Menon Anitha, Patel Payal K, Karmakar Monita, Tipirneni Renuka
University of Michigan Medical School, Ann Arbor, MI, USA.
Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
J Gen Intern Med. 2021 Jun;36(6):1605-1612. doi: 10.1007/s11606-021-06590-2. Epub 2021 Jan 26.
Over half of Americans have not been tested for HIV in their lifetime, and over a third of all HIV diagnoses are made less than a year before progression to AIDS. The Affordable Care Act (ACA) Medicaid expansion of 2014 had potential to improve HIV and other health screenings. We assessed the differential impacts of Medicaid expansion on racial/ethnic and racial/ethnic-sex disparities in HIV testing.
Using Behavioral Risk Factor Surveillance System data from all 50 states and D.C., we sampled low-income (≤ 138% of the federal poverty level) adults ages 19-64 who were non-pregnant and non-disabled. Using a difference-in-differences (DD) and triple difference-in-differences (DDD) study design, we assessed differential impacts by race/ethnicity (White, Black, Hispanic, and other) and race/ethnicity-sex between 2011 and 2013 and 2014-2018. Outcomes were (1) ever having received an HIV test and (2) having received an HIV test in the last year.
Overall, Medicaid expansion was associated with a significant increase in HIV testing (p = 0.003). White females and Black males appeared most likely to benefit from this increase (DD 4.5 and 4.8 percentage points; p = 0.001 and 0.130 respectively). However, despite having baseline higher rates of HIV diagnosis, Black and Hispanic females did not have increased rates of ever having HIV testing following Medicaid expansion (DD - 1.9 and 0.9 percentage points; p = 0.391 and 0.703, respectively), including when compared to a White male reference subgroup and across other race/ethnicity-sex subgroups.
Medicaid expansion was associated with an increased overall probability of HIV testing among low-income, nonelderly adults, but certain groups including Black females were not more likely to benefit from this increase, despite being disproportionately affected by HIV at baseline. Targeted and culturally informed interventions to increase Medicaid enrollment and access to primary care may be needed to expand HIV testing in vulnerable groups.
超过半数的美国人一生中未接受过艾滋病毒检测，超过三分之一的艾滋病毒确诊病例是在病情发展至艾滋病前不到一年时才被发现的。2014年的《平价医疗法案》（ACA）中医疗补助扩大计划有改善艾滋病毒及其他健康筛查的潜力。我们评估了医疗补助扩大计划对艾滋病毒检测方面种族/族裔及种族/族裔-性别的差异影响。
利用来自美国所有50个州及华盛顿特区的行为风险因素监测系统数据，我们抽取了年龄在19至64岁、非孕妇且非残疾的低收入（≤联邦贫困线的138%）成年人作为样本。采用双重差分（DD）和三重差分（DDD）研究设计，我们评估了2011年至2013年以及2014年至2018年期间按种族/族裔（白人、黑人、西班牙裔及其他）和种族/族裔-性别划分的差异影响。结果包括：（1）曾经接受过艾滋病毒检测；（2）在过去一年接受过艾滋病毒检测。
总体而言，医疗补助扩大计划与艾滋病毒检测显著增加相关（p = 0.003）。白人女性和黑人男性似乎最有可能从这一增长中受益（双重差分分别为4.5和4.8个百分点；p分别为0.001和0.130）。然而，尽管黑人及西班牙裔女性的艾滋病毒诊断基线率较高，但在医疗补助扩大计划实施后，她们接受艾滋病毒检测的比例并未增加（双重差分分别为 - 1.9和0.9个百分点；p分别为0.391和0.703），包括与白人男性参照亚组以及其他种族/族裔-性别亚组相比时。
医疗补助扩大计划与低收入、非老年成年人中艾滋病毒检测的总体概率增加相关，但某些群体，包括黑人女性，尽管在基线时受艾滋病毒影响的比例过高，却不太可能从这一增长中受益。可能需要有针对性的、考虑文化因素的干预措施来增加医疗补助登记并改善获得初级保健的机会，以扩大弱势群体中的艾滋病毒检测。
