The South, the U.S. region with the most HIV infections each year, also has the greatest barriers to obtaining drugs that can prevent the disease for people who rely on Affordable Care Act insurance plans, research reveals.

University of Virginia School of Medicine researchers have found that 38% of qualified health plans offered by Southern states require recipients to seek “prior authorization” for the prescription medications. That rate is far higher than in other regions, which range from 13% in the Midwest down to only 3% in the Northeast. 

Outlining their findings in a paper in the journal JAMA Network Open, the researchers said that “discriminatory benefit design” that seeks to prevent people from accessing costly medical care could be a “systemic barrier” contributing to the spread of HIV in the South.

PrEP (pre-exposure prophylaxis) medications are preventative medications for people at higher risk of contracting HIV – either because of sexual activity or other factors. When insurance plans require prior authorization, doctors must justify a drug as medically necessary and may have to document that the patient meets specific criteria. 

“Qualified health plans using prior authorization for HIV pre-exposure prophylaxis at higher rates in the South is a systemic barrier,” said researcher Dr. Kathleen McManus of UVA’s Division of Infectious Diseases and International Health. “Prior authorizations have been cited by clinicians as being one of the biggest barriers for PrEP uptake. For other medications, prior authorizations have been shown to decrease appropriate medication use. If someone lives in the South, they are more likely to face this barrier than someone who lives in the Northeast. This is problem because more than half of the United States’ annual HIV diagnoses are in the South. The South is the region where we need increased PrEP uptake in order to curb new HIV infections.” 

“This policy is an example of structural racism,” she said. “More than half of African Americans live in the South, where they are more likely to face this barrier, and the lifetime risk of acquiring HIV for African American men is one in 20, compared to one in 132 for white men. The lifetime risk of acquiring HIV for African American women is one in 48, compared to one in 880 for white women.”