With PrEP under threat, MISTR crosses milestone of 500k users

MISTR’s blue speedos are everywhere these days, and it’s working.

The pre-exposure prophylaxis (PrEP) telemedicine company, now in its seventh year of operation, recently crossed 500,000 patients, up from 350,000 last June, Out magazine is first to report. By offering no-cost access to preventive care like PrEP — a daily pill that is up to 99 percent effective at preventing HIV — MISTR’s growth is accelerating at a time when health insurance costs and administrative red tape discourage many from exploring their various personal care options.

The milestone arrives at a dramatic legal moment for preventive care. Earlier this month, the Supreme Court agreed to hear arguments this spring on whether access to PrEP and other forms of preventive care via the Affordable Care Act are a violation of religious freedom. In Braidwood Management Inc. v. Becerra, the Texas-based plaintiffs will argue that being required to offer ACA health plans that cover the cost of preventive care services like contraceptives, HPV vaccines, STI screenings, and PrEP infringes on their religious beliefs. In their words, the plaintiffs say these forms of preventive care “encourage homosexual behavior, intravenous drug use, and sexual activity outside of marriage between one man and one woman.”

Although adoption of PrEP has picked up in recent years, it had a sluggish start due to social stigma, financial constraints, and limited access to health care providers. When consumers have no health insurance at all, PrEP becomes financially unattainable, averaging about $2,000 out-of-pocket for a 30-day supply. When they do have insurance, consumers must often navigate a web of in-network referrals, denied claims, and intimate conversations with providers who have varying degrees of awareness about the drug.

“Just trying to get a doctor's appointment, let alone chasing down your doctor for a prescription signature, can take weeks,” said Tristan Schukraft, MISTR’s founder and an Out 100 honoree. “And when providers are unfamiliar with PrEP or DoxyPEP, they don't want to prescribe it. Or you live in a small town, where the only doctor nearby is your family doctor. People just give up.”

The mood mirrors much of the malaise around health care access and cost in America. According to a report from the KFF, a nonprofit organization, one in four adults postponed health care they needed because of cost, a figure that jumps to three in five for those who are uninsured. About 21 percent skipped a prescription refill for similar reasons, and 48 percent of adults worry about the cost of covering their monthly health insurance premiums. Today, it’s vital that queer people understand the various health care options available to them and their costs, whether they be through health care plans or community services, as well as how this access might evolve during the Trump administration.

Soft-launched at Palm Springs Pride in 2018, MISTR provides free, no-cost access to PrEP through at-home telemedicine. After completing a questionnaire and labs at home, users complete a video consult with an assigned physician at MISTR, then are given a prescription if deemed appropriate. Any pharmacy can be used to fill the prescription, but MISTR covers the cost when partner pharmacies are used, including shipping your prescription to your home in discreet packaging.

“Anyone who's sexually active in America, gay or straight, should be on PrEP,” Schukraft said. “I think when you don't have people near and dear to you affected by the disease, you don't think it's an issue.” The company reports that 18 percent of its user base doesn’t identify as gay, and about 4 percent are women. The U.S. Preventive Services Task Force says that, of the over 30,000 new HIV diagnoses in 2020, men who have sex with men accounted for 68 percent of cases, and women accounted for 18 percent of cases.

Schukraft attributes much of MISTR’s growth to the recent addition of doxycycline as post-exposure prophylaxis (Doxy PEP), a “morning-after pill” that reduces the risk of contracting syphilis, chlamydia, and gonorrhea. “About 84 percent of our user base is requesting Doxy PEP, and our [users’] STI positivity rate since we introduced it in April has dropped by 50 percent,” he said. “It’s a radical change.”

Other strategies have included a flurry of high-profile queer celebrity partnerships (including Drag Race legends like Gottmik, Alyssa Edwards, and Roxxxy Andrews) and partnerships with larger retailers. Last summer, the company tested a collaboration with Walmart, supplying free at-home HIV testing kits in seven Atlanta-area store pharmacies. The kits “flew off the shelves” in about a week, Schukraft said, with some stores distributing all their inventory in under 48 hours.

An ACA preventive coverage rollback would reintroduce a copay for access to PrEP, and might open the door for future obstacles to preventive care. “People say “Oh, a $20 copay, what's the big deal?” Well, $20 is more for some than others,” Schukraft said. “It’s just enough of a barrier to prevent someone from getting PrEP.” He pointed out that 30 percent of the company’s user base is uninsured.

“I don't think insurance companies are going to drop coverage of PrEP, but it was a huge advancement years ago when preventive services no longer came out of your deductible,” Schukraft said. “I think that’s going to be rolled back. But that’s what MISTR does best, right? We help those who are both insured and uninsured cover their out-of-pocket expenses, whether it be for the drug, the labs, or the doctor’s visit.”