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Erly S, Dombrowski JC, Khosropour C, Reuer JR, Boersema K, Sharma M. Cost Analysis of Implementing a 12-Month Recertification Criterion for Ryan White HIV/AIDS Program's AIDS Drug Assistance Program in Washington State. Public Health Rep 2024; 139:573-581. [PMID: 38327231 PMCID: PMC11344975 DOI: 10.1177/00333549241227118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024] Open
Abstract
OBJECTIVE AIDS Drug Assistance Programs (ADAPs) are state-administered programs that pay for medical care and medication for people living with HIV (PLWH) in the United States. In October 2021, the federal policy requiring that clients recertify for the program every 6 months was repealed, giving states the authority to set their own recertification policies. However, little data exist on the costs and health effects of alternative recertification schedules. We assessed the cost of changing the legacy 6-month recertification to a 12-month schedule in Washington State to inform policy decisions on recertification. METHODS We used a Markov model to simulate the population of PLWH in Washington State who are eligible or enrolled in ADAP. We obtained model inputs and validation data from the Washington State Ryan White database. We estimated the cost of 12-month and 6-month criteria over a 5-year time horizon. Model outputs included annual program costs, population sizes, and number of people virally suppressed, by scenario. RESULTS Under a continuation of the legacy 6-month recertification criteria, the annual cost of Washington ADAP would be $37 663 000 (95% CI, $34 570 000-$41 686 000) during the next 5 years, with a per-client cost of $7966 (95% CI, $7478-$8494). Under 12-month criteria, the annual cost would be $40 217 000 (95% CI, $36 243 000-$44 401 000) and the per-client cost would be $7543 (95% CI, $7084-$8042). Under the 12-month scenario, 245 more people will have been virally suppressed by the end of 2025. CONCLUSIONS Switching to a less frequent recertification process may improve health outcomes at a modest increase in cost in Washington State.
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Affiliation(s)
- Steven Erly
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Washington State Department of Health, Olympia, WA, USA
| | - Julia C. Dombrowski
- Division of Allergy and Infectious Diseases, University of Washington School of Medicine, Seattle, WA, USA
- Public Health–Seattle & King County, Seattle, WA, USA
| | | | | | | | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, WA, USA
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Ramírez-Ortiz D, Fernandez SB, Jean-Gilles M, Flores A, Santander TG, Dawit R, Ibarra C, Ward MK, Brock P, Ladner R, Devieux J, Trepka MJ. Barriers and facilitators to retention in care and treatment adherence among racially/ethnically diverse women with HIV in South Florida: a qualitative study. Women Health 2023; 63:562-576. [PMID: 37482891 PMCID: PMC10403283 DOI: 10.1080/03630242.2023.2238848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 07/16/2023] [Indexed: 07/25/2023]
Abstract
Women, particularly those from racial/ethnic minority groups, experience disparities in HIV care and treatment, and in achieving viral suppression. This study identified barriers and facilitators influencing retention in HIV care and treatment adherence among women belonging to racial/ethnic minority groups. We conducted semi-structured interviews with 74 African American, Hispanic/Latina and Haitian cisgender women receiving care from the Ryan White HIV/AIDS Program in Miami-Dade County, Florida in 2019. Data were analyzed using a thematic analysis approach. The most salient barriers faced by women were competing life priorities, mental health and substance use issues, medication-related concerns and treatment burden, negative experiences with HIV care services, transportation and parking issues and stigma and discrimination. Important facilitators identified by women included taking personal responsibility for health, social support, and patient-friendly and supportive HIV care services. Our findings suggest that HIV care could be enhanced for this population by understanding the non-HIV needs of the women in care, provide more flexible and relevant services in response to the totality of these needs, and simplify and expand access to care and supportive services.
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Affiliation(s)
- Daisy Ramírez-Ortiz
- Department of Epidemiology, Florida International University, Miami, Florida, USA
- FIU Research Center for Minority Institutions, Florida International University, Miami, Florida, USA
| | - Sofia B. Fernandez
- FIU Research Center for Minority Institutions, Florida International University, Miami, Florida, USA
- School of Social Work, Florida International University, Miami, Florida, USA
| | - Michele Jean-Gilles
- Department of Health Promotion and Disease Prevention, Florida International University, Miami, Florida, USA
| | - Annette Flores
- Department of Epidemiology, Florida International University, Miami, Florida, USA
| | | | - Rahel Dawit
- Department of Epidemiology, Florida International University, Miami, Florida, USA
| | - Cynthia Ibarra
- Department of Epidemiology, Florida International University, Miami, Florida, USA
| | - Melissa K. Ward
- Department of Epidemiology, Florida International University, Miami, Florida, USA
- FIU Research Center for Minority Institutions, Florida International University, Miami, Florida, USA
| | | | - Robert Ladner
- Behavioral Science Research Corporation, Miami, Florida, USA
| | - Jessy Devieux
- Department of Health Promotion and Disease Prevention, Florida International University, Miami, Florida, USA
| | - Mary Jo Trepka
- Department of Epidemiology, Florida International University, Miami, Florida, USA
- FIU Research Center for Minority Institutions, Florida International University, Miami, Florida, USA
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Erly S, Khosropour CM, Hajat A, Sharma M, Reuer J, Grimm M, Kwaiser K, Dombrowski JC. Characterization of the Population Affected by the 6-Month Recertification Criterion of the Ryan White HIV/AIDS Program's AIDS Drug Assistance Program in Washington State, 2017-2019. J Acquir Immune Defic Syndr 2022; 89:27-33. [PMID: 34596081 PMCID: PMC8665124 DOI: 10.1097/qai.0000000000002824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 09/15/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION AIDS Drug Assistance Programs (ADAPs) provide financial support for medical care for people living with HIV (PLWH) in the United States. Federal policy requires that clients recertify for the program every 6 months, which has been described as a barrier to care access. Our objective was to describe the prevalence of and factors associated with ADAP disenrollment in Washington State. METHODS Between 2017 and 2019, we categorized ADAP clients by the success of their recertification applications as follows: (1) continuously enrolled, (2) ruled ineligible, or (3) disenrolled if they failed to recertify. We compared individuals who were disenrolled with those who were continuously enrolled by demographic and socioeconomic characteristics and engagement with case management using data from the Washington State HIV Surveillance and Ryan White data systems. RESULTS From 2017 to 2019, 5480 clients were enrolled in ADAP, of whom 1423 (26%) were disenrolled and 984 (18%) were ruled ineligible at least once. Compared with those who were continuously enrolled, disenrolled PLWH were more likely to be Black [unadjusted prevalence ratio (PR) vs White 1.31, 95% confidence interval (CI): 1.17 to 1.46], uninsured (PR vs private insurance 1.24, 95% CI: 1.10 to 1.40), and younger (PR 25-34 vs 35-44 years 1.23, 95% CI: 1.08 to 1.41). The median time to return after disenrollment was 12 months (95% CI: 8 to 19 months). CONCLUSIONS Disenrollment after failure to recertify was the most common reason why PLWH lost ADAP coverage in Washington State. ADAP recertification procedures disproportionately affect Black, young, and uninsured PLWH and may contribute to disparities in HIV outcomes.
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Affiliation(s)
- Steven Erly
- Department of Epidemiology, University of Washington, Seattle, WA
- Department of Health, Office of Infectious Disease, Washington State, Olympia, WA
| | | | - Anjum Hajat
- Department of Epidemiology, University of Washington, Seattle, WA
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, WA; and
| | - Jen Reuer
- Department of Health, Office of Infectious Disease, Washington State, Olympia, WA
| | - Martha Grimm
- Department of Health, Office of Infectious Disease, Washington State, Olympia, WA
| | - Kelse Kwaiser
- Department of Health, Office of Infectious Disease, Washington State, Olympia, WA
| | - Julia C Dombrowski
- Department of Epidemiology, University of Washington, Seattle, WA
- Division of Allergy and Infectious Disease, University of Washington, Seattle, WA
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Patients, Social Workers, and Pharmacists' Perceptions of Barriers to Providing HIV Care in Community Pharmacies in the United States. PHARMACY 2021; 9:pharmacy9040178. [PMID: 34842829 PMCID: PMC8628938 DOI: 10.3390/pharmacy9040178] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/26/2021] [Accepted: 10/28/2021] [Indexed: 11/30/2022] Open
Abstract
Retaining people living with HIV (PLWH) in clinical care is a global priority to end the HIV epidemic. Community pharmacies in the United States have structural influences on the success or failure of retention in HIV care by supporting patients’ complex needs. However, to date, barriers to retention in care in the community pharmacy setting have not been examined beyond pharmacy services of medication therapy management. We utilized the patient-centered medical home model to examine the barriers to HIV care in the community pharmacy setting. We utilized semi-structured interviews to collect data from 15 participants: five PLWH, five community pharmacists, and five social workers from a midwestern state. Interview data were transcribed and analyzed using directed content analysis. Four key themes emerged regarding the barriers that impact utilization of community pharmacy services by PLWH: the perception of the role of community pharmacists in HIV care, perceptions of pharmacists’ HIV knowledge, perceptions of pharmacy operation and services, and negative experiences within the community pharmacy space. Participants’ perceptions of solutions for improving HIV care in the community pharmacy focused on improving the relationship between pharmacists and patients, ensuring that the community pharmacy is a private and safe space for patients, and having a diverse pharmacy staff that is equipped to take care of the diverse and marginalized HIV population, such as transgender people.
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Buchbinder M, Blue C, Rennie S, Juengst E, Brinkley-Rubinstein L, Rosen DL. Practical and Ethical Concerns in Implementing Enhanced Surveillance Methods to Improve Continuity of HIV Care: Qualitative Expert Stakeholder Study. JMIR Public Health Surveill 2020; 6:e19891. [PMID: 32886069 PMCID: PMC7501574 DOI: 10.2196/19891] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/24/2020] [Accepted: 07/14/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Retention in HIV care is critical to maintaining viral suppression and preventing further transmission, yet less than 50% of people living with HIV in the United States are engaged in care. All US states have a funding mandate to implement Data-to-Care (D2C) programs, which use surveillance data (eg, laboratory, Medicaid billing) to identify out-of-care HIV-positive persons and relink them to treatment. OBJECTIVE The purpose of this qualitative study was to identify and describe practical and ethical considerations that arise in planning for and implementing D2C. METHODS Via purposive sampling, we recruited 43 expert stakeholders-including ethicists, privacy experts, researchers, public health personnel, HIV medical providers, legal experts, and community advocates-to participate in audio-recorded semistructured interviews to share their perspectives on D2C. Interview transcripts were analyzed across a priori and inductively derived thematic categories. RESULTS Stakeholders reported practical and ethical concerns in seven key domains: permission and consent, government assistance versus overreach, privacy and confidentiality, stigma, HIV exceptionalism, criminalization, and data integrity and sharing. CONCLUSIONS Participants expressed a great deal of support for D2C, yet also stressed the role of public trust and transparency in addressing the practical and ethical concerns they identified.
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Affiliation(s)
- Mara Buchbinder
- Department of Social Medicine, Center for Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Colleen Blue
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Stuart Rennie
- Department of Social Medicine, Center for Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Eric Juengst
- Department of Social Medicine, Center for Bioethics, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Lauren Brinkley-Rubinstein
- Department of Social Medicine, Center for Health Equity Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - David L Rosen
- Division of Infectious Diseases, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Wohl DA, Kuwahara RK, Javadi K, Kirby C, Rosen DL, Napravnik S, Farel C. Financial Barriers and Lapses in Treatment and Care of HIV-Infected Adults in a Southern State in the United States. AIDS Patient Care STDS 2017; 31:463-469. [PMID: 29039984 DOI: 10.1089/apc.2017.0125] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Antiretroviral (ARV) adherence has largely been considered from the perspective of an individual's behavior with less attention given to potential structural causes for lapses in treatment, such as the cost of medications and care. HIV medication expense is typically covered by third party payers. However, private insurance premiums and deductibles may rise, or policies terminated such as with a change in employment. Likewise, a patient's eligibility for publicly funded coverage like state AIDS Drug Assistance Programs (ADAP) or Medicaid can also be lost. We conducted a one-time survey of a sample of 300 patients receiving HIV care at a single large academic center in the south of United States to examine lapses in HIV therapy due to financial reasons. We found that during the prior year, financial issues including medication cost or coverage led to a lapse in ARVs in 10% (n = 31) of participants. However, of the 42% (n = 125) participants who had been enrolled in ADAP at any time during the prior year, 21% (n = 26) reported an ARV lapse due to problems with ADAP or medication cost. Respondents cited ADAP's required semi-annual renewal process and other administrative issues as the cause of ARV lapses. The median duration of missed ARVs was 2 weeks (range of <1-23 weeks). Non-HIV medication and transportation to and from clinic costs were also identified as financial burdens to care by respondents. In conclusion, although conducted at a single medical center and one state, this study suggests that a significant minority of HIV-infected patients encounter financial barriers to ARV access, and this is paradoxically more common among those enrolled in the state ADAP. Streamlining, supporting, and simplifying ADAP renewal procedures will likely reduce lapses in ARV adherence and persistence.
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Affiliation(s)
- David A Wohl
- 1 University of North Carolina at Chapel Hill School of Medicine , Division of Infectious Diseases, Chapel Hill, North Carolina
| | | | - Kamran Javadi
- 1 University of North Carolina at Chapel Hill School of Medicine , Division of Infectious Diseases, Chapel Hill, North Carolina
| | - Christine Kirby
- 3 Duke University School of Medicine , Durham, North Carolina
| | - David L Rosen
- 1 University of North Carolina at Chapel Hill School of Medicine , Division of Infectious Diseases, Chapel Hill, North Carolina
| | - Sonia Napravnik
- 1 University of North Carolina at Chapel Hill School of Medicine , Division of Infectious Diseases, Chapel Hill, North Carolina
| | - Claire Farel
- 1 University of North Carolina at Chapel Hill School of Medicine , Division of Infectious Diseases, Chapel Hill, North Carolina
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Berger MB, Sullivan KA, Parnell HE, Keller J, Pollard A, Cox ME, Clymore JM, Quinlivan EB. Barriers and Facilitators to Retaining and Reengaging HIV Clients in Care: A Case Study of North Carolina. J Int Assoc Provid AIDS Care 2015; 15:486-493. [PMID: 26567224 DOI: 10.1177/2325957415616491] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Retention in HIV care is critical to decrease disease-related mortality and morbidity and achieve national benchmarks. However, a myriad of barriers and facilitators impact retention in care; these can be understood within the social-ecological model. To elucidate the unique factors that impact consistent HIV care engagement, a qualitative case study was conducted in North Carolina to examine the barriers and facilitators to retain and reengage HIV clients in care. HIV professionals (n = 21) from a variety of health care settings across the state participated in interviews that were transcribed and analyzed for emergent themes. Respondents described barriers to care at all levels within the HIV prevention and care system including intrapersonal, interpersonal, institutional, community, and public policy. Participants also described recent statewide initiatives with the potential to improve care engagement. Results from this study may assist other states with similar challenges to identify needed programs and priorities to optimize client retention in HIV care.
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Affiliation(s)
- Miriam B Berger
- Center for Health Policy and Inequalities Research, Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Kristen A Sullivan
- Center for Health Policy and Inequalities Research, Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Heather E Parnell
- Center for Health Policy and Inequalities Research, Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Jennifer Keller
- Section on Infectious Diseases, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Alice Pollard
- North Carolina Community Health Center Association, Raleigh, NC, USA
| | - Mary E Cox
- Communicable Disease Branch, North Carolina Department of Health and Human Services, Raleigh, NC, USA
| | - Jacquelyn M Clymore
- Communicable Disease Branch, North Carolina Department of Health and Human Services, Raleigh, NC, USA
| | - Evelyn Byrd Quinlivan
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Snider JT, Goldman DP, Rosenblatt L, Seekins D, Juday T, Sanchez Y, Wu Y, Peneva D, Romley JA. The Impact of State AIDS Drug Assistance Policies on Clinical and Economic Outcomes of People With HIV. Med Care Res Rev 2015; 73:329-48. [PMID: 26537525 DOI: 10.1177/1077558715614479] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 08/13/2015] [Indexed: 11/16/2022]
Abstract
We investigated the effect of changes to state AIDS Drug Assistance Programs (ADAP) policies, which govern access to antiretroviral therapy (ART), on clinical and economic outcomes among low-income people living with HIV/AIDS. Retrospective analyses of ART access were conducted on state ADAP policies, using data from ADAP Monitoring Reports and Kaiser Family Foundation from 2006 to 2010. We found stricter eligibility requirements reduce the number of HIV-positive individuals with ART access through ADAP, and decreased ART use increases mortality by 2.67 quality-adjusted life years (QALYs) per beneficiary. If the ADAP income eligibility cutoff were decreased by 50 percentage points in each state, 4,626 individuals would lose ART access nationwide. Based on a $22,143 cost/QALY, this policy would save $274 million in health care expenditures (2012 dollars), but result in 12,352 QALYs lost, valued at $1.2 billion. Therefore, states should exercise caution in restricting programs that increase ART access for low-income people living with HIV/AIDS.
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Affiliation(s)
| | | | | | | | | | | | - Yanyu Wu
- Precision Health Economics, Los Angeles, CA, USA
| | - Desi Peneva
- Precision Health Economics, Los Angeles, CA, USA
| | - John A Romley
- University of Southern California, Los Angeles, CA, USA
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