Inequities in antiretroviral therapy costs for pregnant women and pregnant people in Canada

Abstract: Background Antiretroviral therapy is critical for preventing perinatal HIV transmission during pregnancy, yet access is shaped by complex structural factors including access to prenatal care, insurance status and provincial drug coverage policies. Despite its importance, little is known about how out-of-pocket antiretroviral therapy costs during pregnancy differ within and across Canada. Methods We performed a secondary analysis of Quebec data from the Canadian Perinatal HIV Surveillance Program collected between 2019 and 2023, which included 225 pregnant women and pregnant people living with HIV. Out-of-pocket antiretroviral therapy costs were estimated using insurance information, medication prices, and provincial drug formularies. Additionally, we modeled hypothetical case scenarios to examine how antiretroviral therapy costs during pregnancy differed based on income level and province of residence. Results In the Quebec cohort, out-of-pocket antiretroviral therapy costs during pregnancy varied substantially by insurance coverage. Individuals without insurance faced median costs in pregnancy nearly ten times higher (9380 CAD) than those with public (934) or private insurance (1196). Those insured under the Interim Federal Health Program incurred no costs (0). Simulated scenarios across provinces and territories revealed further disparities, with some jurisdictions providing full public coverage while others required out-of-pocket payments up to 4296 CAD. Conclusion Out-of-pocket costs for antiretroviral therapy during pregnancy remain high and inequitably distributed in Canada, with uninsured individuals facing the greatest burden in Quebec. These findings highlight the need for policy reforms to ensure free and equitable access to antiretroviral therapy during pregnancy, regardless of insurance coverage.