Despite early Medicaid expansion, decreased durable virologic suppression among publicly insured people with HIV in Washington, DC: a retrospective analysis

Deborah Goldstein,W David Hardy,Qingjiang Hou,Arpi Terzian,Anne Monroe,Rachel Hart

doi:10.1186/s12889-020-08631-7

Abstract

BackgroundDespite widely available access to HIV care in Washington, DC, inequities in HIV outcomes persist. We hypothesized that laboratory monitoring and virologic outcomes would not differ significantly based on insurance type.MethodsWe compared HIV monitoring with outcomes among people with HIV (PWH) with private (commercial payer) versus public (Medicare, Medicaid) insurance receiving care at community and hospital clinics. The DC Cohort follows over 8000 PWH from 14 clinics. We included those ≥18 years old enrolled between 2011 and 2015 with stable insurance. Outcomes included frequency of CD4 count and HIV RNA monitoring (> 2 lab measures/year, > 30 days apart) and durable viral suppression (VS; HIV RNA < 50 copies/mL at last visit and receiving antiretroviral therapy (ART) for ≥12 months). Multivariable logistic regression models examined impact of demographic and clinical factors.ResultsAmong 3908 PWH, 67.9% were publicly-insured and 58.9% attended community clinics. Compared with privately insured participants, a higher proportion of publicly insured participants had the following characteristics: female sex, Black race, heterosexual, unemployed, and attending community clinics. Despite less lab monitoring, privately-insured PWH had greater durable VS than publicly-insured PWH (ART-naïve: private 70.0% vs public 53.1%, p = 0.03; ART-experienced: private 80.2% vs public 69.4%, p < 0.0001). Privately-insured PWH had greater durable VS than publicly-insured PWH at hospital clinics (AOR = 1.59, 95% CI: 1.20, 2.12; p = 0.001).ConclusionsParadoxical differences between HIV monitoring and durable VS exist among publicly and privately-insured PWH in Washington, DC. Programs serving PWH must improve efforts to address barriers creating inequity in HIV outcomes.

Highlights

Despite widely available access to HIV care in Washington, District of Columbia (DC), inequities in HIV outcomes persist
Of 14 DC cohort clinics, 12 were included in this analysis: one clinic was excluded because participants had insufficient follow up time to be included; and the Veterans Administration (VA) Medical Center was excluded due to structural differences in the funding of medical care at this site
Publicly-insured people with HIV (PWH) had a higher prevalence of the five comorbidities assessed at enrollment than privately-insured PWH

Summary

Introduction

Despite widely available access to HIV care in Washington, DC, inequities in HIV outcomes persist. For people with HIV (PWH), health insurance coverage is associated with sustained viral suppression (VS), decreased incidence of AIDS, reduced hospitalization rates, and reduced mortality [1,2,3,4]. PWH in the US are disproportionately uninsured, underinsured, or have public insurance, according to data prior to full Affordable Care Act (ACA) implementation [5, 6]. Uninsured or publicly insured PWH have worse health outcomes compared to those who were privately-insured. PWH with private insurance were more likely to have sustained VS compared with those with public insurance, according to prior studies [1, 5]. PWH with public insurance in the HIV Outpatient Study had higher mortality rates than privately insured participants [2]

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