The prospect of a generation free of HIV may be within reach if the right policy decisions are made

Early Impact of the Patient Protection and Affordable Care Act on People Living With HIV: A Systematic Review

The US Patient Protection and Affordable Care Act (ACA) was the most influential policy-related change to the care of people living with HIV in decades. We systematically searched and analyzed peer-reviewed, empirical research reporting on ACA-related aspects of HIV care post-ACA full implementation, finding 12 articles that met search criteria. The results revealed largely positive evidence regarding the ACA impact on people living with HIV, particularly on their health care coverage in Medicaid expansion states. More recent reporting included improvement in virologic suppression. However, early evidence has been somewhat fragmented, and important questions concerning the impact of the ACA on HIV care quality, patients, and providers remain unanswered. As the political struggle over the ACA continues, future analyses should use national- and state-level data to examine ACA impact on HIV care quality and patient-centered health outcomes to provide in-depth, holistic understanding of HIV care in the wake of this policy change.

National Survey of United States Human Immunodeficiency Virus Medical Providers' Knowledge and Attitudes About the Affordable Care Act

Background

The Affordable Care Act (ACA) affects United States’ healthcare by offering Medicaid expansion and tax subsidies to persons with low incomes, and its interaction with the current human immunodeficiency virus (HIV) healthcare delivery system is complex. The objective was to explore HIV medical providers’ knowledge and attitudes about the ACA.

Methods

HIV medical providers were emailed a weblink to a survey. Descriptive statistics, Mann-Whitney U tests, and binary logistic regression were performed.

Results

Of the 253 survey participants, the majority (61%) answered all 4 knowledge questions correctly. About 70% knew whether or not their state had decided to expand Medicaid. About 1 in 10 did not know if the ACA eliminated the Ryan White Program. When rating whether the ACA would improve their patients’ HIV outcomes from 1–5 with 5 as “strongly agree,” the providers’ mean responses varied by state Medicaid status: 3.78 (standard deviation [SD], 0.83) for Medicaid expansion compared with 3.37 (SD, 1.00) for Medicaid nonexpansion (P = .002). Adjusting for medical provider type, years of HIV practice, and sources of ACA information, correct ACA knowledge was associated with providing care in a Medicaid nonexpansion state (adjusted odds ratio [aOR], 2.07; 95% confidence interval [CI], 1.11–3.88), obtaining knowledge from case managers (aOR, 1.89; 95% CI, 1.03–3.48), and obtaining knowledge from newspapers/magazines (aOR, 1.94; 95% CI, .99–3.81).

Conclusions

Medical providers in Medicaid expansion states were more optimistic about the ACA’s likelihood to improve their patients’ HIV outcomes. There are gaps in HIV medical providers’ understanding of the ACA. Education could enhance systems-based practice.

The Ryan White HIV/AIDS Program: Supplementary Service Provision Post-Affordable Care Act

The Ryan White HIV/AIDS program (RWHAP) provides essential primary and supplementary health services to people living with HIV (PLWH). We examined the relationship between supplementary RWHAP services (Part B) and two outcomes: viral suppression (VS) and two separate measures of retention in care (RiC) based on kept- and missed-visits. We used purposive sampling to identify adult patients who received primary medical care at an academically-affiliated HIV/AIDS clinic in the southeastern United States (N = 1159) and who attended at least one scheduled HIV primary care appointment at the study site during 2015. Unadjusted and adjusted logistic regression models were fit, in which RWHAP supplementary services were the primary independent variables of interest. Age, race, gender, education level, and income were control variables. Among 1159 PLWH, 45.3% received RWHAP supplementary services in addition to public insurance, private insurance, or primary RWHAP. Among participants, 91.4% were virally suppressed, 87.4% were retained in care using the Institute of Medicine (IOM) kept-visits measure, and 60% were retained in care using the missed-visits measure. In multivariable models, patients with RWHAP supplementary services had significantly higher odds of (1) VS [adjusted odds ratio (AOR) = 1.91], (2) RiC using the IOM kept-visits measure (AOR = 2.56), and (3) RiC using the missed-visits measure (AOR = 1.58). Receipt of supplementary RWHAP services is associated with increased odds of VS and two measures of RiC when adjusting for key sociodemographic variables. Policymakers should consider the vital role of RWHAP as continued funding is uncertain.

Year 2 of Affordable Care Act Qualified Health Plans (QHPs) in a Medicaid Nonexpansion State: QHPs Associated With Viral Suppression for Virginia AIDS Drug Assistance Program Clients

Background

For year 1 of the Affordable Care Act (ACA), Virginia AIDS Drug Assistance Program (ADAP) clients with Qualified Health Plans (QHPs) achieved a higher rate of viral suppression. This study characterizes the demographic and health care delivery factors associated with QHP enrollment in year 2 and assesses the relationship between 2015 QHP coverage and HIV viral suppression.

Methods

The cohort included Virginia ADAP clients who were eligible for ADAP-funded QHPs. Data were collected from 2014 to 2015. Multivariable binary logistic regression was conducted to assess the association of demographic and health care delivery factors with QHP enrollment and viral suppression.

Results

In year 2, 63% of the cohort (n = 4631) enrolled in QHPs; 2015 ADAP-funded QHP enrollment was associated with 2014 ADAP-funded QHP (adjusted odds ratio [aOR], 111.11; 95% confidence interval [CI], 90.91–166.67), 2014 engagement in care (aOR, 2.16; 95% CI, 1.65–2.82), age (P < .001), race/ethnicity (P = .03), financial status (P < .001), and region (P < .001). For clients engaged in care (n = 2501), viral suppression was higher (83.3%) for those with ADAP-funded QHP coverage than for those who received medications from ADAP (79.9%). In multivariable binary logistic regression, achieving viral suppression was associated with 2015 QHP coverage (aOR, 1.27; 95% CI, 1.01–1.60), an initially undetectable viral load (aOR, 2.69; 95% CI, 2.13–3.39), gender (P = .03), age (P = .01), no AIDS diagnosis (aOR, 1.41; 95% CI, 1.12–1.78), financial status (P = .004), and region (P < .001).

Conclusions

Virginia ADAP client 2015 QHP enrollment increased compared with year 1 and varied based on demographic and health care delivery factors. QHP coverage was again associated with viral suppression, an essential outcome for individuals and for public health.

PPACA and Low-Income People Living with HIV: 2014 Qualified Health Plan Enrollment in a Medicaid Nonexpansion State

People living with human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) often are uninsured or underinsured, and they may benefit from the Patient Protection and Affordable Care Act (PL 111-148) and its improved access to medical care. Safety net programs, such as AIDS Drug Assistance Programs (ADAP) funded through the Ryan White HIV/AIDS Program, which serve low-income people living with HIV, are incorporating Patient Protection and Affordable Care Act Marketplace-qualified health plans (QHPs) and helping to fund patients' participation. This changing landscape differs from state to state, and one main element contributing to the differing situations is whether a state elected to expand Medicaid. This review examines QHP enrollment of ADAP clients in Virginia, a Medicaid nonexpansion state, and explores some issues that affect people living with HIV in other Medicaid nonexpansion states. Virginia is a leader in the shift of ADAP healthcare delivery from direct medication provision to purchasing QHPs. Virginia ADAP clients accounted for approximately 2% of ADAP clients nationally, but they represent 17% of ADAP clients enrolled in QHPs nationwide. Ensuring good HIV care of the ADAP population is important to each patient's personal longevity, the public health, and the efficient use of healthcare dollars. As healthcare delivery models shift, the effects on patients and health outcomes achieved should be monitored, particularly for chronic diseases such as HIV.

Affordable Care Act Qualified Health Plan Enrollment for AIDS Drug Assistance Program Clients: Virginia's Experience and Best Practices

With the implementation of the Affordable Care Act (ACA) in 2014, many safety net resources, including state AIDS Drug Assistance Programs (ADAPs), incorporated ACA Qualified Health Plans (QHPs) into their healthcare delivery model. This article highlights the benefits of the ACA for persons living with HIV. It also describes the range of strategies employed by state ADAPs to enroll patients in QHPs. The Virginia ADAP ACA implementation experience is described to illustrate one ADAP's shift to purchasing QHPs in addition to providing direct medications. Virginia ADAP is in a Medicaid nonexpansion state and funds the full costs of the QHP premiums, deductibles, and medication copayments. Virginia's experience is applicable to other Medicaid nonexpansion states and to state ADAPs in Medicaid expansion states, who are looking for options for their Medicaid ineligible clients. This article provides practical details of Virginia ADAP's ACA implementation as well as insights and best practices at both the state and clinic level.

Affordable Care Act Qualified Health Plan Coverage: Association With Improved HIV Viral Suppression for AIDS Drug Assistance Program Clients in a Medicaid Nonexpansion State

BACKGROUND

With the Patient Protection and Affordable Care Act, many state AIDS Drug Assistance Programs (ADAPs) shifted their healthcare delivery model from direct medication provision to purchasing qualified health plans (QHPs). The objective of this study was to characterize the demographic and healthcare delivery factors associated with Virginia ADAP clients' QHP enrollment and to assess the relationship between QHP coverage and human immunodeficiency virus (HIV) viral suppression.

METHODS

The cohort included persons living with HIV who were enrolled in the Virginia ADAP (n = 3933). Data were collected from 1 January 2013 through 31 December 2014. Multivariable binary logistic regression was conducted to assess for associations with QHP enrollment and between QHP coverage and viral load (VL) suppression.

RESULTS

In the cohort, 47.1% enrolled in QHPs, and enrollment varied significantly based on demographic and healthcare delivery factors. In multivariable binary logistic regression, controlling for time, age, sex, race/ethnicity, and region, factors significantly associated with achieving HIV viral suppression included QHP coverage (adjusted odds ratio, 1.346; 95% confidence interval, 1.041-1.740; P = .02), an initially undetectable VL (2.809; 2.174-3.636; P < .001), HIV rather than AIDS disease status (1.377; 1.049-1.808; P = .02), and HIV clinic (P < .001).

CONCLUSIONS

QHP coverage was associated with viral suppression, an essential outcome for individuals and for public health. Promoting QHP coverage in clinics that provide care to persons living with HIV may offer a new opportunity to increase rates of viral suppression.