Drive time to care and retention in HIV care: Rural-urban differences among Medicaid enrollees in the United States South.

PURPOSE: Less than 50% of people with HIV (PWH) in the United States are retained in care, a key step along the HIV care continuum. We examined the impact of geographic access to care on retention in care for urban and rural PWH. METHODS: We used Medicaid claims and clinician data (Medicaid Analytic eXtract and MAX Provider Characteristics, 2009-2012) for 13 Southern states plus the District of Columbia. We calculated drive time from the enrollees' ZIP Code Tabulation Area to their usual source of care. We used generalized estimating equations to examine the association between drive time to care >30 min (versus ≤30 min) and retention in care, overall and stratified by rurality. In sensitivity analysis, we examined the definition of retention in care, states included in the analysis, and enrollee- and care-related characteristics. FINDINGS: The sample included 49,596 PWH. Overall, the association between drive time >30 min and retention was significant, but small (adjusted odds ratio [aOR] 1.01, 95% confidence interval [CI] 1.00, 1.01) and was not significant in urban areas; however, the significance and direction of the association differed in sensitivity analysis. In rural areas, driving >30 min to care was associated with 7% higher odds of retention in care (aOR 1.07, 95% CI 1.05, 1.08) and this association remained significant and positive in nearly all sensitivity analyses. CONCLUSIONS: For PWH in rural areas, greater drive time is consistently associated with greater retention in care. Disentangling the mechanisms of this relationship is a future research priority.

Development and calibration of a mathematical model of HIV outcomes among Rwandan adults: informing equitable achievement of targets in Rwanda.

Background: We developed and calibrated the Central Africa-International epidemiology Databases to Evaluate AIDS (CA-IeDEA) HIV policy model to inform equitable achievement of global goals, overall and across sub-populations, in Rwanda. Methods: We created a deterministic dynamic model to project adult HIV epidemic and care continuum outcomes, overall and for 25 subpopulations (age group, sex, HIV acquisition risk, urbanicity). Data came from the Rwanda cohort of CA-IeDEA, 2004-2020; Rwanda Demographic and Health Surveys, 2005, 2010, 2015; Rwanda Population-based HIV Impact Assessment, 2019; and the literature and reports. We calibrated the model to 47 targets by selecting the 50 best-fitting parameter sets among 20,000 simulations. Calibration targets reflected epidemic (HIV prevalence, incidence), global goals (percentage on antiretroviral therapy (ART) among diagnosed, percentage virally suppressed among on ART) and other (number on ART, percentage virally suppressed) indicators, overall and by sex. Best-fitting sets minimized the summed absolute value of the percentage deviation (AVPD) between model projections and calibration targets. Good model performance was mean AVPD ≤5% across the 50 best-fitting sets and/or projections within the target confidence intervals; acceptable was mean AVPD >5% and ≤15%. Results: Across indicators, 1,841 of 2,350 (78.3%) model projections were a good or acceptable fit to calibration targets. For HIV epidemic indicators, 256 of 300 (85.3%) projections were a good fit to targets, with the model performing better for women (83.3% a good fit) than for men (71.7% a good fit). For global goals indicators, 96 of 100 (96.0%) projections were a good fit; model performance was similar for women and men. For other indicators, 653 of 950 (68.7%) projections were a good or acceptable fit. Fit was better for women than for men (percentage virally suppressed only) and when restricting targets for number on ART to 2013 and beyond. Conclusions: The CA-IeDEA HIV policy model fits historical data and can inform policy solutions for equitably achieving global goals to end the HIV epidemic in Rwanda. High-quality, unbiased population-based data, as well as novel approaches that account for calibration target quality, are critical to ongoing use of mathematical models for programmatic planning.

Healthy Communities for Youth: A Cost Analysis of a Community-Level Program to Prevent Youth Violence.

Youth violence is a national public health concern in USA, especially in resource-constrained urban communities. Between 2018 and 2021, the Healthy Communities for Youth (HCFY) program addressed youth violence prevention in select economically marginalized urban communities, with the HCFY program reducing the likelihood of youth-involved violent crime. Leveraging costs from program expense reports, this study analyzes the costs of the HCFY program in order to inform policymaking and the program's future ongoing implementation. Total HCFY program costs were $821,000 ($290,100 annually including program start-up costs) over the 34-month project period. Operationalization costs contributed the largest share (64.8%), with 45% attributable to intervention coordinators. In the intervention community, the program costs $100 per capita, $1100 per youth-involved crime case, and $8100 per youth-involved violent crime case. Findings were sensitive to the number of youth-involved crime or violent crime cases and costs of high-level program leadership and self-evaluation analysts, with the per youth-involved violent crime case cost ranging between $700 and $1600 over the program period. Analysis of HCFY program costs is an important step in determining the affordability of a community-level program to prevent youth violence in resource-limited urban communities.

Urban-rural disparities in geographic accessibility to care for people living with HIV.

In the United States, people living with HIV (PLWH) in rural areas fare worse along the HIV care continuum than their urban counterparts; this may be due in part to limited geographic access to care. We estimated drive time to care for PLWH, focusing on urban-rural differences. Adult Medicaid enrollees living with HIV and their usual care clinicians were identified using administrative claims data from 14 states (Medicaid Analytic eXtract, 2009-2012). We used geographic network analysis to calculate one-way drive time from the enrollee's ZIP code tabulation area centroid to their clinician's practice address, then examined urban-rural differences using bivariate statistics. Additional analyses included altering the definition of rurality; examining subsamples based on the state of residence, services received, and clinician specialty; and adjusting for individual and county characteristics. Across n = 49,596 PLWH, median drive time to care was 12.8 min (interquartile range 26.3). Median drive time for rural enrollees (43.6 (82.0)) was nearly four times longer than for urban enrollees (11.9 (20.6) minutes, p < 0.0001), and drive times exceeded one hour for 38% of rural enrollees (versus 12% of urban, p < 0.0001). Urban-rural disparities remained in all additional analyses. Sustained efforts to circumvent limited geographic access to care are critical for rural areas.

Brief Report: Physician Reimbursement and Retention in HIV Care: Racial Disparities in the US South.

BACKGROUND: Retention in HIV care remains a national challenge. Addressing structural barriers to care may improve retention. We examined the association between physician reimbursement and retention in HIV care, including racial differences. METHODS: We integrated person-level administrative claims (Medicaid Analytic eXtract, 2008-2012), state Medicaid-to-Medicare physician fee ratios (Urban Institute, 2008, 2012), and county characteristics for 15 Southern states plus District of Columbia. The fee ratio is a standardized measure of physician reimbursement capturing Medicaid relative to Medicare physician reimbursement across states. Generalized estimating equations assessed the association between the fee ratio and retention (≥2 care markers ≥90 days apart in a calendar year). Stratified analyses assessed racial differences. We varied definitions of retention, subsamples, and definitions of the fee ratio, including the fee ratio at parity. RESULTS: The sample included 55,237 adult Medicaid enrollees with HIV (179,002 enrollee years). Enrollees were retained in HIV care for 76.6% of their enrollment years, with retention lower among non-Hispanic Black (76.1%) versus non-Hispanic White enrollees (81.3%, P < 0.001). A 10-percentage point increase in physician reimbursement was associated with 4% increased odds of retention (adjusted odds ratio 1.04, 95% confidence interval: 1.01 to 1.07). In stratified analyses, the positive, significant association occurred among non-Hispanic Black (1.08, 1.05-1.12) but not non-Hispanic White enrollees (0.87, 0.74-1.02). Findings were robust across sensitivity analyses. When the fee ratio reached parity, predicted retention increased significantly overall and for non-Hispanic Black enrollees. CONCLUSION: Higher physician reimbursement may improve retention in HIV care, particularly among non-Hispanic Black individuals, and could be a mechanism to promote health equity.