Fayaz Farkhad Bita, Holtgrave David R, Albarracín Dolores
Department of Psychology, University of Illinois at Urbana-Champaign, Champaign, Illinois.
School of Public Health, University at Albany, Albany, New York.
Am J Prev Med. 2021 Mar;60(3):335-342. doi: 10.1016/j.amepre.2020.10.021. Epub 2021 Jan 25.
Increased insurance coverage and access to health care can increase identification of undiagnosed HIV infection and use of HIV prevention services such as pre-exposure prophylaxis. This study investigates whether the Medicaid expansions facilitated by the Affordable Care Act had these effects.
A difference-in-differences design was used to estimate the effects of the Medicaid expansions using data on HIV diagnoses per 100,000 population, awareness of HIV status, and pre-exposure prophylaxis use. The analyses involved first calculating differences in new diagnoses and pre-exposure prophylaxis use before and after the expansions and then comparing these differences between treatment counties (i.e., all counties in states that expanded Medicaid) and control counties (i.e., all counties in states that did not expand Medicaid). Further analyses to investigate mechanisms addressed associations with HIV incidence, rates of sexually transmitted infections, and substance use. Analyses were conducted between August 2019 and July 2020.
Medicaid expansions were associated with an increase in HIV diagnoses of 0.508 per 100,000 population, or 13.9% (p=0.037), particularly for infections contracted via injection drug use and among low-income, rural counties with a high share of pre-Affordable Care Act uninsured rates that were most likely to be affected by the expansions. In addition, Medicaid expansions were associated with improvements in the knowledge of HIV status and pre-exposure prophylaxis use. There was no impact of the expansions on incident HIV, substance use, or sexually transmitted infection rates with the exception of gonorrhea, which decreased after the expansions. Altogether, these results suggest that the changes in new HIV diagnoses, awareness of HIV status, and pre-exposure prophylaxis were not simply because of a higher incidence or an increase in infection risk.
Medicaid expansions were associated with increases in the percentage of people living with HIV who are aware of their status and pre-exposure prophylaxis use. Expanding public health insurance may be an avenue for curbing the HIV epidemic.
保险覆盖范围的扩大和医疗保健服务可及性的提高，能够增加未确诊艾滋病毒感染的识别率，并促进艾滋病毒预防服务的使用，如暴露前预防。本研究调查了《平价医疗法案》推动的医疗补助扩大计划是否产生了这些效果。
采用差异中的差异设计，利用每10万人中艾滋病毒诊断数据、艾滋病毒感染状况知晓率以及暴露前预防使用情况数据，来估计医疗补助扩大计划的效果。分析过程包括首先计算扩大计划前后新诊断病例和暴露前预防使用情况的差异，然后比较治疗县（即医疗补助扩大的州的所有县）和对照县（即医疗补助未扩大的州的所有县）之间的这些差异。为调查作用机制而进行的进一步分析涉及与艾滋病毒发病率、性传播感染率和药物使用的关联。分析于2019年8月至2020年7月期间进行。
医疗补助扩大计划与每10万人中艾滋病毒诊断病例增加0.508例相关，增幅为13.9%（p = 0.037），特别是通过注射吸毒感染的病例，以及在《平价医疗法案》实施前未参保率较高、最有可能受扩大计划影响的低收入农村县。此外，医疗补助扩大计划与艾滋病毒感染状况知晓率和暴露前预防使用情况的改善相关。扩大计划对艾滋病毒新发感染、药物使用或性传播感染率没有影响，但淋病除外，淋病在扩大计划实施后有所下降。总体而言，这些结果表明，新增艾滋病毒诊断病例、艾滋病毒感染状况知晓率和暴露前预防的变化并非仅仅是因为发病率上升或感染风险增加。
医疗补助扩大计划与知晓自身感染状况并使用暴露前预防的艾滋病毒感染者比例增加相关。扩大公共医疗保险可能是遏制艾滋病毒流行的一条途径。
