As Gilead prepared to launch Descovy, it focused marketing efforts on providers and consumers of the benefits of the new drug to capture patients who could have switched to generic Truvada. “What seems to be happening is that doctors are being encouraged to switch patients to Descovy based on the surface impression that it has a better safety profile, but for most of us, generic Truvada is perfectly safe. The switch to Descovy has more to do with Gilead trying to hold onto its market share of PrEP users in the face of generics,” said Kenyon Farrow of advocacy group PrEP4All.^[10] Gilead transitioned 49% of Truvada utilization to Descovy, according to Part D data, even though the switch from Truvada to Descovy was found to be unwarranted in five of six switches, on average.^[11 12]

When taken daily, PrEP reduces the risk of contracting HIV through sex by 99% and through intravenous drug use by 74%.^[13] Despite the high efficacy rates, nearly three-quarters (73%) of individuals who could benefit from PrEP have not been prescribed the medication.^[14] Further, the rate at which patients have switched from brand-name drugs to less expensive generic alternatives has been very low, despite the high cost of Truvada ($22,415) and Descovy ($24,807).^[15]

The 340B federal drug pricing program is designed to support the health needs of vulnerable populations. Under the program, organizations such as safety net hospitals and clinics can obtain PrEP at steeply discounted prices. They are reimbursed per the terms of the payer, whether it’s Medicare, Medicaid, or commercial insurance. The organizations then use the difference between the lower purchase price and higher reimbursement to meet the needs of low-income patients.^[16] Because the difference is greater when prescribing more expensive drugs, the hospitals and clinics lean toward the use of Truvada and Descovy over generics. While in many settings, including Federally Qualified Community Health Centers and clinics enrolled in the Ryan White program, this is done to achieve an overall net positive impact on care for vulnerable patients, it nonetheless shapes the pricing dynamic.^[17]

In 2020, the U.S. Preventive Services Task Force (USPSTF) gave Truvada an “A” recommendation.^[18] Under the Patient Protection and Affordable Care Act (ACA), that means at least one PrEP option (e.g., Truvada or generic) must be covered without cost-sharing to enrollees in most private health insurance plans.^[19] Prior to this recommendation, the high list price for PrEP meant patients often needed to seek prior authorization or use a special mail-order pharmacy to get their medication.^[20] While this is an improvement for Truvada, as of August 2023, Descovy had not yet been officially included in the recommendation and may still be subject to prior authorization and co-pays.

PrEP is only available by prescription--meaning a prospective patient must be seen by a licensed health care provider and test negative for HIV. Patients also likely need to see their provider every three months to continue receiving the medication. This high level of engagement with a provider may create structural or logistical barriers to accessing PrEP, and it may also impact the patient’s out-of-pocket costs. Co-pays for visits, lab tests, and filling the prescription indefinitely will add up. Taken alongside the price of PrEP, the added costs may further inhibit starting or continuing treatment.