
Earlier this year, amid sizable cuts to US Health and Human
Services public health staff and programs, reducing public funding for PrEP
programs through approaches such as increasing out-of-pocket costs and
copayments was discussed.
"PrEP, when taken as directed, reduces the risk of
acquiring HIV by as much as 99%," the investigators wrote.
"Critically, changes in policies that lead to increased out-of-pocket PrEP
costs or that decrease access to proximate PrEP locations could reduce PrEP
coverage, resulting in excess HIV infections and costs."
8,600 excess HIV infections, $3.6 billion in costs
The authors noted that PrEP use is four times more likely
among patients with health insurance and that equitable PrEP use is
substantially higher in states with Medicaid expansion or PrEP drug–assistance
programs and highest in states with both.
In 2012, of 9,565 US PrEP users, 61.2% were male, 74.3% were
aged 25 to 54 years, 56.5% were White, 19.4% were Black, and 12.9% were
Hispanic.
Assuming that cuts to PrEP programs reduced PrEP coverage by
3.3 per 100 people each year with indications for PrEP over the next decade
(eg, effects of discontinuing interventions to increase PrEP awareness,
increasing out-of-pocket PrEP costs), HIV diagnosis rates were estimated to
increase by, on average, 2.3%.
"This modest decrease in PrEP coverage would be
expected to erase all the reductions in HIV transmissions achieved during the
past decade," the study authors wrote.
"Based on analyses of data from a census of US PrEP
users including 17,333,732 person-years of time using PrEP, an absolute 3.3%
annual reduction in PrEP coverage during the next 10 years (eg, 2023 to 2033)
would result in 8,618 avoidable HIV infections, with lifetime medical costs of
$3.6 billion (discounted) for treatment," they added.
Net costs over the decade under this scenario would be $1.4
billion (discounted) and
$1.9 billion (undiscounted). Evaluating a scenario of larger cuts to PrEP
programs, with estimates of yearly decrease in PrEP coverage of 10 per 100
people with indications for PrEP, resulted in 26,873 HIV infections that failed
to be prevented in a decade, with correspondingly higher lifetime medical costs
of $11.2 billion (discounted) and $29.0 billion (undiscounted).
"HIV prevention via PrEP improves the health of US
residents and can save money in terms of medical costs from the payer
perspective," the researchers wrote. "Moreover, although not
considered in this study, cost estimates from the societal perspective would
likely show even more cost savings, because most HIV infections occur in
younger people."
They said that consideration of policy changes couldn't come
at a worse time, with advanced PrEP treatments and more in development
promising further reductions in HIV infections.
"Disinvestment in PrEP programs will slow the current
progress in reducing new infections; disinvestment in PrEP research structures
will also destabilize a present (and desperately needed) acceleration in HIV
prevention technologies," they concluded.
Nearly 50% more infections by 2030
The second study, published in the Annals
of Internal Medicine, involved a simulation of HIV transmission and Ryan
White clients in 31 high-burden US cities and a survey of clinic directors and
administrators to estimate how many new HIV infections could ensue if federal
funding cuts disrupted or ended Ryan White services for 18 to 42 months by
2030.
The Ryan White HIV/AIDS Program has provided prevention and
treatment services to over half of people with HIV in the United States for 35
years.
A team led by Johns Hopkins researchers modeled four model
scenarios were continued services, cessation in July 2025, interruption until
January 2027, and interruption until January 2029.
The researchers estimated that ending Ryan White services in
July 2025 would result in 75,436 additional infections (95% credible interval
[CrI], 19,251 to 134,175 infections) by 2030—a 49% (95% CrI, 12% to 86%)
increase. The increases ranged from 9% in Riverside, California, to 110% in
Baltimore, Maryland. Eighteen- and 42-month interruptions resulted in 19% and
38% more infections, respectively.
A "conservative" sensitivity analysis using
observational studies with lower simulated loss of suppression projected 34,051
excess infections (95% CrI, 23,902 to 45,147 infections).
"The most powerful form of prevention is making sure we
treat people with HIV effectively,” senior author Anthony "Todd"
Fojo, MD, MHS, of Johns Hopkins, said in a university news release. "Providing
medical treatment for HIV is a public health issue in that it is a lifelong
condition. With antiretroviral therapy, people with HIV can expect to live a
normal lifespan and do not transmit HIV."
Fojo noted that, if Ryan White funding ends now, the
predicted increase in HIV infections in Baltimore by 2030 would easily be the
worst among the studied cities. "I'm dismayed to see that Baltimore
City's infections would increase by 110%, meaning infections over the next five
years would double," he said.
