An upcoming Supreme Court case could make PrEP less affordable—does it have to?

One of the most effective factors in containing the spread of HIV has been the widespread availability of preexposure prophylaxis (PrEP). A PrEP regimen—which has grown to include daily pills or injections every few months—can decrease the chances of HIV infection by up to 99%. To build on those gains, in 2021, the federal government, under the Affordable Care Act, mandated that health insurers fully cover PrEP, as well as clinical visits and the labs required every three months.

But an upcoming hearing before the Supreme Court could upend that mandate. The case—brought by six individuals and two companies—is focused on whether mandating coverage of PrEP violates the religious freedom of certain business owners. Braidwood Management, one of the companies, is arguing PrEP coverage “facilitates and encourages homosexual behavior, intravenous drug use, and sexual activity outside of marriage between one man and one woman,” according to the organization’s petition to the Supreme Court.

“HIV doesn’t just impact the LGBTQ community,” says Kate Steinle, chief clinical cfficer at Folx Health, a healthcare provider focused on the queer community. “Removing this coverage [would] affect so many people.”

There are currently 1.2 million people in the United States with HIV. While HIV infection rates have decreased over 75% since the mid-1980s, in 2022 there were at over 31,000 new cases of HIV infection in the US. About 20% of the new cases are women, 83% of whom were infected during sex with men.

Without insurance coverage, generic PrEP could cost up to $60 a month, not including lab-work and clinical visits. At Folx Health, cash prices for an initial visit to get PrEP costs $159, follow-up visits cost $79 each, and labs run $97 a year.

“If you have good insurance, the out-of-pocket costs might not prevent you from getting PrEP,” says Edwin Corbin-Gutierrez, a senior program advisor at NASTAD, a nonprofit that represents public health officials focused on HIV and hepatitis. “However, it can be a big burden for some people and the biggest impact will be on lower income people and the most marginalized.”

A 2024 study found that a small price increase from $0 to $10 a month for PrEP would double the rate of people who don’t use PrEP. The study also found that the rate of new HIV infections among people who don’t have a PrEP prescription was double or triple the rate of new HIV infections for people who use PrEP.

Companies who sell PrEP are now scrambling to come up with a plan that protects public health should coverage fall through. “We’re in wait and see mode,” says Daphne Chen, cofounder of TBD Health, a telehealth company that offers PrEP and sexual health services. “We’re hopeful that the government doesn’t want an HIV epidemic on its hands.”

Both TBD Health and Nurx, another telehealth company that prescribes PrEP and treats other health conditions, have said that they’ll work to keep costs as low as possible and to partner with nonprofits to help fund people who won’t be able to pay for PrEP without insurance. Nurx says approximately 15% to 20% of its patients are not using insurance to pay for PrEP.

“This comes at a really unfortunate time when we’re making great strides in the fight against HIV,” says Neil Parikh, chief medical officer at Thirty Madison, Nurx’s parent company. “We’ll do whatever we can to make this affordable and connect patients to assistance programs.”

However, it’s not always as simple as wanting to make healthcare accessible. Blue Cross Blue Shield filed an amicus brief with the Supreme Court in which it argued that if some insurers drop PrEP and other preventative service coverage, other insurers will feel pressured to follow suit in the interest of keeping costs down and remaining competitive.

“Preventative care isn’t just a health policy issue, it’s a business issue,” says Elizabeth Kaplan, director of health care access at the Center for Health Law and Policy Innovation at Harvard Law School. According to a 2021 study, the cost of treating HIV can range from $400,000 to $1 million per person over the course of their life.

Kaplan also points out there’s a new treatment for PrEP on the horizon: an injection that can last for six months (some existing injections last for three months at a time). This could further reduce HIV transmission rates for had to reach people facing housing insecurity or addiction issues who may struggle with PrEP in the form of a daily pill, or with the three-month testing requirement.

Kaplan adds that a ruling that ends required coverage of PrEP doesn’t have to spell the end of it. “Companies can still choose to cover PrEP without copays,” she says. “We urge them to do so. It’s the right thing to do.”