HIV Patients Do Better With Insurance Than Drug Assistance

Marcia Frellick

October 09, 2015

SAN DIEGO — Low-income HIV patients who transitioned to Affordable Care Act health plans in Virginia, a state that did not expand Medicaid, had better outcomes and were more likely to attain viral suppression than their peers who continued to receive medications through the state's AIDS Drug Assistance Program, according to a new study.

This finding is important for public health because the more viral suppression, the fewer transmissions, said Kathleen McManus, MD, from the division of infectious diseases and international health at the University of Virginia in Charlottesville.

"We also found that the relationship is a dose-related response," she said during a news conference here at IDWeek 2015. "If someone enrolled in Affordable Care in January, they were more likely to achieve virologic suppression than if they enrolled by April or June."

Many low-income patients with HIV face obstacles to getting care. Some fall through the cracks because they earn too much to get Medicaid coverage, but not enough to pay for insurance and medications.

Before the Affordable Care Act, the Virginia AIDS Drug Assistance Program provided antiretroviral therapy to the uninsured and underinsured living with HIV, typically through HIV clinics funded by the Ryan White Program. When Affordable Care was introduced, the AIDS Drug Assistance Program helped eligible patients sign up for a plan and paid for the premiums, deductibles, and medication copays.

Dr McManus and her team assessed data collected by the Virginia Department of Health from January 1, 2013 to December 31, 2014. They identified 3933 HIV-infected adults enrolled in the state AIDS Drug Assistance Program before July 1, 2013 who were eligible for Affordable Care. Of these, 47.1% enrolled in the insurance plans.

Decision to Enroll

The decision to enroll was affected by many factors, including age, sex, where patients got their care, and the amount of tax credits received.

Patients 25 to 44 years of age were less likely to enroll than those 18 to 24 years or those older than 44 years. In addition, "patients with AIDS were less likely to enroll than patients with HIV, and women were more likely to enroll than men," Dr McManus reported.

Viral suppression, the most important HIV clinical outcome, was achieved by more patients enrolled in Affordable Care than in the drug assistance program (85.5% vs 78.7%).

This study provides yet more evidence that having insurance improves outcomes for people with chronic diseases, said Dr McManus.

Affordable Care provides more comprehensive care for the same amount of money, or less, and patients might have done better because they had access to medications and treatments beyond HIV-specific drugs, she explained.

The Ryan White program, which works with cities, states, and local community-based organizations to provide HIV-related services, gives patients "access to HIV care, but that doesn't always mean that someone can get their primary care, their diabetes care, or their colonoscopy," she pointed out.

And, because HIV medications are so expensive, providing insurance is more cost-effective than paying for the medications directly, said Dr McManus. Before Affordable Care, Virginia's AIDS Drug Assistance Program often had a waitlist.

The association should continue to be tracked over time, say the researchers, as more people living with HIV remain on insurance for longer periods of time.

The Program or the Patients?

The better virologic outcomes achieved by the patients who enrolled in insurance plans might be a function of the kinds of patients who chose to enroll in an insurance plan, rather than an advantage of the plans themselves, said Loren Miller, MD, from the University of California at Los Angeles.

"For example, more motivated patients with better health-seeking behavior might have chosen insurance plans," Dr Miller told Medscape Medical News.

Regardless, it is very reassuring that clinical outcomes do not worsen in patients transitioning from drug programs to insurance plans. "In fact, outcomes may be better for those who chose the insurance plans," he said.

These findings could trigger a reassessment of the way AIDS Drug Assistance Program funds are spent, and inspire expanded choices to maximize clinical outcomes for HIV-infected patients, he added.

Dr McManus and Dr Smith have disclosed no relevant financial relationships.

IDWeek 2015: Abstract 728. Presented October 9, 2015.

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