Medicaid Expansion's Impact on Human Immunodeficiency Virus Outcomes in a Nonurban Southeastern Ryan White HIV/AIDS Program Clinic

The impact of Medicaid expansion under the Affordable Care Act on HIV care continuum outcomes across the United States

HIV care continuum outcome disparities by health insurance status have been noted among people with HIV (PWH). We therefore examined associations between state Medicaid expansion and HIV outcomes in the United States. Adults (≥18 years) with ≥1 visit in NA-ACCORD clinical cohorts from 2012-2017 contributed person-time annually between first and final visit or death; in each calendar year, clinical retention was ≥2 completed visits > 90 days apart, antiretroviral therapy (ART) receipt was receipt of ≥3 antiretroviral agents, and viral suppression was last measured HIV-1 RNA < 200 copies/mL. CD4 at enrollment was obtained within 6 months of enrollment in cohort. Difference-in-difference (DID) models quantified associations between Medicaid expansion changes (by state of residence) and HIV outcomes. Across 50 states, 87 290 PWH contributed 325 113 person-years of follow-up. Medicaid expansion had a substantial positive effect on CD4 at enrollment (DID = 93.5, 95% CI: 52.9, 134 cells/mm3), a small negative effect on proportions clinically retained (DID = -0.19, 95% CI: -0.037, -0.01), and no effects on ART receipt (DID = 0.001, 95% CI: -0.003, 0.005) or viral suppression (DID = -0.14, 95% CI: -0.34, 0.07). Medicaid expansion had a positive effect on CD4 at entry, suggesting more timely HIV testing and care linkage, but generally null effects on downstream HIV care continuum measures.

Strategies of Managing Repeated Measures: Using Synthetic Random Forest to Predict HIV Viral Suppression Status Among Hospitalized Persons with HIV

The HIV/AIDS epidemic remains a major public health concern since the 1980s; untreated HIV infection has numerous consequences on quality of life. To optimize patients' health outcomes and to reduce HIV transmission, this study focused on vulnerable populations of people living with HIV (PLWH) and compared different predictive strategies for viral suppression using longitudinal or repeated measures. The four methods of predicting viral suppression are (1) including the repeated measures of each feature as predictors, (2) utilizing only the initial (baseline) value of the feature as predictor, (3) using the last observed value as the predictors and (4) using a growth curve estimated from the features to create individual-specific prediction of growth curves as features. This study suggested the individual-specific prediction of the growth curve performed the best in terms of lowest error rate on an independent set of test data.

Racial disparity in ART adherence is closed in states with high social trust: Results from the Medical Monitoring Project (MMP), 2015

Racial/ethnic disparities persist in antiretroviral therapy (ART) adherence and viral suppression. We examined associations between state-level social trust and individual-level ART adherence and viral suppression and assessed whether these relationships varied by race/ethnicity. The Medical Monitoring Project (MMP) annually reports nationally representative estimates of the behavioral and clinical characteristics of HIV-positive adults in primary care. A total of 3298 adults diagnosed with HIV between 2015 and 2016 from 16 US states were included. We used weighted logistic regression to model the association between state-level social trust, race/ethnicity (Non-Hispanic Black, White, and Hispanic/Latino), and cross-product interactions with ART adherence (a binary measure derived from three self-reported questions), and viral suppression (a binary measure corresponding to plasma HIV RNA < 200 copies/ml). Social trust was the percentage of people in each state who agreed that most people in their neighborhood could be trusted. A high level of social trust was associated with a higher likelihood of ART adherence (PR [prevalence ratio] = 1.17; 95% confidence interval [CI]: 1.05-1.30). In covariate-adjusted analyses, the association between state-level social trust and individual-level ART adherence significantly varied by race/ethnicity (Wald χ2  F = 9.8 [df = 4], p = 0.044). Social trust was positively associated with ART, but the effect was smaller for Blacks than for Whites (PR = 0.66; 95% CI: 0.57-0.82) in states with the lowest social trust. Black-White differences were closed and no longer significant above mean social trust (PP [predicted probability] = 0.50 vs. 0.53, at two standard deviations). Racial/ethnic disparities in ART adherence were closed among individuals living in states with high social trust. Understanding the mechanisms that promote social trust among neighbors may have downstream impacts on reducing disparities in ART adherence among people with HIV (PWH).

Patient Perspective of People with HIV Who Gained Medicaid Through Medicaid Expansion: A Cross-Sectional Qualitative Study

Given the large numbers of people with HIV (PWH) with Medicaid coverage, it is important to understand the patient experience with Medicaid. Understanding experiences with and attitudes around the program have important policy and clinical implications. The objective was to understand the patient perspective of PWH in Virginia, who transitioned to Medicaid in 2019 due to Medicaid expansion. English-speaking PWH who gained Medicaid due to Medicaid expansion in 2019 were recruited at one Virginia Ryan White HIV/AIDS Program clinic. The goal was to enroll >33% of those who newly were on Medicaid for 2019. Participants were surveyed about demographic characteristics, and semistructured interviews were performed. Descriptive analyses were performed for cohort characteristics. Using qualitative description and an open coding strategy, codebooks were generated for the interviews and themes were identified. The cohort (n = 28) met our recruitment goal. Most participants had positive feelings about Medicaid before enrollment (general: 68%; good for general health: 75%, and good for HIV care: 67%) and after enrollment (general: 93% and good for HIV care: 93%). All participants expressed incomplete understanding about Medicaid before enrollment. Seventy-nine percent needed outside help to complete enrollment. Approximately 40% described overlaps of Medicaid with other insurance/payers or gaps in insurance coverage when transitioning from one insurance/payer (such as AIDS Drug Assistance Program [ADAP] medication provision and ADAP-subsidized insurance) to Medicaid. Participants suggested more access or easier access to information about Medicaid and more explanation of Medicaid benefits would be helpful. Our findings indicate participants had mostly positive perceptions of Medicaid before and after enrollment. Even with enrollment help, participants voiced that dealing with insurance is hard. Medicaid and other programs should prioritize more access to information, smoother processes, and less burdensome enrollment/re-enrollment.