Health Care Falters on AIDS Coverage

By SAM URETSKY

It’s in the manufacturer’s package insert: nnTRUVADA is a two-drug combination of emtricitabine (FTC) and tenofovir disoproxil fumarate (TDF), both HIV-1 nucleoside analog reverse transcriptase inhibitors, and is indicated:

In combination with other antiretroviral agents for the treatment of HIV-1 infection in adults and pediatric patients weighing at least 17 kg.

In combination with safer sex practices for HIV-1 pre-exposure prophylaxis (PrEP) to reduce the risk of sexually acquired HIV-1 in at-risk adults and adolescents weighing at least 35 kg

There are plenty of drug regimens for treatment of HIV-1 infections – not simply many drugs, but many classes of drugs. While there is still no way to cure an HIV infection, and no vaccine to provide immunity, combination therapy has achieved the goal of turning HIV infection into a chronic disease, rather like arthritis or diabetes, which can’t be cured but can be controlled for long periods.

What makes Truvada particularly important is the second use. In reports presented at the 2012 Conference on Retroviruses and Opportunistic Infections, Truvada appeared to be close to 100% effective in preventing HIV infection. For this use it’s known as Truvada PrEP, meaning pre exposure prophylaxis. The dose is one tablet a day, and should be used in combination with safer sex practices. Used properly, the drug is close to 100% effective.

There’s some good news and some bad news about Truvada. The good news, of course, is that the drug can almost completely stop the spread of AIDS. The bad news is that the drug costs about $20,000/year when used as directed. More good news: President Trump may have managed a really good deal for a change. According to Fox Business News, “Gilead Sciences, the maker of HIV prevention drug Truvada, is sending the United States a very big gift. It will be donating enough supply to support Trump’s initiative that seeks to eliminate transmission of the virus within the next decade.”

There are more problems. Insurance companies have been using use of Truvada as a marker of a high-risk patient, and in some cases refusing coverage, in other cases no longer covering the drug, or simply raising their rates. The New York Times reported, “He Took a Drug to Prevent AIDS. Then He Couldn’t Get Disability Insurance.” The Advocate reported “Some of the largest insurance companies in the nation are engaging in this categorical exclusion of PrEP users. GLAD (GLBTQ Advocates and Defenders) has heard directly about cases of discrimination by State Farm, Aetna, Metropolitan Life, John Hancock, Protective Life, Lincoln Financial, and many more. … gay men can either get insurance or they can forgo taking the best biomedical HIV prevention method in the history of an epidemic that has claimed so many lives”.

While President Trump proposed, for 2020, a $291 million increase in funding for HIV prevention, care and treatment at the Centers for Disease Control and Prevention (CDC), the Ryan White Program and Community Health Centers, and the Indian Health Service, there are cuts in other programs that reduce the anticipated level of benefits. According to the web site “them,” “The White House wants to pull $63 million from the Housing Opportunities for People with AIDS program, which would make it much harder for people living with HIV to find stable housing and reduce their viral load. The budget also proposes a 12% reduction in overall funding for the Department of Health and Human Services, which experts say would limit access to medication, reduce access to insurance ...” The 2020 increase, however, comes after two years of major cuts in the budget for AIDS research, which represents two years of lost time.

Significantly, while the AIDS crisis was initially associated with California and New York, the focus of the disease has moved to the southern states. If President Trump’s trade policies hurt the farmers who supported him in 2016, the victims of his cuts in AIDS funding are also his supporters. While California has 11.4 HIV infected persons per 100,000 and New York has 14.0 infections per 100,000, Georgia has 24.9, Florida 22.9 and Louisiana 22.1.

One of the questions that has been raised is the position of President Trump in terms of the evangelical vote. The web site Paleos carried a report “Trump’s New CDC Director: AIDS Is ‘God’s Judgment’ Against Gays” A report by CNN (5/13/18) indicates that Dr. Robert Redfield, the director of the CDC has a deplorable record on the subject of HIV disease. Even so, the CDC appears to be continuing Obama era programs and publicizing National HIV Testing Day. (June 27).

In theory there’s a possibility of eradicating AIDS – although from experience with measles vaccination which is simpler and far less expensive, that won’t happen. Still, it seems as if the government response, while less than might have been wished, is better than might have been expected. Even Big Pharma, Gilead, with its donation of enough of the drug to supply 200,000 patients annually for more than a decade, is doing something, although it is only enough drug for 20% of the current patient load and the company has not offered to reduce the $20,000-a-year price. The one group that seems to be doing the least is the health insurers. In a race to the bottom, they win.

Sam Uretsky is a writer and pharmacist living in Louisville, Ky. Email sdu01@outlook.com.

From The Progressive Populist, August 1, 2019

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