Physicians Hope Free Contraceptives Will Limit Zika's Impact in Puerto Rico

Brenda Goodman

March 17, 2016

In an effort to blunt the impact of the Zika virus in Puerto Rico, local physicians say they are working on a plan to make long-acting, reversible contraceptives (LARCs) freely available to women on the island.

The Zika virus has been strongly linked to a range of severe birth defects, including microcephaly. It has been 50 years since a pathogen has been identified that can cause this kind of damage to the fetal brain and nervous system. Never before has there been a mosquito-borne disease known to cause birth defects, said Centers for Disease Control and Prevention (CDC) Director Tom Frieden, MD, in a recent press conference from the US territory.

There are roughly 34,000 births annually in Puerto Rico. Roughly two thirds of pregnancies on the island are unplanned, according to the CDC.

"I'm thinking of this like a war. Our first wave of attack against the Zika is going to be donated implants, because that's going to be fastest way to get as many IUDs [intrauterine devices] out there to the largest amount of people," said Nabal J. Bracero, MD, an obstetrician-gynecologist in San Juan and chair of the Puerto Rican section of the American College of Obstetricians and Gynecologists.

Dr Bracero recently met with Dr Frieden, who traveled to Puerto Rico to bring attention to the crisis and to assess the public health response. The two men are working on a plan to replicate public health programs in Colorado and Iowa, where LARC giveaways have had impressive results.

In Colorado, which received a $24 million donation to give away 30,000 IUDs at public health clinics, the state saw steep drops in the number of teen pregnancies and unplanned pregnancies. The teen birth rate fell 40% from 2009 to 2013. Abortion rates among teens and among women in their 20s plunged 42% and 18%, respectively.

It is unclear whether LARCs will be as popular in Puerto Rico as they have been stateside. Most Puerto Ricans are Catholic, and traditionally, contraception has run counter to their personal beliefs. But Pope Francis recently suggested that birth control could be acceptable if used to protect against Zika.

Dr Frieden thinks the plan will work.

"We know from contraceptive choice projects elsewhere that when women are provided with a full range of options, two thirds or more will select long-acting options," he told Medscape Medical News.

"We'd like to see increased access to voluntary contraception" on the island, Dr Frieden said.

Barriers to Long-acting Contraceptives

As reported by Medscape Medical News, a long-term study of nearly 7500 women that was published in the New England Journal of Medicine in 2012 showed that women who used LARCs were about twenty times less likely to have an unintended pregnancy as those using contraceptive pills, patches, or rings.

But the initial cost of these devices, which utilize subdermal etonogestrel (multiple brands) or levonorgestrel (multiple brands), can be a barrier to use.

The devices can range in price from $400 to $900, depending on where a woman gets them. Federally funded Title X clinics provide them at a lower cost than private offices. There is also the physician's fee for implantation, which ranges from $100 to $500, depending on whether additional anesthesia is provided, according to Kirsten Thompson, MPH, project director at the Bixby Center for Global Reproductive Health at the University of California, San Francisco.

A new hormone-releasing IUD, called Liletta, available from the nonprofit pharmaceutical company Medicines360, can cost patients as little as $50 if purchased through a federally funded Title X clinic.

The Affordable Care Act mandates coverage for contraceptive options approved by the US Food and Drug Administration, with no cost sharing for patients.

But insurance providers have found ways around the law.

For example, companies that have a limited number of shareholders (so-called closely held comanies) do not have to pay for employees' contraception if the use of contraception is in violation of the employees' religious beliefs. This exception was codified by the 2014 Supreme Court ruling in the Hobby Lobby case.

Women covered by grandfathered insurance plans ― those purchased before March 23, 2010 — may not have contraceptive coverage.

"Then there are the companies that do questionable things, like apply medical management to contraception, wherein they require that you fail at other methods before they will give you access to an IUD or an implant," said Thompson, who coauthored a reimbursement guide to intrauterine devices and implants for physicians.

"There are all these little exceptions that add up to a substantial number of women who don't have this coverage yet, and may not ever have it," she said. Thompson said it is not surprising that women in Puerto Rico have limited access to LARCs.

"That would be totally consistent with what I've seen in other places," she said.

In Puerto Rico, most women of childbearing age are covered by government-sponsored health plans, said Ricardo A. Rivera Cardona, executive director of Puerto Rico's Health Insurance Administration, which administers Medicaid and Medicare funds.

The Medicaid program does include two older long-acting options ― Paragard (Teva Pharmaceuticals), which is a copper IUD, and Depo-Provera (Pharmacia and Upjohn), an injectable form of medroxyprogestgerone ― on its preferred drug list, which means that those options are covered without special permission from the plan, Rivera said.

Physicians looking to prescribe newer hormone-releasing implants or IUDs would have to explain why their patients could not use other forms of birth control that are on the preferred drug list before the plan would cover them, Rivera said.

Rivera said the plan would like to fully cover all LARC options, but it simply does not have the money.

"It's all about cost. It's all about resources. We are capped in our Medicaid funds," he said.

Dr Bracero said physicians on the island have had a tough time getting insurers to pay for the options patients want.

"If you give a patient a prescription for an IUD, and she goes to the pharmacy if she has a public health system insurance card, she's going to have a hard time. She may come back to you and say, 'They told me at the pharmacy it wasn't covered,' " he said.

Then, Dr Bracero said, "The physician has to pick up the phone, call the insurance company, request an appointment with a case manager, and then explain to the case manager on the insurance side why the patient needs the IUD.

"Anything that gets in the way of getting the prescription filled in terms of contraception is going to weaken the effort," he said.

Making It Happen

The details of the plan are still being fleshed out. Dr Bracero said the CDC is negotiating with a pharmaceutical company to donate the devices. He said he and Dr Frieden discussed what hands would take possession of the devices and help distribute them to physicians on the island.

The last piece that needed to be worked out, he said, was getting insurance companies to pay physicians to insert the devices.

But even if a deal cannot be reached, Dr Bracero pledged that women in Puerto Rico will have access to the devices.

"We are in such a crunch time here that we're going to get together — all the ob-gyns — and probably do our best to either do it for free or have a delay in the charge, but we're not going to hold them," he said.

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