State-level variation in access to long-acting injectable antiretroviral therapy for HIV in the United States

Long-acting injectable antiretroviral therapy (LAI-ART) is expected to improve health outcomes among persons with HIV. Yet, uptake has been slow and data on potential barriers to access are sparse. We used medication formulary data from state Medicaid and AIDS Drug Assistance Programs (ADAPs) to examine state-level variation in access to LAI-ART among uninsured and low-income persons with HIV. We identified substantial coverage gaps: cabotegravir/rilpivirine was not covered without prior authorization by 26 state Medicaid programs and not covered at all by 15 state ADAPs; lenacapavir was not covered without prior authorization by 32 Medicaid programs and not covered at all by 18 ADAPs. As a result of these gaps, many US persons with HIV are currently unable to access LAI-ART. Policies that increase access are needed to ensure the equitable distribution of LAI-ART. As states work to reduce supply and payment chain barriers, the US Department of Health and Human Services, notably its Centers for Medicare & Medicaid Services and the Health Resources and Services Administration, should provide increased federal assistance, guidance, and oversight to improve LAI-ART access among people with HIV.