ABSTRACT
In 2010, the US health insurance system underwent one of its most substantial transformations with the passage of the Affordable Care Act, which increased coverage for millions of people in the USA, including those with and at risk of HIV. Even so, the system of HIV care and prevention services in the USA is a complex patchwork of payers, providers, and financing mechanisms. People with HIV are primarily covered by Medicaid, Medicare, private insurance, or a combination of these; many get care through other programmes, particularly the Ryan White HIV/AIDS Program, which serves as the nation's safety net for people with HIV who remain uninsured or underinsured but offers modest to no support for prevention services. While uninsurance has drastically declined over the past decade, the USA trails other high-income countries in key HIV-specific metrics, including rates of viral suppression. In this paper in the Series, we provide an overview of the coverage and financing landscape for HIV treatment and prevention in the USA, discuss how the Affordable Care Act has changed the domestic health-care system, examine the major programmes that provide coverage and services, and identify remaining challenges.
Subject(s)
Acquired Immunodeficiency Syndrome/epidemiology , COVID-19/economics , HIV Infections/drug therapy , HIV Infections/prevention & control , Insurance Coverage/legislation & jurisprudence , Insurance, Health/legislation & jurisprudence , Acquired Immunodeficiency Syndrome/drug therapy , Adult , Aged , Anti-Retroviral Agents/therapeutic use , COVID-19/diagnosis , COVID-19/epidemiology , COVID-19/virology , Female , Gender Identity , HIV Infections/economics , HIV Infections/epidemiology , Humans , Incidence , Male , Medicaid/statistics & numerical data , Medically Uninsured/statistics & numerical data , Medicare/statistics & numerical data , Middle Aged , Patient Protection and Affordable Care Act , Risk Assessment , SARS-CoV-2/genetics , United States/epidemiologyABSTRACT
Approximately 84% of human immunodeficiency virus (HIV)-infected US residents on antiretroviral therapy currently receive some form of tenofovir disoproxil fumarate (TDF) as part of their HIV treatment regimen. The TDF analogue tenofovir alafenamide (TAF) has demonstrated equal efficacy but with decreased renal injury and bone mineral density loss compared with TDF. We examine how much more society ought to be willing to pay for TAF over TDF, in exchange for its improved toxicity profile. Using cost-effectiveness methods, we find that current conditions warrant an annual premium of up to $1000 over the average wholesale price (AWP) of TDF. Once generic coformulations of tenofovir/lamivudine become accessible, however, the appropriate premium for TAF will likely merit a downward adjustment, using generic TDF-based costs as the benchmark.