Affordable Care Act helps Virginia improve HIV outcomes

The study found that patients enrolled in ACA health care plans had higher rates of viral suppression -- no or very little HIV virus detectable in the blood, the marker of successful HIV treatment -- than those who received only medications for HIV through the state's direct AIDS Drug Assistance Program (ADAP). Researchers determined that ACA enrollment was affected by demographics such as age, race, gender and progression to an AIDS diagnosis, as well as systems-level factors, such as the 2013 ADAP coverage program they used, the federal tax credits they received and the specific HIV clinic where they received care.

"We found patients fared better under ACA health plans, possibly due to broader access to medical care and medications beyond those that target HIV," said Kathleen McManus, MD, MS, lead author of the study and a fellow physician in the Division of Infectious Diseases and International Health at the University of Virginia School of Medicine, Charlottesville. "Additionally, this approach allows the state to cover the largest number of patients in the most cost-effective way. ACA plans provide more comprehensive care for the same or less money."

Patients with HIV who are engaged in HIV care and take their anti-retroviral (ART) medications as prescribed are more likely to achieve viral suppression. Patients with viral suppression stay healthier, live longer, and are less likely to pass the virus on to others.

Using the ACA approach is particularly helpful because Virginia is one of 20 states that did not elect to expand Medicaid, meaning that many patients with low incomes remain ineligible for Medicaid and often fall through the cracks because they can't afford insurance and medications. Virginia provides care to these "Medicaid gap" HIV patients and to other low-income patients through the ADAP program. Since the passage of the ACA, there are two mechanisms through which ADAP can support care. Through direct ADAP, the state pays for patients' medications, and the patients typically receive treatment through Ryan White-funded clinics, which provide medical care and essential support services to people with HIV/AIDS who have insufficient health care coverage. The other option is for patients to sign up with an ACA health plan. Virginia ADAP then pays patients' premiums, deductibles and medication copays.

The two-year study included the 3,933 ACA-eligible ADAP patients in Virginia, comparing the outcomes of the 1,849 (47.1 percent) who enrolled in ACA plans to the 2,084 (52.9 percent) who continued to receive medications through direct ADAP. Viral suppression was achieved by 85.5 percent of those enrolled in the ACA, vs. 78.7 percent of those in the direct ADAP.

Because HIV medications are so expensive, researchers say providing ACA insurance is more cost-effective than paying for those medications directly. Therefore, more people living with HIV are covered. Prior to the availability of the ACA option, direct ADAP often had a waitlist due to limited resources. "Moving patients to ACA insurance helps the Virginia ADAP use federal and state funds to cover a larger number of patients and help avoid waitlists for medications and services," said Dr. McManus.

Every state has an ADAP, and while eligibility and coverage differ by state, all provide a safety net for people with HIV. One-third of people with HIV in the United States receive medications through a state ADAP.

"We believe enrolling patients in ACA health plans would help ADAP clients in states without Medicaid expansion and those in states with Medicaid expansion who still do not qualify for Medicaid, but are struggling to afford care," she said.