Are These Companies Discriminating Against PrEP Users?

Editor's Note: Representatives from John Hancock offered the following response to this op-ed:

John Hancock does not decline insurance coverage solely based on use of the drug PrEP. Absent other significant contributing factors, PrEP use in isolation to prevent HIV infection would not lead to an adverse underwriting decision.

John Hancock and Manulife have been proactive in working with prospective customers who are HIV-positive. In fact, in 2016 John Hancock and Manulife were among the first life insurance companies in North America to offer term and permanent life insurance coverage to applicants living with human immunodeficiency virus (HIV) if they meet certain criteria.

The authors stand by their piece, writing:

In the Doe v. Mutual litigation, after our client was denied long-term care insurance by Mutual of Omaha solely based on his use of PrEP, an independent marketing company that works with our client's financial advisor to obtain quotes from long-term care insurers checked with all of the other carriers it works with to see if they would offer insurance to a person on PrEP. This list included John Hancock. A representative of the marketing company testified under oath in a deposition that none of these companies, including John Hancock, would offer long-term care insurance to an individual on Truvada because it is uninsurable regardless if taken as a preventative by an HIV-negative person.

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Perhaps we have become a little too accustomed to Fortune 500 companies that tout their LGBTQ employee affinity groups, advertise to our community with the rainbow flag, march in our parades, and even donate to our organizations and sign briefs in the U.S. Supreme Court showing considerable business support for our rights. Those corporate acts make a big difference and reflect tangible positive change in the world we live in.

But what about actual business practices? Here's our vote for the most unrecognized antigay and AIDS-phobic corporate policy in America today: the largest insurance companies in America that are blatantly discriminating against gay men who take steps to prevent HIV transmission by using PrEP (or HIV pre-exposure prophylaxis), a once-a-day dosage of the medication Truvada.

Fortunately, most health insurers and state Medicaid agencies are covering the cost of the medication so people can have access to this extraordinary breakthrough in prevention. But when people take PrEP and then individually apply for life insurance, long-term care insurance, and disability insurance, they are automatically denied coverage solely because they take PrEP.

Some of the largest insurance companies in the nation are engaging in this categorical exclusion of PrEP users. GLAD has heard directly about cases of discrimination by State Farm, Aetna, Metropolitan Life, John Hancock, Protective Life, Lincoln Financial, and many more. We have sued Mutual of Omaha Insurance Co. for denying long-term care insurance to a qualified HIV-negative gay man because he uses PrEP. This is an industry-wide policy and practice. Gay men can either get insurance or they can forgo taking the best biomedical HIV prevention method in the history of an epidemic that has claimed so many lives.

So what are all these corporate giants saying about PrEP users? Life, disability, and long-term care insurers underwrite the risk that an applicant will claim benefits and when. They get your medical records and exclude you if you have a disqualifying health condition, or charge you higher premiums if you have certain health conditions. But people who are excluded solely because they take PrEP do not have any disqualifying health condition. They are excluded because these corporations believe they are engaging in "high-risk sexual behavior" and deem them at high risk for HIV. Let's be frank: They are talking about anal intercourse. In other words, you are fully eligible for insurance, but you are turned away because of the sex you are having.

In an industry that is based on rationalit, and is supposed to make decisions based on actual data, how does this make sense? Research demonstrates that PrEP is close to 100 percent effective at reducing the risk of HIV transmission, far more effective than condoms. Let us say that again: Close to 100 percent effective in stopping HIV. And yet the insurers ignore the efficacy of PrEP and instead use it as a proxy for "high-risk sexual behavior" in their underwriting. That is not science; it's a moral judgment about the people who use PrEP. By the way, 80 percent of PrEP users are gay men.

These insurers argue that not everybody takes PrEP as directed (once daily) which reduces its effectiveness, or that the long-term effects of Truvada usage are unknown (PrEP has been demonstrated to be well tolerated with no significant side effects). These same insurers offer insurance to people with a range of conditions, such as diabetes and bipolar disorder, as long as the applicant demonstrates adherence to medications that control those conditions. Yet they don't allow PrEP users to demonstrate adherence. And insurers obviously don't exclude every new drug approved as safe by the Food and Drug Adaministration simply because there is not long-term data for new drugs.

This "no PrEP users need apply" policy belongs on the long list of just plain stupid beliefs about HIV transmission that have been proffered over the course of the epidemic. This corporate policy does nothing to achieve its stated goal of reducing the overall prevalence of HIV in an insurer's pool of beneficiaries. Take two people with identical sex lives: The PrEP user is denied insurance; the person who doesn't use PrEP is covered. That make zero sense. And worse, it actually risks discouraging use of a powerful tool that could help end the HIV epidemic.

And the fact is that most people at risk for HIV in the United States are not yet on PrEP. The Centers for Disease Control and Prevention estimates that 1.2 million people could benefit from PrEP. Yet since use of Truvada as PrEP was approved by the FDA in 2012, there have only been about 145,000 total PrEP users. Before the advent of PrEP, life, disability, and long-term care insurers did not assess for HIV risk. They did not ask applicants about sexual practices or condom use and make underwriting decisions on that basis. But with the advent of PrEP, they are carving out and excluding just a small percentage of the whole group of people who have some risk for HIV -- those who use the most effective prevention tool. This is discrimination, not a rational policy.

From the earliest days of HIV, we have often said, we're not going to end this epidemic if myths, fear, and discrimination interfere with our best public health policies. We need to be doing everything we can to end the stigma associated with PrEP so that people can make decisions based on what's best for their own health, not based on barriers to access or fear of discrimination. The corporate practices of these insurance companies reflect and reinforce stigma. They put the public health at risk by creating an incentive to avoid or delay PrEP.

Many of the companies perpetuating this policy and practice are Fortune 500 companies, and some, like Aetna, John Hancock, State Farm, and Mutual of Omaha have a 100 percent approval rating from the Human Rights Campaign. These corporations can't wave the rainbow flag with one hand and with the other turn us away because of our sex lives. It's time to end the PrEP exclusion in America's insurance industry.

BEN KLEIN is a senior attorney at GLBTQ Legal Advocates & Defenders and has been the AIDS Law Project Director at GLAD since 1994. ALEX WEINSTEIN has been a legal assistant at GLAD since 2016.