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Anne Neilan, MD, MPH, physician-investigator in the Department of Pediatrics and Medicine and an assistant professor of Medicine at Harvard Medical School, is the co-senior author of a new paper in Open Forum Infectious Diseases, Increased HIV transmissions with reduced insurance coverage for HIV pre-exposure prophylaxis: Potential consequences of Braidwood Management v. Becerra

What was the question you set out to answer with this study?

The study addresses the potential clinical consequences of a September 2022 decision by U.S. District Judge Reed O’Connor of Texas in a case known as Braidwood Management v. Becerra. This is a U.S. federal court ruling that could remove a requirement for employers to provide insurance coverage for the HIV prevention medications known as Pre-Exposure Prophylaxis or PrEP.

What Methods or Approach Did You Use?

Our team – a collaborative group including investigators from Yale and others within the Medical Practice Evaluation Center at MGH –  assembled U.S.-based data on the epidemiology of HIV infection, current rates of PrEP coverage and effectiveness, and likely reductions in coverage if access to private health insurance coverage for PrEP in the U.S. were curtailed. Using amathematical model, we used these data to project outcomes related to the decision.

What Did You Find?

We estimated that for every 1% decrease in the number of PrEP-eligible men who have sex with men (MSM) receiving PrEP treatment, 114 new HIV infections would occur in the following year. We projected that at a minimum, this decision could result in more than 2,000 entirely preventable HIV infections in the coming year.

What are the Implications?

This analysis suggests that by removing the requirement for insurers to cover PrEP, the court’s ruling will harm both individuals and public health, undermining years of effort and investment to end the HIV epidemic in the United States.

The final outcome of the Braidwood case remains unclear. Judge O’Connor has yet to rule on a request by the plaintiffs for a nationwide injunction against the PrEP mandate as well as a religious exemption for PrEP insurance coverage. A decision on those elements of the case is expected in the coming weeks. Potential remedies could narrowly apply to the plaintiffs alone, or in more sweeping terms, apply to all U.S. health plans.

What's next? 

To apply these approaches to understand the implications of other policy decisions in the US, such as Tennessee’s recent plan to turn down $10 million in CDC funding for HIV-related services.

Paper cited:

A David Paltiel, PhD, Ali R Ahmed, BA, Elena Y Jin, BA, Meredithe McNamara, MD, MSc, Kenneth A Freedberg, MD, MSc, Anne M Neilan, MD, MPH, Gregg S Gonsalves, PhD, Increased HIV transmissions with reduced insurance coverage for HIV pre-exposure prophylaxis: Potential consequences of Braidwood Management v. Becerra, Open Forum Infectious Diseases, 2023;, ofad139, https://doi.org/10.1093/ofid/ofad139

About the Massachusetts General Hospital

Massachusetts General Hospital, founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The Mass General Research Institute conducts the largest hospital-based research program in the nation, with annual research operations of more than $1 billion and comprises more than 9,500 researchers working across more than 30 institutes, centers and departments. In July 2022, Mass General was named #8 in the U.S. News & World Report list of "America’s Best Hospitals." MGH is a founding member of the Mass General Brigham healthcare system.