Does access to free antiretroviral drugs impact their use for HIV treatment and prevention?

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Drug costs can be a barrier to the use of antiretroviral (ARV) drugs for HIV treatment and pre-exposure prophylaxis (PrEP) for HIV prevention.1,2 Removing cost as a barrier to ARV drug access can improve the use of HIV treatment for people living with HIV and the use of PrEP for people at risk of HIV infection. Greater access to ARV drugs can also help in the achievement of the global 95-95-95 targets to eliminate HIV as a public health threat by 2030. This article summarizes a systematic review that examined the impact of providing free ARV drugs on HIV treatment and prevention outcomes.3

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What kind of research did the systematic review include? 

The review included 22 articles published from 2002 to 2024. An article was included if it met the following criteria:

  • It included people living with HIV or people at risk of HIV infection.
  • It compared the use of ARV drugs obtained for free with the use of ARV drugs obtained with an out-of-pocket payment. Out-of-pocket costs included co-payments, deductibles or direct purchase costs.
  • It examined the impact that free ARV drugs had on being on ARV treatment, achieving viral suppression or being on PrEP. In addition to these three main outcomes, the review also examined the impact of free ARV drugs on two secondary outcomes: mortality and HIV infection rates.

The studies in the review had the following characteristics:

  • Ten studies were from the Americas, including one study from Canada. Five studies were from Africa and three studies were from the western Pacific. Half the studies (11) were from high-income countries.
  • The median sample size for the studies was over 10,000 participants.
  • ARV drugs were obtained for free in a variety of ways. In half of the studies (11), ARV drugs were provided for free as part of a national or state policy. In eight studies, ARV drugs were provided through government-funded support programs and in three studies, ARV drugs were provided for free through hospitals or clinics.
  • The majority of the studies (18) compared the use of ARV drugs accessed for free with the use of ARV drugs accessed with an out-of-pocket cost-sharing payment like a co-payment or deductible.
  • Data were gathered in the studies through surveys, interviews, medical records, national or state surveillance databases or insurance claim databases.

Does free access to ARV drugs impact use of these drugs for HIV treatment?

Seven studies examined the impact of free ARV drugs on being on HIV treatment. Overall, the review found that free access to ARV drugs improved use of HIV treatment among people living with HIV compared with people who accessed ARV drugs with out-of-pocket costs. For example, one study found that women with HIV enrolled in a government program providing free ARV drugs were two times more likely to be on treatment than women who were not enrolled in the program.

Does free access to ARV drugs impact the achievement of viral suppression among people living with HIV?

Four studies examined the impact of free ARV drugs on viral suppression. Two studies measured the likelihood of staying virally suppressed and two studies measured the frequency of an unsuppressed viral load. In all four studies, free ARV drugs had a positive impact on achieving viral suppression or reducing the likelihood of an unsuppressed viral load.

Does free access to ARV drugs impact use of HIV PrEP?

Two studies examined the impact of out-of-pocket costs on PrEP use. Both studies took place in the United States and collected information using insurance claim databases with nationwide data. Both studies examined PrEP discontinuation or abandonment and found that higher out-of-pocket costs were associated with greater likelihood of discontinuing PrEP.

Does free access to ARV drugs impact HIV mortality?

Seven studies conducted in low- and middle-income countries examined the impact of free ARV drugs on HIV mortality. Five studies examined overall mortality and two studies examined deaths related to AIDS, with all studies finding that free ARV drugs were associated with a reduction in mortality among people living with HIV.

Does free access to ARV drugs impact rates of HIV infection?

Four studies in high-income countries examined the impact of free ARV drugs for PrEP on HIV infection rates. Two studies examined free PrEP among men who have sex with men and two studies examined free PrEP among the broader population. Overall, three studies found a statistically significant decrease in HIV incidence following the introduction of free access to PrEP. One of these three studies was the only Canadian study included in the review, which was a modelling study. It showed that if Montreal, a city where individuals must pay out-of-pocket costs for PrEP, attained the same PrEP coverage as Vancouver, where PrEP is free, up to 63% of new HIV infections between 2015 and 2021 could have been prevented.

What are the implications of the review for service providers?

The review demonstrates that providing free ARV drugs improves HIV treatment and prevention outcomes. Free access to ARV drugs is associated with being on HIV treatment, being virally suppressed and reduced mortality. Free access to ARV drugs for HIV PrEP is associated with lower rates of PrEP discontinuation and lower rates of HIV infection.

Being on HIV treatment and achieving viral suppression are two of the global 95-95-95 targets aimed at eliminating HIV as a public health threat by 2030. The review provides support for free access to ARV drugs as a strategy to help achieve these targets. Service providers and policy-makers can support initiatives and advocacy efforts to remove cost barriers to ARV drugs in Canada. These barriers may include deductibles and co-payments in the publicly funded drug programs that many Canadians use to access ARV drugs for HIV treatment and prevention.4

When considering this review, it is important to remember the following:

In the review, the benefits of providing free access to ARV drugs were observed across different countries and healthcare systems. The authors note this broad perspective means that the review results are generally applicable across different locations and populations. Additional evidence and an examination of the Canadian context will help service providers better understand the extent to which free access to ARV drugs will impact Canada’s achievement of the global 95-95-95 targets and how free access can be best implemented.

The review looked at whether free access to ARV drugs had an impact on selected HIV treatment and prevention outcomes but did not provide overall numbers to quantify the magnitude of any observed associations or examine the outcomes in specific populations. Additional research may expand our understanding of the degree to which free access to ARV drugs impacts different HIV treatment and prevention outcomes, and if there are differences across populations.

What is a systematic review?  

Systematic reviews are important tools for informing evidence-based programming. A systematic review is a critical summary of the available evidence on a specific topic. It uses a rigorous process to identify all the studies related to a specific research question. Relevant studies can then be assessed for quality and their results summarized to identify and present key findings and limitations. If studies within a systematic review contain numerical data, these data can be combined in strategic ways to calculate summary (“pooled”) estimates. Combining data to produce pooled estimates can provide a better overall picture of the topic being studied. The process of pooling estimates from different studies is referred to as a meta-analysis.  

References 

  1. Mate KKV, Engler K, Lessard D et al. Barriers to adherence to antiretroviral therapy: identifying priority areas for people with HIV and healthcare professionals. International Journal of STD and AIDS. 2023 Sep;34(10):677-86. Available from: https://journals.sagepub.com/doi/full/10.1177/09564624231169329
  2. Sang JM, McAllister K, Wang L et al. Examining provincial PrEP coverage and characterizing PrEP awareness and use among gay, bisexual and other men who have sex with men in Vancouver, Toronto and Montreal, 2017-2020. Journal of the International AIDS Society. 2022 Oct;25(10):e26017. Available from: https://onlinelibrary.wiley.com/doi/10.1002/jia2.26017
  3. Doutre M, Godin MP, Dmitriev I et al. Free antiretrovirals as a key tool against the HIV pandemic: a systematic review. HIV Medicine. 2025;26(9):1329-42. Available from: https://onlinelibrary.wiley.com/doi/10.1111/hiv.70051
  4. Yoong D, Bayoumi AM, Robinson L et al. Public prescription drug plan coverage for antiretrovirals and the potential cost to people living with HIV in Canada: a descriptive study. CMAJ Open. 2018;6(4):E551-60. Available from: https://www.cmajopen.ca/content/6/4/E551.long

About the author(s)

Erica Lee is CATIE’s manager of website content and evaluation. Since earning her master of information studies, Erica has worked in the health library field, supporting the information needs of frontline service providers and service users. Before joining CATIE, Erica worked as the Librarian at the AIDS Committee of Toronto (ACT).