870. Coverage, Cost Sharing, and Out-of-Pocket Costs for Single-Tablet HIV Antiretroviral Regimens in Qualified Health Plans in the United States, 2018-2020

Abstract Background A key pillar of the US “Ending the HIV Epidemic” (EHE) plan is rapidly providing antiretroviral therapy (ART) to achieve viral suppression. However, access to ART is hindered by discriminatory benefit design through non-coverage, adverse tiering (including pricier cost sharing via coinsurance instead of copays), and excessive and arbitrary utilization management for ART, all of which make rapid access to HIV treatment challenging. To understand how ACA Qualified Health Plan (QHP) formularies adapt in response to new ART single tablet regimens (STRs), we analyzed QHP coverage of two first-line STRs: dolutegravir/abacavir/lamivudine (Triumeq; approved 2014) and bictegravir/emtricitabine/tenofovir alafenamide (Biktarvy; approved 2018). Methods For all QHPs offered in the 2018-2020 ACA Marketplaces, we analyzed Biktarvy and Triumeq coverage, cost sharing, and out-of-pocket (OOP) costs at state, regional, and EHE priority jurisdiction levels. Figure 1. Qualified Health Plan Coverage of Triumeq and Biktarvy by State, 2018-2020 Results For 2018, 2019, and 2020, respectively, we identified 19,533, 17,007, and 21,547 QHPs. In 2018, 26 states had < 50% of QHPs covering Biktarvy, and 9 states had 0%. Conversely, 41 states had 100% of QHPs covering Triumeq, and only 2 states had < 50% (Fig. 1). Biktarvy coverage improved from 2018-2020, especially in the Midwest (27% to 88%). Improvements were driven by increased coverage with copay except in the South, where coverage with copay remained stagnant and coverage with coinsurance increased (22% to 33%) (Fig. 2). Biktarvy coverage increased in EHE jurisdictions from 74% to 90%, driven by increased coverage with coinsurance (20% to 34%) (Fig. 3). Although Biktarvy had a higher national average wholesale price than Triumeq (&4,073 vs. &3,639 per month in 2020, respectively), monthly OOP cost trends only differed regionally in the Midwest and did not differ by EHE priority jurisdiction status (Fig. 4). Figure 2. Qualified Health Plan Coverage and Cost Sharing for Triumeq and Biktarvy by Region, 2018-2020 Figure 3. Qualified Health Plan Coverage and Cost Sharing for Triumeq and Biktarvy by “Ending the HIV Epidemic” Priority Jurisdiction Status, 2018-2020 Figure 4. Monthly Out-of-Pocket Cost for Qualified Health Plan Premium and Triumeq or Biktarvy by Cost Sharing Type and (A) Region or (B) “Ending the HIV Epidemic” Priority Jurisdiction Status, 2018-2020 Conclusion STR coverage remains heterogenous across the United States. Over time, coverage of the newer STR increased, but many QHPs in EHE jurisdictions still required coinsurance. Access to newer ART regimens may be slowed by delayed QHP coverage or complex negotiations with manufacturers about formulary inclusion as ART options become more competitive, even if patients are insulated from cost differences. Disclosures Kathleen A. McManus, MD, MSCR, Gilead Sciences, Inc. (Research Grant or Support, Shareholder)


Background.
A key pillar of the US "Ending the HIV Epidemic" (EHE) plan is rapidly providing antiretroviral therapy (ART) to achieve viral suppression. However, access to ART is hindered by discriminatory benefit design through non-coverage, adverse tiering (including pricier cost sharing via coinsurance instead of copays), and excessive and arbitrary utilization management for ART, all of which make rapid access to HIV treatment challenging. To understand how ACA Qualified Health Plan (QHP) formularies adapt in response to new ART single tablet regimens (STRs), we analyzed QHP coverage of two first-line STRs: dolutegravir/abacavir/lamivudine (Triumeq; approved 2014) and bictegravir/emtricitabine/tenofovir alafenamide (Biktarvy; approved 2018).
Methods. For all QHPs offered in the 2018-2020 ACA Marketplaces, we analyzed Biktarvy and Triumeq coverage, cost sharing, and out-of-pocket (OOP) costs at state, regional, and EHE priority jurisdiction levels. Results. For 2018For , 2019For , and 2020 QHPs. In 2018, 26 states had < 50% of QHPs covering Biktarvy, and 9 states had 0%. Conversely, 41 states had 100% of QHPs covering Triumeq, and only 2 states had < 50% (Fig. 1). Biktarvy coverage improved from 2018-2020, especially in the Midwest (27% to 88%). Improvements were driven by increased coverage with copay except in the South, where coverage with copay remained stagnant and coverage with coinsurance increased (22% to 33%) (Fig. 2). Biktarvy coverage increased in EHE jurisdictions from 74% to 90%, driven by increased coverage with coinsurance (20% to 34%) (Fig.  3). Although Biktarvy had a higher national average wholesale price than Triumeq ($4,073 vs. $3,639 per month in 2020, respectively), monthly OOP cost trends only differed regionally in the Midwest and did not differ by EHE priority jurisdiction status (Fig. 4). Conclusion. STR coverage remains heterogenous across the United States. Over time, coverage of the newer STR increased, but many QHPs in EHE jurisdictions still required coinsurance. Access to newer ART regimens may be slowed by delayed QHP coverage or complex negotiations with manufacturers about formulary inclusion as ART options become more competitive, even if patients are insulated from cost differences. Methods. A brief survey was offered to clients at four MP locations from September 2020 to June 2021. Multiple-choice questions addressed healthcare access, usage, and experience as well as preferences for service receipt including home-based, mobile clinic, and telehealth options. Brief qualitative short answer responses were also elicited. Results were tabulated and presented descriptively.
Results. A total of 115 clients were surveyed. Mean age was 36; 82.6% identified as male. Most respondents were either White/Caucasian (56.5%) or Black/African-American (19.1%) and 78 (67.8%) identified as Hispanic/Latinx. Of the 66% that reported being born outside the US, 34.2% had immigrated in the past 5 years. Only 41.7% of respondents had a primary care provider. Before coming to the MP clinic, 27% had not been seen for sexual health services in over 2 years. Most clients indicated satisfaction with MP services. The most important characteristics for a care site identified included comfort with staff, location, and affordability. 43.5% preferred a clinic time outside of 9am-5pm. Only 13% of clients preferred home-based labs using a self-collection kit with a majority preference for in-person follow-up at the MP clinic.
Conclusion. Key populations at risk for HIV infection including immigrants and Black and Latino MSM may experience barriers to traditional clinic care. Clients expressed satisfaction with MP services, and a preference for clinic-collected rather than self-collected specimens. Further research to tailor service delivery to client preferences is needed.
Disclosures. Methods. Data were utilized from the Aging with Dignity, Health, Optimism and Community (ADHOC) cohort, an observational study of OALWH from ten US clinics.
To measure sexual activity, participants were asked "How many sexual partners have you had in the last year?" with response options ranging from zero to "greater than five. " Loneliness was measured using the Three-item Loneliness Scale, and depression was measured using the Patient Health Questionnaire-2. Significance was determined by Kruskal-Wallis tests followed by unadjusted pairwise comparisons.
Results. Of 1,027 participants, the mean (SD) age was 58.9 (6.1) and 876 (85%) were male. 312 (30%) had zero sexual partners in the past year, 308 (30%) had one partner, 197 (19%) had 2-5 partners, and 210 (20%) had >5 partners. Of the participants with one partner, 230 (75%) were married, coupled or partnered, and 78 (25%) were single, widowed, separated, or divorced (Single). Figure 1 shows that people with one partner were significantly less lonely than any other group (p< 0.01 for pairwise comparisons), and all other groups were statistically similar to each other. This pattern was also seen with depression (p< 0.01 for pairwise comparisons, Figure 2). Among subgroup of people with one sexual partner, those who were married, coupled or partnered were less lonely (4.41 vs. 5.67, p< 0.01) and less depressed (0.95 vs 1.38, p=0.02) than those who were single, widowed, separated, or divorced.