July 30 was the 61stth anniversary for passage of Medicaid, the healthcare program for low-income people signed by President Lyndon B. Johnson in 1965 as an amendment to the Social Security Act. Connecticut’s Medicaid program, called Husky, is a model program, with a generous eligibility thresho ld, comprehensive health benefits, and good health outcomes. As an HIV Specialist who has cared for patients with HIV for 41 years, Medicaid has been a lifeline for many of my patients living with HIV. About 45% of people in Connecticut who receive HIV care are in the Medicaid program, and our state is one of the top performing states for HIV treatment and prevention. Since the start of the HIV/AIDS epidemic (yes, it is still an epidemic) HIV providers in Connecticut have had access to the full array of available medications to treat HIV. In addition, Connecticut has been a leader in making available by oral and long-acting injectable medications that are better than 99 percent effective in preventing HIV for people at highest risk of contracting this infection. HIV medications, when taken as prescribed, suppress the amount of virus to an undetectable level, which allows the immune system to be restored, and equally important, a person with an undetectable virus level cannot be transmit the virus to others through sexual contact.  We call this “treatment as prevention.” Given Connecticut’s success providing a model for HIV treatment and prevention, it is concerning that the Medicaid program is now considering limiting the treatment options available to patients, with plans to create a “Preferred Drug List,” or PDL.  Medicaid uses a preferred drug list for certain other diseases, but it has never done so for HIV. This chart uses Connecticut Department of Health surveillance data. Credit: CTMirror It is important to understand that people living with HIV have more complex life circumstances and health conditions than most people treated for other conditions.  People with HIV suffer have higher rates of mental health and/or substance use disorders, are more likely to suffer from cardiovascular and pulmonary diseases, more likely to be frail, and at greater risk for cognitive impairment as compared with people with most other illnesses.  They are more likely to have housing instability or be homeless, have higher rates of food insecurity, and more likely to suffer from depression. But perhaps most significant, is the stigma faced by people diagnosed with HIV.  Stigma can prevent someone with HIV from even being tested and diagnosed, it can delay entry into care and can lead to poor adherence to treatment. The patient and the HIV specialist need to have access to the full array of available treatment options.  Today’s newest antiviral medications tend to have fewer side effects, have fewer interactions with other medications, and allow for once daily, or even once every two months treatments.  And the newest HIV prevention medication can be given every six months. Given the complexity of conditions faced by people who live with HIV, or for those at highest risk of becoming infected with the virus, it will be harmful to limit the choice of medications to treat or prevent this disease.   In my experience treating HIV patients, I have learned that of the major medications we can offer, the best antiviral regimen is one that is least likely to become resistant to the virus, has the least side effects, and most importantly, the one my patient will take as prescribed. Research has shown that starting someone newly diagnosed with HIV on the day of, or as close to the day of diagnosis as possible protects the immune system, can reduce chronic inflammation and improve adherence to treatment.  This benefits not only the patient but reduces the risk of transmission to others as well.  Limiting treatment options or requiring a prior authorization to start treatment with a more limited formulary is a barrier that can reduce the choice of tailoring a medication to a patient’s unique needs.   While the proposed consideration of a preferred drug list for HIV antivirals is intended to reduce cost, it may delay the start of treatment with the best medication tailored to the individual patient need and perhaps be more costly long-term. In 2015, when the Connecticut Medicaid program placed restrictions on which patients with chronic hepatitis C (HCV) could be treated with a new class of drugs to treat HCV in order to reduce cost, it quickly realized that doing so would cause harm to many of the people with this infection who would be denied access. By reversing this restriction, Connecticut became the first state in the nation to allow all persons with Hepatitis C to be treated, and today it is one of only three states in the U.S. that is on target to meet the Federal HCV elimination goal as a public threat by 2030.  Our state chose to lead the nation by its decision. Connecticut has made tremendous progress in both HIV treatment and prevention.  A preferred drug list will be harmful to patients and risks impeding the progress made towards ending the HIV epidemic.  We can do better. Gary F. Spinner is an HIV Specialist retired from clinical care.  He is a co-editor of the textbook “Fundamentals of HIV Medicine” and continues to lecture on HIV treatment and prevention.   ...read more read less