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Many people with HIV in the U.S. are not covered by traditional private health insurance and rely on alternatives such as Medicaid, AIDS Drug Assistance Programs (ADAP), and other care funded by the Ryan White HIV/AIDS Program. However, more than a third of states have not expanded their Medicaid programs and many historically have not fully funded their ADAPs to cover everyone needing assistance to pay for HIV drugs. Several of these states are in the southeast and have a large population of low-income people of color living with HIV.

Kathleen McManus from the University of Virginia School of Medicine and colleagues looked at outcomes for ADAP clients in Virginia who switched to ACA plans. Their analysis included 3,933 HIV-positive adults enrolled in Virginia's ADAP who were eligible for ACA insurance. The study period ran from July 2013 (one year before ACA implementation) through December 2014 (one year after implementation).

Since the implementation of the ACA (aka Obamacare) in 2014, state ADAPs can either opt for direct provision of HIV medication, usually with essential HIV-related medical care provided by Ryan White-funded clinics, or they can purchase ACA insurance for clients. Virginia chose the latter option, and ADAP helped clients enroll in ACA plans and pays for their monthly premiums and medication copays.

"We wanted to make sure that patients would achieve at least the same, if not better outcomes" on ACA plans compared to those with direct ADAP coverage, McManus said at an IDWeek media briefing. While ACA plans offer more comprehensive non-HIV-related care, there were concerns about changes in formularies, HIV drugs being shifted to higher tiers with larger copays, and excessive administration and paperwork burden for clients and providers.

Results

• Out of 3933 eligible ADAP clients, 1849 (47%) enrolled in ACA plans.
• Enrollment in ACA plans varied according to demographic factors including age, sex, race/ethnicity, income, and AIDS diagnosis, as well as system-level factors including type of ADAP coverage, having federal ACA tax credits, and specific HIV clinic where patients were seen.
• People in the 25-44 year age range were less likely to enroll in ACA plans than younger or older clients.
• Men were less likely to enroll in ACA plans than women, and African-Americans were less likely to do so than white patients.
• Enrollment ranged from 14% to 74% across different clinics.
• 86% of people who enrolled in ACA plans achieved undetectable viral load, compared with 79% of those who received HIV medication directly through ADAP -- a significant 45% decrease.
• Each additional month enrolled in an ACA plan was associated with about a 6% greater likelihood of viral suppression, and people enrolled for a full year were 67% more likely to have undetectable HIV.

"ACA enrollment in 2014 was associated with HIV viral load suppression, an essential outcome for the individual and for public health," the researchers concluded. "This association should continue to be tracked over time, as more people living with HIV enroll in insurance programs and remain on insurance for longer periods of time."

McManus and her team found that Virginia not only paid less to treat people who were covered under ACA plans -- thus enabling coverage of more people -- but they also had better outcomes, as viral suppression has both individual health benefits for people with HIV and an added public health benefit of lowering the likelihood of HIV transmission.

"We found patients fared better under ACA health plans, possibly due to broader access to medical care and medications beyond those that target HIV," McManus said in an IDWeek news release. "Moving patients to ACA insurance helps the Virginia ADAP use federal and state funds to cover a larger number of patients and help avoid wait-lists for medications and services."

Asked how ACA coverage under ADAP might compare to Medicaid expansion, McManus noted that 75% of the ADAP clients would be eligible for expanded Medicaid under the higher threshold (138% of the federal poverty level).

"Those sorts of head-to-head comparison will have to be done, maybe working with Medicaid expansion states," she suggested. "We need to figure out how all these different delivery systems fit together and how to optimize them."

McManus added that most ADAPs -- in both Medicaid expansion and non-expansion states -- have incorporated the ACA, but all did it in their own way; some, for example, cover medication copays but not premiums. Virginia has been a leader in this regard, accounting for 17% of all ADAP clients on ACA plans.

"With the ACA people have access to more comprehensive care," HIVMA Chair-elect Carlos del Rio from Emory University summarized at the briefing. "Using ADAP funds as a gap filler is a wise use of resources."

Recent Related Studies

These findings add to the growing body of evidence that having healthcare coverage improves outcomes for people with HIV.

At the International AIDS Society conference this summer, Christina Ludema from the University of North Carolina and colleagues reported that among more than 1400 participants in the Women's Interagency HIV Study, having private insurance or coverage through ADAP were independently associated with a lower likelihood of having detectable viral load (this study was done before ACA implementation).

A recent study published in JAMA Internal Medicine found that 34% of facilities providing outpatient HIV care received funds through the Ryan White HIV/AIDS Program, and 73% of the more than 8000 HIV-positive people included in the Medical Monitoring Project received care at Ryan White-funded clinics. These patients were more likely to be black or Latino, to have incomes below the poverty level, and to lack healthcare coverage. Ryan White-funded clinics were more likely than non-funded facilities to provide case management (76% vs 15%), mental health care (64% vs 18%), and substance abuse services (34% vs 12%).

After adjusting for patient characteristics, people who received care through Ryan White funded and non-funded clinics were about equally likely to be prescribed antiretroviral therapy, but patients under the poverty level who attended Ryan White clinics had a better chance of achieving viral suppression.

"In this new era of treatment as prevention, the [Ryan White] program is once again proving to be flexible in adapting to new challenges," Stephen Morin from the UCSF Center for AIDS Prevention Studies wrote in an accompanying editorial. "As some HIV primary care is being shifted to ACA coverage, the need for more intensive medical case management and other support services not covered by ACA or Medicaid plans is now being recognized as essential to getting the maximum proportion of HIV patients virally suppressed."

"The ACA not going to do away with Ryan White," del Rio concurred at the IDWeek briefing, noting that Ryan White funds provide "wrap-around" services like transportation and mental health care than many people with HIV need to maintain optimal health.

10/8/15

References

K McManus, A Rhodes, L Yerkes, et al. 2014 Affordable Care Act Enrollment of AIDS Drug Assistance Program Clients and Associated HIV Outcomes. IDWeek 2015. San Diego, October 7-11, 2015. Abstract 728.

C Ludema, SR Cole, JJ Eron, et al. Health insurance, ADAP and HIV viral load among women in the Women's Interagency HIV study, 2006-2009. 8th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention. Vancouver, July 19-22, 2015. Abstract WEPEC613.

J Weiser, L Beer, EL Frazier, et al. Service Delivery and Patient Outcomes in Ryan White HIV/AIDS Program-Funded and -Nonfunded Health Care Facilities in the United States. JAMA Internal Medicine 175(10):1650-1659. 2015.

SF Morin. The Future of the Ryan White HIV/AIDS Program. JAMA Internal Medicine 175(10):1660-1661. 2015.

Other Source

IDWeek. Affordable Care Act Helps Virginia Improve HIV Outcomes While Providing Care for More for at-Risk Patients, Study Shows. Press release. October 8, 2015.