Examining access and cost implications for HIV serodiscordant couples seeking conception services: an integrative approach
Leech, Ashley Ann
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The FDA approved pre-exposure prophylaxis (PrEP) with Truvada® in 2012 as the first drug to reduce the risk of HIV infection among uninfected individuals (FDA 2012). There is a strong scientific base for its effectiveness among uninfected heterosexual individuals who engage in sexual intercourse with HIV-infected partners. Studies further reveal no significant differences by HIV-infection status in regard to childbearing motivations or future pregnancy motivations (Finocchario-Kessler 2012). Historically, serodiscordant couples comprised of an HIV-positive male and HIV-negative female have faced challenges to accessible, affordable options for safe conception. Assisted reproductive technologies (ART) are often prohibitively expensive and also largely inaccessible to this population. The CDC suggests PrEP as another reproductive option for these couples to reduce the risk of sexual HIV acquisition during periconception and pregnancy. Truvada® for PrEP, however, is also costly and may provide only modest additional prevention benefits to serodiscordant couples in which the HIV-infected partner is already on anti-retroviral therapy with suppressed HIV viremia. cART for the infected partner is recommended regardless of conception plans due to proven health benefits for people living with HIV (PLHIV). However, there is also a prevention benefit to the non-infected partner when the HIV-positive partner is on cART, with a relative risk reduction of 96% (Cohen et al. 2011). While Truvada® for PrEP is potentially a more accessible option for these couples compared to assisted reproductive technology services, adoption of PrEP has been slow among providers. In addition to better understanding the impact of PrEP when the male partner is consistently on cART, it is also critical to understand the barriers to prescribing Truvada® for this indication. There is also insufficient information on the ability of HIV-serodiscordant couples to access other reproductive options outside of PrEP. Whether for the purpose of risk reduction or for supported fertility, serodiscordant couples should have access to the same spectrum of reproductive services as non-HIV affected couples. The overall research question this thesis addressed was: What are the access and cost implications for HIV serodiscordant couples seeking conception services in the United States? To address these issues, I used the following methods: (1) a cross-sectional survey of infectious disease, internal medicine, and family medicine providers to determine prescribing behaviors and perceptions of PrEP utilization; results analyzed using multivariable regression modeling; (2) “secret shopper” methodology whereby a physician and “patient” carried out scripted phone calls to fertility clinics to gauge a more realistic picture of access; results analyzed using McNemar tests to assess marginal homogeneity and chi square goodness of fit; and (3) cost effectiveness analysis using a Markov state-transition model to project long-term clinical outcomes, costs, and cost-effectiveness of different HIV prevention strategies for serodiscordant couples seeking conception.