Should benefit plans cover HIV prophylactic?

Plan sponsors and provincial governments alike should include the HIV prevention medication PrEP in their formularies, AIDS activists say.

Health Canada approved PrEP — a medication also known as pre-exposure prophylaxis and sold under the brand name Truvada — as a preventative measure in February 2016. Prior to that, it had approved the drug as a treatment for active HIV infections since 2006, according to the Canadian AIDS Treatment Information Exchange.

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At $1,000 per month, PrEP is pricey, but advocates suggest covering it can save employers and governments money in the long term.

First of all, those who contract HIV often face a host of other medical problems their employer and the province will have to pay for, both in terms of pharmaceutical costs and lost productivity. “Some of [the outcomes] involve time off work,” says Chris Thomas, communications co-ordinator at the AIDS Committee of Toronto. “Some of them involve long-term disability. Some of them involve death.”

Even before longer-term issues arise, having an employee on PrEP is cheaper than one on standard HIV treatment, since the former consists of two medications and the latter involving three, says Jack Mohr, the men’s health promotion co-ordinator at the AIDS Committee of York Region.

Thomas and Mohr also note some patients don’t take PrEP for their entire lives.

“When we’re thinking about costs, people tend to be taking PrEP for periods of their life, or intermittently, or for a month here, two months there, maybe a year there,” says Thomas, noting employees with HIV will take multiple drugs a day for the rest of their lives.

On the other hand, some will want to take PrEP for the rest of their lives.

“Somebody who has a permanent partner [with HIV] — they might want to be on it indefinitely,” says Joanne Jung, director of pharmacy services at Pacific Blue Cross in Vancouver. “You can’t define how long you would cover it. That would be very inconsistent to say we only cover it for a month.”

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While all provinces include options for publicly funded HIV/AIDS treatment, only Quebec covers PrEP. Grassroots organizations are urging other provinces to follow suit.

Employer-sponsored plans are more generous about including PrEP, but that may be because the majority are on open formularies, says Helen Stevenson, founder and chief executive officer of the Reformulary Group in Toronto.

Stevenson’s formulary covers Truvada as a preferred drug “because it does have the best combination of clinical and cost-effectiveness,” she says. Stevenson notes she has only seen two additional Truvada claims since Health Canada approved PrEP in February, which suggests few plan members take the drug prophylactically.

Earlier this year, on the other hand, Pacific Blue Cross cancelled “a handful” of plan members’ PrEP coverage because it hadn’t realized people were using the drugs preventatively and therefore off label, says Jung.

“Most contracts don’t cover things for prevention,” she says. “Like vaccines, if you’re going to be travelling out of the country and you’re making that choice to go to a high-risk area, then most employers feel the onus is on you to pay for those vaccines.”

But, Jung adds, Pacific Blue Cross is happy to add a preventative drug upon a plan sponsor’s request.

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Responding to the concern expressed in some quarters that PrEP may lead to a rise in unsafe sex practices, Mohr points to a 2010 study of 2,500 men who have sex with men in the United States and Latin America. It found they didn’t change their condom use after starting on the medication. “So obviously, folks who weren’t using condoms at all when they started PrEP haven’t started using them, but also people who were using them some of the time or most of the time continue to do so while they’re on PrEP,” he says.

Other than including PrEP on their formularies, plan sponsors can ensure employees know what the drug does and that coverage is available, perhaps through workplace meetings or regular emails, Mohr notes.

“I don’t see the role of employers to be dictating to their employees how to be safe but being supportive in their decision-making and providing the resources, both monetary and sociocultural, to help them make informed decisions when it comes to HIV, sex and substance,” says John Maxwell, executive director of the AIDS Committee of Toronto.

Employers, Stevenson points out, are often reluctant to get into discussions about staff members’ decisions because they don’t want to make judgments about people’s behaviour. But the dilemma is similar to that around expensive hepatitis C drugs, she says. “These drugs are virtually a cure, so if you get it again, it’s because of your behaviour. The way it gets addressed with those drugs, at least under our plan, is the member really only gets the one-time treatment. So there’s some responsibility by the patients as well. But that conversation is difficult to have.”