Affordable Care Act coverage improves chances of viral suppression for Americans with HIV

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Enrolling low-income and under-insured people with HIV in one of the new Affordable Care Act (ACA) health plans in the US improves the likelihood of achieving undetectable HIV viral load, according to a presentation on Thursday at IDWeek 2015 in San Diego.

"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 lead researcher Kathleen McManus of the University of Virginia.

Many Americans living with HIV do not have private employment-based health insurance – the mainstay of health coverage in the US. Instead they rely on alternatives such as Medicaid (state-administered coverage for low-income people), Medicare (federal coverage for the elderly) or AIDS Drug Assistance Programs (ADAPs) and other care funded by the federal Ryan White HIV/AIDS Program.



In the United States, a programme providing health insurance to people on low-incomes of all ages. Provision varies from state to state, although some types of care are covered in all states.


In the United States, a federal health insurance programme that guarantees health coverage for people aged 65 and over and some younger people with disabilities.

middle income countries

The World Bank classifies countries according to their income: low, lower-middle, upper-middle and high. There are around 50 lower-middle income countries (mostly in Africa and Asia) and around 60 upper-middle income countries (in Africa, Eastern Europe, Asia, Latin America and the Caribbean).

Ryan White HIV/AIDS Program

In the United States, the largest federally funded programme providing HIV-related services to low-income, uninsured, and underinsured people with HIV/AIDS.

virological suppression

Halting of the function or replication of a virus. In HIV, optimal viral suppression is measured as the reduction of viral load (HIV RNA) to undetectable levels and is the goal of antiretroviral therapy.

ADAPs provide free HIV medications to qualified low- and middle-income people, and eligible clients can receive basic HIV-related care at Ryan White-funded clinics. ADAPs are jointly funded by federal and state money, and the states can decide how much to contribute and what drugs to include on their formularies.

The Affordable Care Act (also known as 'Obamacare'), implemented in 2014, dramatically broadened healthcare coverage. Most Americans are now required to have insurance either through their employer, Medicaid, Medicare or a plan purchased through state or federal insurance exchanges or 'marketplaces'. Federal tax subsidies are provided to help middle-income people afford monthly premiums or dues.

One provision of the ACA allowed states to expand their Medicaid programs to cover people up to a higher income threshold, with the federal government picking up most of the additional cost; currently this threshold is 138% of the federal poverty level, which is approximately $11,500 for a single individual and $24,000 for a family of four (annually). But more than a third of states have not done so, usually due to political opposition to the ACA in more conservative parts of the country.

Since the implementation of the ACA, state ADAPs can either opt to directly provide HIV medications or they can pay for ACA insurance premiums and drug co-pays for eligible people with HIV.

McManus and her colleagues looked at outcomes among ADAP clients in the state of Virginia who switched to ACA plans. Virginia did not expand its Medicaid program but it does allow its ADAP to pay for ACA premiums and co-pays.

Their analysis included 3,933 HIV-positive adults enrolled in Virginia's ADAP who were eligible for ACA insurance. The study looked at data collected from January 2013 (one year before ACA implementation) to December 2014 (one year after implementation).

While ACA plans provide more comprehensive health services than the HIV-specific care covered by ADAPs and Ryan White clinics, there were concerns about ACA plan drug formularies with limited antiretroviral options, HIV drugs being shifted to higher 'tiers' with larger co-pays, and excessive paperwork burden for clients and providers.

"We wanted to make sure that patients would achieve at least the same, if not better outcomes" on ACA plans compared to those with direct ADAP coverage, McManus said at an IDWeek news briefing.

Overall, just under half of eligible ADAP clients (47%) chose to enrol in ACA plans.

ACA enrolment varied according to a number of demographic factors including age, sex, race/ethnicity and AIDS diagnosis. People in the 25-44 year age range were less likely to enrol than younger or older clients. Men were less likely to enrol than women, while African-Americans were less likely to do so than white patients.

Enrolment was also influenced by system-level factors including eligibility for federal tax credits and the specific HIV clinic where patients were seen, with enrolment rates ranging from 14% to 74% across different clinics.

The researchers found that 86% of people who enrolled in ACA plans achieved undetectable viral load compared with 79% of those who continued to receive HIV medications directly through ADAP – a significant difference. Each additional month enrolled in an ACA plan was associated with about a 6% greater likelihood of viral suppression, with people enrolled for a full year being over 60% more likely to have undetectable HIV.

"ACA enrolment in 2014 was associated with HIV viral load suppression, an essential outcome for the individual and for public health," the researchers concluded. Viral suppression both improves the health of people with HIV and has an added public health benefit of lowering the likelihood of HIV transmission.

McManus noted that Virginia paid less to treat those covered under ACA plans, thereby enabling coverage of more people. "Moving patients to ACA insurance helps the Virginia ADAP use federal and state funds to cover a larger number of patients and helps avoid wait-lists for medications and services," she said.

Asked how ACA coverage under ADAP might compare to Medicaid expansion, McManus noted that 75% of the ADAP clients would potentially be eligible for expanded Medicaid under the higher threshold, if Virginia should decide to do so.

"Those sorts of head-to-head comparison will have to be done, maybe working with Medicaid expansion states," she suggested. "We need to figure out how all these different delivery systems fit together and how to optimise them."


McManus K et al. 2014 Affordable Care Act enrollment of AIDS Drug Assistance Program clients and associated HIV outcomes. IDWeek 2015, San Diego, abstract 728, 2015.