When Cost-Cutting Undermines HIV Care—The Case for Single-Tablet Regimens
PositivelyAware
by Scott Bertani; Director of Advocacy, HealthHIV | Apr 21, 2026
The cost of healthcare has outpaced wage growth, evidenced by nearly half of Americans surveyed saying they can’t afford healthcare (West Health, 2025). Equally concerning, 20% also reported being unable to pay for their prescription medications. That national trend is reflected in our own data: in HealthHIV’s State of Aging with HIV annual survey, nearly one in five respondents (19.9%) reported delaying or avoiding care due to cost concerns, and 23.5% said their out-of-pocket HIV care costs were difficult to afford.
Clearly, something needs to be done to right the ship, as the saying goes, but government-sponsored price policies or approaches aren’t the full answer; in fact, such an approach could result in fewer therapeutics and reduced access to care, with little evidence that patients would save money at the pharmacy counter. Rallying cries for lower drug costs are important. Through the lens of antiretroviral therapy (ART)—where individualized dosing plays a critical role in adherence and health outcomes—HealthHIV sees several areas that warrant deeper consideration and contextualization, particularly around how the federal government proposes to group and value HIV medications.
Single-tablet regimens (STRs) simplify treatment, improve adherence and help prevent resistance and transmission—particularly for people with complex medical or psychosocial needs. Even small disruptions in access can severely impact people with HIV (PWH), as regimens that share ingredients may vary significantly in their effects and interactions. For those aging with HIV or dealing with comorbidities, STRs reduce pill burden and support adherence.
The Centers for Medicare and Medicaid Services (CMS), in selecting the antiretroviral medication Biktarvy for review under the Medicare Drug Price Negotiation Program (MDPNP) (CMS, 2025), has set a problematic standard of grouping rules for STRs that could undermine the HIV care delivery system. Such a framework fails to account for clinical realities, health outcomes and adherence challenges faced by PWH. CMS suggests grouping drugs for negotiation solely based on having a common active ingredient, but in HIV care, fixed-dose combinations are not always interchangeable. Three state prescription drug affordability boards—in Colorado, Maryland and Oregon—recently excluded HIV medications from reviews for this reason.
STRs reflect a shift that emerged from the epidemic itself. For many of us, treatment once meant managing a “cocktail” of multiple pills across the day, and moving to a simpler regimen changed how that care fits into daily life. In practice, many patients find single-tablet regimens helpful because they are straightforward and reduce the burden of managing multiple dosing schedules. This simplicity can support consistency in treatment and make long-term management more sustainable. There is real value in recognizing the patient experience beyond simple cost considerations.
Beyond convenience, there is a broader value reflected in patient health. An observational retrospective cohort analysis found that STRs are an effective therapeutic option for reducing selective non-adherence and, in turn, preventing virological failure and disease progression (Antinori, 2012). The real-world implications are clear: sustained viral suppression improves individual health and reduces the risk of transmission. When individuals maintain an undetectable viral load, this supports both personal and public health outcomes and avoids substantial lifetime treatment costs, which can exceed $500,000 per individual. This is the practical embodiment of Undetectable = Untransmittable (U=U).
A December 2024 Washington State Medicaid report found that STR use increased from 49.5% to 58% and was associated with higher rates of viral suppression (86% compared to 81%). While the report reflects a subset of patients and should not be interpreted as definitive or causal, it provides a meaningful real-world signal of how regimen structure and stability can influence outcomes. These findings highlight the importance of considering real-world care dynamics, not just ingredient similarity, in evaluating HIV treatment.
Treating STRs as interchangeable drugs ignores their practical role in care, especially for people with advanced or complex health needs. Switching medications requires coordination and support; without it, PWH face risks of treatment disruption, and providers face increased administrative burdens. CMS’s current approach could undermine treatment stability and provider judgment, making cost-based decisions that put long-term health at risk.
CMS’s proposed value framework omits viral suppression, adherence outcomes and public health costs of preventing HIV transmissions. ART regimens—especially STRs and long-acting injectables—prevent new infections and sustain viral suppression. That stability is what helps reduce the risk of rebound and onward transmission.
If CMS chooses to negotiate prices without factoring in these long-term public health impacts, it will fail to reflect the true value of HIV treatment and prevention. That approach may be penny-wise but pound-foolish.
Scott Bertani is a long-term survivor and graying consumer of HIV services. He brings lived experience and policy leadership to conversations on LGBTQ+ health, HIV, viral hepatitis, STIs, mpox and access. With over 28 years in public health systems, he currently directs HealthHIV’s efforts on healthy aging with HIV, including leading the Pozitively Aging program and development of its annual State of Aging with HIV National Survey. He has contributed to federal and state policy development, administered Ryan White, HOPWA and prevention programs and led efforts to modernize Washington state’s STI statutes.
References
Antinori, A., Angeletti, C., Ammassari, A., Sangiorgi, D., Giannetti, A., Buda, S., Girardi, E. and Degli Esposti, L. (2012), Adherence in HIV-positive patients treated with single-tablet regimens and multi-pill regimens: findings from the COMPACT study. Journal of the International AIDS Society, 15: 18098. doi.org/10.7448/IAS.15.6.18098
Centers for Medicare and Medicaid Services. (2025, September 30). Medicare Drug Price Negotiation Program: Final Guidance, Implementation of Sections 1191 – 1198 of the Social Security Act for Initial Price Applicability Year 2028 and Manufacturer Effectuation of the Maximum Fair Price in 2026, 2027, and 2028. U.S. Department of Health & Human Services. edit.cms.gov/files/document/ipay-2028-final-guidance.pdf
Freddie. (2024, October 2). What Does HIV Really Cost in the U.S.? gofreddie.com/magazine/hiv-costs-data-2024
