2014 Affordable Care Act Enrollment of AIDS Drug Assistance Program Clients and Associated HIV Outcomes

Background: Before the Affordable Care Act (ACA), state AIDS Drug Assistance Programs (ADAPs) were the safety net providing antiretroviral therapy to uninsured/underinsured people living with HIV (PLWH). Many ADAPs, including Virginia, shifted their healthcare delivery model from a focus on direct medication provision to the purchase of insurance with the advent of ACA in 2014. Virginia ADAP helped enroll clients in ACA insurance plans and paid monthly premiums, medication copayments and deductibles. The objective of this study is to characterize the demographic and systems-level factors in Virginia ADAP clients’ ACA enrollment and to assess the relationship between ACA enrollment and HIV viral load (VL) suppression.

Methods: The cohort includes people with a diagnosis of HIV who were at least 18 years old, enrolled in ADAP before July 1, 2013, and eligible for ACA insurance. The Virginia Department of Health (VDH) provided a database with data collected from January 1, 2013 through December 31, 2014.

Results: Of Virginia’s 3933 ACA-eligible ADAP clients, 47.1% enrolled in ACA insurance plans. In multivariable binary logistic regression analysis assessing factors associated with ACA enrollment, age, race/ethnicity, sex, Income/Financial Incentives, HIV/AIDS Diagnosis, 2013 ADAP Plan, and HIV Clinic were statistically significant. In multivariable binary logistic regression analysis, statistically significant factors associated with achieving HIV VL suppression include ACA enrollment (OR 1.45, p=0.006), starting with an undetectable HIV VL in 2013, more time between VLs, HIV/AIDS diagnosis, and HIV clinic.

Conclusion: This unique and timely project creates a statewide picture of the transition of the ADAP care delivery model in Virginia, a state without Medicaid expansion. This analysis demonstrates that across demographic and systems-level factors, there was variability in ADAP clients’ ACA insurance enrollment. Importantly, ACA enrollment in 2014 was associated with HIV VL suppression, an essential outcome for the individual and for public health. This association should continue to be tracked over time, as more PLWH enroll in insurance programs and remain on insurance for longer periods of time.