Thread by @ryan_levi

Great thread here from @dmgorenstein on the some of the key facts from our story about Truvada and PrEP today. We talk about a lot more in the episode on online which you should def check out: tradeoffs.org/2021/04/22/pre…

I wanted to share a few of my own big picture takeaways... 🧵

https://twitter.com/dmgorenstein/status/1385276759256576001

The Truvada case is fascinating to me because it includes so many classic drug pricing issues (patents, pay-for-delay, product hopping), but it also has so many unique wrinkles that make it that much harder to draw simple conclusions about the impact of high prices on use.

There's this wild patchwork (see @CDCgov flow chart below) of public and private insurance, safety-net providers, public health depts and drugmaker payment assistance programs that make it so most people who want to be on PrEP can do so without significant out-of-pocket costs.

But the patchwork is hard to navigate and not perfect (ex: copay assistance can't be used for Medicaid/Medicare). And it's only necessary because the drug costs so much and so many people have unaffordable insurance or no insurance at all.

khn.org/news/out-of-po…

And even the entry of a bunch of new cheap generics isn't guaranteed to make a big difference because there are so many other barriers that are unique to PrEP (lack of awareness, stigma, additional lab costs) and those that are not (uninsurance, lack of Medicaid expansion.)

This meta-analysis by Kenneth Mayer, @AgwuAllison and @DMalebranche does a fantastic job of laying out the research on all these barriers:

link.springer.com/article/10.100…

And like @dmgorenstein points out, these barriers/risks are not evenly distributed. HIV risk is ⬆️ in the South and for Black and Hispanic ppl, where we see ⬇️ PrEP use. Trans folks and straight women are also high-risk, low-PrEP groups that get less attn

https://twitter.com/dmgorenstein/status/1385276766269415426?s=20

And then there's #340B which means many safety-net clinics on the ground actually getting PrEP to people who need it the most could lose money on cheaper generics because their clinics are funded by giant discounts off of brand name drugs. See below from @NASTAD.

And I haven't even touched on how this speaks to our core price vs. innovation conversation around drug prices (more here: tradeoffs.org/2020/01/22/sea…) or whether Gilead owes @CDCgov billions for infringing on the gov'ts PrEP patents (more here: sciencemag.org/news/2019/11/u…)

Speaking of that CDC lawsuit, it's worth pointing out that we only know so much about how Truvada got priced how it did because activists like @PrEP4AllNow and others have been shining a light on the high cost of this drug for years. Most drugs don't have that.

To me, the story of Truvada shows us how our system prizes innovation, how that can get us miracles like a pill to prevent HIV, how that same system can make it hard for people to access those miracles, and how that lack of access is not always just about price.

And with the new generics, we'll finally have a chance to see how big a role price has played.

Will we see a major ⬆️ in PrEP use? Will health depts start bulk buying PrEP to give out? Will cheap pills open up resources to tackle other barriers?

That's what I'll be watching.

There's so much more in our episode and on our website. @ProfRobnFeldman, @realtahiramin, @oni_blackstock, @NASTAD's Tim Horn and @C_Garthwaite are full of knowledge and help us break down this nuanced and important story.

tradeoffs.org/2021/04/22/pre…

And they are just the tip of the iceberg. This s*** is weedy, complex and nuanced, which can make it really hard to report on, but also really important. I am so thankful to the dozens of experts who patiently answered our questions about drug prices, drug patents and HIV/AIDS.