Financing biomedical HIV prevention: Assessing obstacles to health insurance coverage for new biomedical prevention technologies

Background: Reducing the incidence of HIV continues to be an important US public health priority, especially among populations at elevated risk. Although HIV prevention efforts have historically focused on changing risky behaviors, recent trials have yielded efficacious new biomedical technologies designed to prevent infection, such as oral pre-exposure prophylaxis and antiretroviral microbicides. Research has also newly identified preventive effects of existing treatments, such as antiretroviral therapy, male circumcision, and substance abuse treatment. Because access to prevention technologies will help drive the next phase of the response to HIV, insurance coverage for these interventions is a crucial question. These technologies, however, arrive amidst escalating healthcare costs, prompting questions about health priorities and the extent to which private and public insurers should bear responsibility for public health.

Approach: The goals of this study are (1) to analyze the public policy implications of health insurance coverage decisions regarding biomedical HIV prevention, and (2) to evaluate potential legal challenges to providing coverage for this care. This inquiry identifies several legal bases on which insurers may deny coverage for biomedical HIV prevention services, assessing the extent to which these denials may survive external and judicial review. Because a few of these legal grounds may be persuasive, such as medical necessity and experimental treatment exclusions, this study also identifies alternative strategies for financing biomedical HIV prevention.

Conclusions: Insurance coverage for emerging HIV prevention technologies will likely be variable and subject to several grounds for denial, requiring consideration of alternative access strategies (e.g., statutory mandates, governmental financing).