Current Challenges to the United States’ AIDS Drug Assistance Program and Possible Implications of the Affordable Care Act

AIDS Drug Assistance Programs, enacted through the Ryan White Comprehensive AIDS Resources Emergency Act of 1990, are the “payer of last resort” for prescription medications for lower income, uninsured, or underinsured people living with HIV/AIDS. ADAPs face declining funding from the federal government. State funding of ADAP is discretionary, but some states increased their contributions to meet the gap in funding. The demand for ADAP support is increasing as people living with HIV are living longer; the antiretroviral therapy (ART) guidelines have been changed to recommend initiation of treatment for all; the United States is increasing HIV testing goals; and the recession continues. In the setting of increased demand and limited funding, ADAPs are employing cost containment measures. Since 2010, emergency federal funds have bailed out ADAP, but these are not sustainable. In the coming years, providers and policy makers associated with HIV care will need to navigate the implementation of the Affordable Care Act (ACA). Lessons learned from the challenges associated with providing sustainable access to ART for vulnerable populations through ADAP should inform upcoming decisions about how to ensure delivery of ART during and after the implementation of the ACA.

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Adhering to antiretroviral therapy: A qualitative analysis of motivations for and obstacles to consistent use of antiretroviral therapy in people living with HIV

SAGE Open Medicine ◽

10.1177/2050312120915405 ◽

2020 ◽

Vol 8 ◽

pp. 205031212091540

Author(s):

Lisa Fleischer ◽

Ann Avery

Keyword(s):

United States ◽

Antiretroviral Therapy ◽

Qualitative Analysis ◽

The United States ◽

Care Team ◽

Hiv Care ◽

People Living With Hiv ◽

Care Clinic ◽

Main Motivation ◽

Living With Hiv

Objectives: Based on the 2015 U.S. Centers for Disease Control and Prevention data, 40% of people living with HIV in the United States with an HIV diagnosis and 18.5% of people living with HIV in HIV care in the United States are not virally suppressed. Many HIV care clinics have implemented recommendations to improve the percentage of people living with HIV on antiretroviral therapy. To understand what more could be done, we examine patients’ motivations and obstacles to maintaining adherence to antiretroviral therapy. Methods: We conducted qualitative analysis using a qualitative description framework of in-depth interviews with people living with HIV receiving care at an urban HIV care clinic in the midwestern United States. Results: We found that while many traditional barriers to care have been addressed by existing programs, there are key differences between those consistent with antiretroviral therapy and those inconsistent with antiretroviral therapy. In particular, self-motivation, diagnosis acceptance, treatment for depression, spiritual beliefs, perceived value of the HIV care team, and prior experience with health care distinguish these two groups. Most significantly, we found that people living with HIV consistent with antiretroviral therapy describe their main motivation as coming from themselves, whereas people living with HIV inconsistent with antiretroviral therapy more often describe their main motivation as coming from the HIV care team. Conclusion: Our results highlight the importance of the HIV care team’s encouragement of maintaining antiretroviral adherence, as well as encouraging treatment for depression.

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Social determinants of health and care outcomes among people living with HIV in the United States

Open Forum Infectious Diseases ◽

10.1093/ofid/ofab330 ◽

2021 ◽

Author(s):

Timothy W Menza ◽

Lindsay K Hixson ◽

Lauren Lipira ◽

Linda Drach

Keyword(s):

United States ◽

Social Determinants ◽

Viral Suppression ◽

The United States ◽

Hiv Care ◽

Economic Disadvantage ◽

People Living With Hiv ◽

Care Outcomes ◽

Durable Viral Suppression ◽

Living With Hiv

Abstract Background Fewer than 70% of people living with HIV (PLHIV) in the United States have achieved durable viral suppression. To end the HIV epidemic in the United States, clinicians, researchers, and public health practitioners must devise ways to remove barriers to effective HIV treatment. To identify PLHIV who experience challenges to accessing healthcare, we created a simple assessment of social determinants of health (SDOH) among PLHIV and examined the impact of cumulative social and economic disadvantage on key HIV care outcomes. Methods We used data from the 2015-2019 Medical Monitoring Project, a yearly cross-sectional survey of PLHIV in the United States (N=15,964). We created a ten-item index of SDOH and assessed differences in HIV care outcomes of missed medical appointments, medication adherence, and durable viral suppression by SDOH using this index using prevalence ratios with predicted marginal means. Results Eighty-three percent of PLHIV reported at least one SDOH indicator. Compared to PLHIV who experienced none of the SDOH indicators, people who experienced one, two, three, and four or more SDOH indicators, were 1.6, 2.1, 2.6 and 3.6 as likely to miss a medical appointment in the prior year; 11%, 17%, 20% and 31% less likely to report excellent adherence in the prior 30 days; and, 2%, 4%, 10% and 20% less likely to achieve durable viral suppression in the prior year, respectively. Conclusions Among PLHIV, cumulative exposure to social and economic disadvantage impacts care outcomes in a dose-dependent fashion. A simple index may identify PLHIV experiencing barriers to HIV care, adherence, and durable viral suppression in need of critical supportive services.

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1316. Gathering Trauma Narratives: A Qualitative Study on the Impact of Traumas on People Living with HIV (PLWH)

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1179 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S475-S475

Author(s):

Doris Pierson ◽

Vaidehi Mujumdar ◽

Brittany Briceño ◽

Elaina Cummer ◽

Kshipra Hemal ◽

...

Keyword(s):

United States ◽

Reproductive Health ◽

Viral Suppression ◽

The United States ◽

Hiv Care ◽

People Living With Hiv ◽

Structured Interviews ◽

Reproductive Intentions ◽

Living With Hiv ◽

The Impact

Abstract Background Trauma—emotional, physical, and psychological—is common and associated with increased risk behaviors, low rates of care engagement and viral suppression, and overall poor health outcomes for people living with HIV (PLWH). In the United States, there are limited data on how trauma affects reproductive health beliefs for PLWH and even less data on HIV providers’ understanding and consideration of these experiences in their approach to patients. Methods Fifteen semi-structured interviews were conducted with PLWH and nine semi-structured interviews were conducted with HIV care and service providers at an academic medical center in the Southeastern United States. Transcripts were analyzed using thematic analysis. Each transcript was coded by two investigators and discussed to ensure consensus. Results Participants’ narratives described diverse traumas, including sexual abuse (n = 6), the loss of a loved one (n = 8), and personal illness (n = 7). Types of trauma shared with providers included physical, sexual, illness, loss, and psychological. For patients, trauma was both a motivation for having children and a reason to stop having children. Providers perceived a variety of effects of trauma on both sexual behaviors and reproductive intentions. Reproductive counseling by HIV care providers (n = 5) focused on maintaining a healthy pregnancy and less on reproductive intentions prior to pregnancy. Reproductive discussions with pregnant female patients typically centered on reducing the risk of transmission in utero (including the importance of medication adherence to maintain viral suppression), what will happen during delivery, and breastfeeding risks. Reproductive discussions with males typically centered on preventing infection or re-infection of the mother. Conclusion PLWH interpret their trauma experiences differently, particularly when considering reproduction. Providers may not incorporate this information in counseling around reproductive health, highlighting the need fora trauma-informed healthcare practice that promotes awareness, education on the effect of past traumas on health, and access to appropriate resources. Disclosures All authors: No reported disclosures.

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The Affordable Care Act Helps People Living with HIV/AIDS

PsycEXTRA Dataset ◽

10.1037/e524832013-001 ◽

2012 ◽

Keyword(s):

Affordable Care Act ◽

People Living With Hiv ◽

The Affordable Care Act ◽

Living With Hiv ◽

Hiv Aids

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The Impact of the Affordable Care Act Medicaid Expansions on the Sources of Health Insurance Coverage of Undergraduate Students in the United States

Medical Care Research and Review ◽

10.1177/10775587211015816 ◽

2021 ◽

pp. 107755872110158

Author(s):

Priyanka Anand ◽

Dora Gicheva

Keyword(s):

United States ◽

Health Insurance ◽

Undergraduate Students ◽

Affordable Care Act ◽

Insurance Coverage ◽

Health Insurance Coverage ◽

The United States ◽

Percentage Points ◽

The Affordable Care Act ◽

Medicaid Expansions

This article examines how the Affordable Care Act Medicaid expansions affected the sources of health insurance coverage of undergraduate students in the United States. We show that the Affordable Care Act expansions increased the Medicaid coverage of undergraduate students by 5 to 7 percentage points more in expansion states than in nonexpansion states, resulting in 17% of undergraduate students in expansion states being covered by Medicaid postexpansion (up from 9% prior to the expansion). In contrast, the growth in employer and private direct coverage was 1 to 2 percentage points lower postexpansion for students in expansion states compared with nonexpansion states. Our findings demonstrate that policy efforts to expand Medicaid eligibility have been successful in increasing the Medicaid coverage rates for undergraduate students in the United States, but there is evidence of some crowd out after the expansions—that is, some students substituted their private and employer-sponsored coverage for Medicaid.

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Analyzing patient choices for routine procedures in the United States vs overseas before and after the affordable care act: a case study

Health Systems ◽

10.1057/hs.2015.7 ◽

2016 ◽

Vol 5 (1) ◽

pp. 21-28 ◽

Cited By ~ 1

Author(s):

Sameer Kumar ◽

Muer Yang

Keyword(s):

United States ◽

Affordable Care Act ◽

The United States ◽

Before And After ◽

The Affordable Care Act ◽

Routine Procedures

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Association of Medicaid expansion under the Affordable Care Act with access to elective spine surgical care

Journal of Neurosurgery Spine ◽

10.3171/2021.3.spine2122 ◽

2021 ◽

pp. 1-9

Author(s):

Jacob K. Greenberg ◽

Derek S. Brown ◽

Margaret A. Olsen ◽

Wilson Z. Ray

Keyword(s):

United States ◽

Spine Surgery ◽

Surgical Procedures ◽

Affordable Care Act ◽

Surgical Care ◽

The United States ◽

Medicaid Expansion ◽

Percentage Points ◽

The Affordable Care Act ◽

The Impact

OBJECTIVE The Affordable Care Act expanded Medicaid eligibility in many states, improving access to some forms of elective healthcare in the United States. Whether this effort increased access to elective spine surgical care is unknown. This study’s objective was to evaluate the impact of Medicaid expansion under the Affordable Care Act on the volume and payer mix of elective spine surgery in the United States. METHODS This study evaluated elective spine surgical procedures performed from 2011 to 2016 and included in the all-payer State Inpatient Databases of 10 states that expanded Medicaid access in 2014, as well as 4 states that did not expand Medicaid access. Adult patients aged 18–64 years who underwent elective spine surgery were included. The authors used a quasi-experimental difference-in-difference design to evaluate the impact of Medicaid expansion on hospital procedure volume and payer mix, independent of time-dependent trends. Subgroup analysis was conducted that stratified results according to cervical fusion, thoracolumbar fusion, and noninstrumented surgery. RESULTS The authors identified 218,648 surgical procedures performed in 10 Medicaid expansion states and 118,693 procedures performed in 4 nonexpansion states. Medicaid expansion was associated with a 17% (95% CI 2%–35%, p = 0.03) increase in mean hospital spine surgical volume and a 23% (95% CI −0.3% to 52%, p = 0.054) increase in Medicaid volume. Privately insured surgical volumes did not change significantly (incidence rate ratio 1.13, 95% CI −5% to 34%, p = 0.18). The increase in Medicaid volume led to a shift in payer mix, with the proportion of Medicaid patients increasing by 6.0 percentage points (95% CI 4.1–7.0, p < 0.001) and the proportion of private payers decreasing by 6.7 percentage points (95% CI 4.5–8.8, p < 0.001). Although the magnitude of effects varied, these trends were similar across procedure subgroups. CONCLUSIONS Medicaid expansion under the Affordable Care Act was associated with an economically and statistically significant increase in spine surgery volume and the proportion of surgical patients with Medicaid insurance, indicating improved access to care.

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Conclusion

10.5149/northcarolina/9781469661339.003.0009 ◽

2020 ◽

pp. 223-226

Author(s):

Dan Royles

Keyword(s):

Climate Change ◽

United States ◽

Health Equity ◽

Affordable Care Act ◽

The United States ◽

First Year ◽

Communities Of Color ◽

History Of ◽

The Affordable Care Act ◽

Hiv Aids

This chapter considers what it means to write the history of a crisis that has not yet ended, and briefly traces connections among the stories told in previous chapters. It connects these stories to the ongoing fight for health equity in the United States, including the author’s involvement in the fight to preserve the Affordable Care Act in the first year of Donald Trump’s presidency. Finally, it compares HIV/AIDS to climate change, as both are existential crises that will disproportionately affect poor communities of color.

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