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Switch From ADAP to Obamacare Linked to HIV Control in Virginia
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IDSA/IDWeek 2015, October 7-11, San Diego
Mark Mascolini
Virginia AIDS Drug Assistance Program (ADAP) users who got insured through the Affordable Care Act (ACA, Obamacare) had almost a 50% higher chance of an undetectable viral load than those who continued to rely on ADAP, according to results of a 2085-person analysis [1]. Almost half of eligible Virginia ADAP clients signed up for health insurance through the ACA during the study period.
Before the ACA began enrolling people late in 2013, ADAP provided the main HIV care safety net for uninsured and underinsured people. With the arrival of the ACA, noted University of Virginia researchers who conducted this study, Virginia's ADAP and those in some other states began using federal and state funds to enroll clients in insurance plans through the ACA and to pay their monthly premiums, medication copayments, and deductibles. Virginia encouraged people with HIV to switch from ADAP to full health insurance through the ACA as a way to support the largest number of HIV clients. Virginia did not opt to expand Medicaid when the ACA took effect.
The University of Virginia team conducted this study (1) to assess the impact of demographic and other factors on ADAP client enrollment in the ACA and (2) to explore the impact of ACA enrollment on viral load control. This retrospective analysis involved ADAP clients from January 2013 through December 2014. Of the 4324 Virginia ADAP clients, 3933 were eligible for the ACA and had data available for analysis. Everyone was 18 to 64 years old and enrolled in Virginia ADAP before July 2013; no one had Medicare. A subgroup of 2085 people had at least one viral load recorded in 2013 and at least one in the second half of 2014.
In the overall study group, 66% were black, 25% white, and 7% Hispanic. Almost three quarters (72%) were men, and 36% had an AIDS diagnosis. Among 3933 ACA-eligible people, 1853 (47%) enrolled in insurance plans through the ACA during the study period. People less likely to enroll included those 25 to 44 years old (P = 0.017), blacks (P = 0.03), and those diagnosed with AIDS (P = 0.001). Women were more likely to enroll than men (P = 0.026).
ACA enrollment varied from 14% to 74% from clinic to clinic. The researchers were uncertain what clinic-level factors explain this wide range. They suggested clinics with certified ACA application counselors may have enrolled more people, while concerns about limited formularies and new copays or cost sharing may have discouraged enrollment.
Among the 2085 people with viral load data, ACA enrollees proved more likely to have an undetectable viral load in 2014 than people who maintained ADAP and did not get insured through ACA (85.5% versus 78.7%). Multivariable logistic regression analysis determined that ACA enrollment improved odds of viral suppression 45% (adjusted odds ratio [aOR] 1.451, 95% confidence interval [CI] 1.113 to 1.892, P = 0.006). Each additional month of ACA insurance enrollment boosted the likelihood of viral suppression by 5.6%. Among people with 1 year of ACA insurance, chances of viral suppression were 67.1% higher than in non-ACA clients.
Two factors predicted lower odds of viral suppression: a detectable viral load in 2013 (aOR 0.341, 95% CI 0.262 to 0.443, P < 0.001) and an AIDS diagnosis (aOR 0.726, 95% CI 0.553 to 0.953, P = 0.021). Lack of insurance, the researchers proposed, "creates a barrier to . . . accessing care--even when people living with HIV can access care through Ryan White HIV clinics."
The University of Virginia team suggested that targeted promotion of ACA enrollment among ADAP clients could improve viral suppression rates and lead to "substantial individual and community health benefits."
Reference
1. McManus K, Rhodes A, Yerkes L, Bailey S, Dillingham R. 2014 Affordable Care Act enrollment of AIDS Drug Assistance Program clients and associated HIV outcomes. IDWeek 2015, October 7-11, San Diego. Abstract 728.
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