Questions and Answers
Q: Does PrEP require a preauthorization? How do you handle that?
Dr Frasca: In Colorado, Medicaid does not require prior authorization, but many private insurances do. It varies by insurance. The insurers that do require a prior authorization require that you and the patient sign the Gilead agreement form available on their website that documents that you discussed risks/benefits of PrEP and required follow-up. They require that the baseline required labs be submitted to them, including the HIV test that is negative. Our pharmacist runs the prescription and then submits this form if needed to the insurer for the prior authorization; we have not had any rejected so far.
Q: How do we assure that PrEP doesn’t drive HIV resistance?
Dr Frasca: As far as we know so far, there is some evidence of a few patients acquiring resistant HIV in studies if they seroconvert while on PrEP at the initiation phase only. This is why it is so key to rule out ARS [acute retroviral syndrome] with a symptom screen and exposure history. You can always send an HIV VL or defer PrEP for 1 month and repeat HIV ABY if the patient has symptoms or high-risk exposure in the 4 weeks prior to starting PrEP to minimize the risk. It is also important to tell patients that PrEP is not 100% effective, given the rare risk of exposure to HIV that is resistant to emtricitabine/tenofovir.
Q: The economic discussion of PrEP and the prevention of HIV was impressive (eg, PrEP saves the $500k that would be associated with an HIV infection). But what time frame for PrEP was used for that model?
Dr Frasca: The study on PrEP economic benefit is a modeling study looking at covering at-risk MSM with PrEP; given this is hypothetical, there was not a time-frame specified to have to stay on PrEP, but the estimates were over a 10-year period. The study did not provide more detail. Here is the link to the study, for those who are interested: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3670988/#SD1.
Q: The people who most need PrEP are likely those who engage in risky behaviors. Yet these seem to be the same patients who are most likely to not take PrEP or be nonadherent to it. How do you address this inherent challenge?
Dr Frasca: This is a major challenge of PrEP, to keep engaging these patients in care; stressing the importance of the follow up that is required up front is key before initiating PrEP. To address adherence, we recommend addressing barriers with referral to mental health, substance abuse, or other programs related to underlying adherence issues. They can also check with the pharmacist to see if the patient is refilling on time.
Ms. Jessica Kobylinski: The CHN regional offices can also offer some case management services to those on PrEP to address barriers that affect medical adherence. There are a range of financial support services available as outlined by the Colorado CDPHE.
Q: Are there any current data about how the PrEP regimen potentially interacts with medication-assisted treatment (MAT) for substance abuse?
Dr Frasca: The combination of emtricitabine and tenofovir does not interact with methadone or suboxone, so there should be minimal issues prescribing it to individuals in substance use treatment.