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WIHS Viral Load Suppression - Impact of Health Insurance, ADAP, and Income on HIV Viral Suppression Among US Women in the Women's
Interagency HIV Study, 2006-2009
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JAIDS Nov 2016 - Christina Ludema, PhD,* Stephen R. Cole, PhD, Joseph J. Eron, Jr, MD,* Andrew Edmonds, PhD,
G. Mark Holmes, PhD, Kathryn Anastos, MD, Jennifer Cocohoba, PharmD,k Mardge Cohen, MD,
Hannah L. F. Cooper, ScD,** Elizabeth T. Golub, PhD, Seble Kassaye, MS, MD,
Deborah Konkle-Parker, PhD, Lisa Metsch, PhD,kk Joel Milam, PhD, Tracey E. Wilson, PhD,***
and Adaora A. Adimora, MPH, MD*
Abstract
Background: Implementation of the Affordable Care Act motivates assessment of health insurance and supplementary programs, such as the AIDS Drug Assistance Program (ADAP) on health outcomes of HIV-infected people in the United States. We assessed the effects of health insurance, ADAP, and income on HIV viral load suppression.
Methods: We used existing cohort data from the HIV-infected participants of the Women's Interagency HIV Study. Cox proportional hazards models were used to estimate the time from 2006 to unsuppressed HIV viral load (>200 copies/mL) among those with Medicaid, private, Medicare, or other public insurance, and no insurance, stratified by the use of ADAP.
Results: In 2006, 65% of women had Medicaid, 18% had private insurance, 3% had Medicare or other public insurance, and 14% reported no health insurance. ADAP coverage was reported by 284 women (20%); 56% of uninsured participants reported ADAP coverage. After accounting for study site, age, race, lowest observed CD4, and previous health insurance, the hazard ratio (HR) for unsuppressed viral load among those privately insured without ADAP, compared with those on Medicaid without ADAP (referent group), was 0.61 (95% CI: 0.48 to 0.77). Among the uninsured, those with ADAP had a lower relative hazard of unsuppressed viral load compared with the referent group (HR, 95% CI: 0.49, 0.28 to 0.85) than those without ADAP (HR, 95% CI: 1.00, 0.63 to 1.57).
Conclusions: Although women with private insurance are most likely to be virally suppressed, ADAP also contributes to viral load suppression. Continued support of this program may be especially critical for states that have not expanded Medicaid.
Ascertainment of Viral Load
Viral load was measured every 6 months using the Nuclisens HIV-1 QT assay, which has a lower limit of detection of 80 copies per milliliter and an upper limit of quantification of 3.47 x 106 copies per milliliter. Unsuppressed viral load was defined as a single viral load measurement of >200 copies per milliliter.17
RESULTS
Among 1481 HIV-infected WIHS women, most (65%) reported Medicaid as their insurance provider, 18% had private insurance, 3% had Medicare or other public insurance, and 14% reported no health insurance (Table 1). Over the 3-year study period, 15% of participants reported a change in insurance type subsequent to the index date. Changes in insurance (loss or gain) were not differentially distributed by unsuppressed viral load.
There were 898 women who had viral load measurements >200 copies per milliliter over the 4917 visits that occurred during 2006-2009. The median time to first unsuppressed viral load was 525 days (IQR: 189-1082) with a median unsuppressed viral load of 3400 copies per milliliter (IQR: 710-23,000). In the crude analysis, participants with Medicaid without ADAP (the referent group) had the highest hazard of a viral load >200 copies per milliliter (Table 2).
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