#AIDS2016: ​HIV may be a prescribed benefit, but not all medical schemes cover ARVs

Almost 30 years ago, virtually no medical scheme covered HIV. Today, legislation has made medical cover for HIV non-negotiable, but some patients are still paying out of pocket for life-saving antiretrovirals (ARVs).

“Initially, very few private medical aids schemes covered HIV treatment, mainly due to the unknown financial risk,” says Bonitas Medical Fund principal officer Bobby Ramasia.

HIV has since been designated as a prescribed minimum benefit (PMB) — a condition that schemes are legally required to cover — according to the Medical Schemes Act.

But activist organisations such as Section27 argue that HIV’s PMB status is no guarantee that medical schemes will foot the bill for ARVs.

In February, the Competition Commission conducted the first hearing of its market inquiry into the alleged high cost of private healthcare.

The commission received a written submission from Section27 claiming that Genesis Medical Scheme had refused to pay for one woman’s ARVs. Section27 argues Genesis told the woman she would have to pay for her ARVs from her medical savings account, or procure the drugs for free from the public sector.

Unable to take time off work to queue at her local public clinic monthly for ARVs, the woman lodged a successful complaint against Genesis with the Council for Medical Schemes. But Genesis has appealed the council’s verdict. While the matter is being reviewed, the patient is paying R500 per month for her ARVs.

Section27 argues that Genesis’s failure to pay in full for the woman’s ARVs violates the Medical Schemes Act and her right to health.

Genesis spokesperson Elmarie Jensen confirmed that the scheme requires members to procure ARVs from the public sector or pay for the drugs. “ARVs have to be obtained from the state, but we do pay for the hospitalisation of HIV-related conditions like pneumonia,” says Jensen.

Who pays for PrEP?
In December, South Africa became the second country in the world to approve the use of a two-in-one antiretroviral pill, Truvada, for HIV prevention.

This prevention strategy is called pre-exposure prophylaxis (PrEP). Research has shown if Truvada is taken daily, at more or less the same time, it can reduce an HIV- negative person’s risk of contracting HIV by more than 90%.

Medical schemes such as Fedhealth and Bonitas already cover PrEP for up to an initial six months, on the condition that a doctor has prescribed it. After six months, doctors can review the case and may choose to prescribe it for longer. Metropolitan Health began providing PrEP in August last year.

Discovery Health and Genesis members can also access PrEP but will pay for it out of their medical savings accounts.

In February the HIV Clinicians Society of Southern Africa’s chief executive Lauren Jankelowitz testified before the Competition Commission’s market inquiry that her organisation’s members regularly complain that medical schemes often have such complex claiming codes for PrEP that it results in patients paying for the drug themselves.

Metropolitan Health is meanwhile expected to launch a free tuberculosis clinical guideline app on July 16. It will help improve care in the public and private sectors, according to Metropolitan’s HIV risk manager Shayhana Ganesh. Developed in partnership with the health department, the app follows a similar tool launched in 2015 for HIV treatment guidelines.

Two challenges are likely to dominate the future of private HIV care in the country, according to the head of Discovery Health’s Centre for Clinical Excellence, Noluthando Nemetswerani: how to fund the roll-out of new HIV prevention science, and how to manage rising rates of non-communicable diseases among people for whom HIV is no longer a death sentence.

Read more from our special AIDS 2016 report.

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