RESUMO
OBJECTIVE: In the United States, one in five newly insurer-approved pre-exposure prophylaxis (PrEP) prescriptions are reversed with over 70% of those reversed, being abandoned. Given the Ending the HIV Epidemic (EHE) initiative's goals, we assessed geographic variations of PrEP reversal and abandonment across EHE and non-EHE counties in the United States. DESIGN: This was a cross-sectional analysis of secondary data. METHODS: Data were collected from Symphony Analytics for adults 18 years and older, with a newly prescribed PrEP claim. Using the proportion of PrEP prescriptions by county, hotspot analysis was conducted utilizing Getis Ord Gi∗ statistics stratified by EHE and non EHE counties. Multivariable logistic regression was used to identify factors associated with residing in hotspots of PrEP reversal or PrEP abandonments. RESULTS: Across 516 counties representing 36,204 patients, the overall PrEP reversal rate was 19.4%, whereas the PrEP abandonment rate was 13.7%. Reversals and abandonments were higher for non-EHE (22.7 and 17.1%) than EHE (15.6 and 10.5%) counties. In both EHE and non-EHE counties, younger age, less education, females, and an out-of-pocket cost of greater than $100, were significantly associated with greater likelihood of residing in hotspots of PrEP reversal or abandonment, while Hispanics, Medicaid recipients, and an out-of-pocket cost of $10 or less had lower likelihood of residing in hotspots of reversal and abandonment. CONCLUSION: Findings indicate the need for implementation of focused interventions to address disparities observed in PrEP reversal and abandonment. Moreover, to improve primary PrEP adherence, national PrEP access programs should streamline and improve PrEP accessibility across different geographic jurisdictions.
Assuntos
Fármacos Anti-HIV , Infecções por HIV , Profilaxia Pré-Exposição , Adulto , Feminino , Humanos , Estados Unidos , Infecções por HIV/prevenção & controle , Infecções por HIV/epidemiologia , Estudos Transversais , Medicaid , Prescrições , Fármacos Anti-HIV/uso terapêuticoRESUMO
BACKGROUND: It is unknown what levels of preexposure prophylaxis (PrEP) use are needed to reduce racial disparities in HIV incidence among men who have sex with men (MSM). Using an agent-based model, we quantified the impact of achieving PrEP coverage targets grounded in equity on racial disparities in HIV incidence among MSM in an urban setting in the Southeastern United States. METHODS: An agent-based model was adapted to simulate HIV transmission in a network of Black/African American and White MSM aged 18-39 years in the Atlanta-Sandy Springs-Roswell metropolitan area over 10 years (2015-2024). Scenarios simulated coverage levels consistent with targets based on the ratio of the number of individuals using PrEP to the number of individuals newly diagnosed in a calendar year (i.e., the 'PrEP-to-need ratio'), ranging from 1 to 10. Incidence rate ratios and differences were calculated as measures of disparities. RESULTS: Without PrEP, the model predicted a rate ratio of 3.82 and a rate difference of 4.50 comparing HIV incidence in Black/African American and White MSM, respectively. Decreases in the rate ratio of at least 50% and in the rate difference of at least 75% were observed in all scenarios in which the PrEP-to-need ratio among Black/African American MSM was 10, regardless of the value among White MSM. CONCLUSION: Significant increases in PrEP use are needed among Black/African American MSM to reduce racial disparities in HIV incidence. PrEP expansion must be coupled with structural interventions to address vulnerability to HIV infection among Black/African American MSM.
Assuntos
Infecções por HIV , Equidade em Saúde , Disparidades em Assistência à Saúde , Profilaxia Pré-Exposição , Grupos Raciais , Minorias Sexuais e de Gênero , Adolescente , Adulto , Negro ou Afro-Americano , Georgia , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Humanos , Incidência , Masculino , População Branca , Adulto JovemRESUMO
Receiving regular HIV care is crucial for maintaining good health among persons with HIV. However, racial and gender disparities in HIV care receipt exist. Discrimination and its impact may vary by race/ethnicity and gender, contributing to disparities. Data from 1578 women in the Women's Interagency HIV Study ascertained from 10/1/2012 to 9/30/2016 were used to: (1) estimate the relationship between discrimination and missing any scheduled HIV care appointments and (2) assess whether this relationship is effect measure modified by race/ethnicity. Self-reported measures captured discrimination and the primary outcome of missing any HIV care appointments in the last 6 months. Log-binomial models accounting for measured sources of confounding and selection bias were fit. For the primary outcome analyses, women experiencing discrimination typically had a higher prevalence of missing an HIV care appointment. Moreover, there was no statistically significant evidence for effect measure modification by race/ethnicity. Interventions to minimize discrimination or its impact may improve HIV care engagement among women.
Assuntos
Discriminação Psicológica , Infecções por HIV/psicologia , Cooperação do Paciente/psicologia , Estigma Social , Saúde da Mulher/etnologia , Adulto , Fármacos Anti-HIV/uso terapêutico , Agendamento de Consultas , Atitude do Pessoal de Saúde , Estudos de Coortes , Etnicidade/estatística & dados numéricos , Feminino , Infecções por HIV/tratamento farmacológico , Disparidades nos Níveis de Saúde , Humanos , Pessoa de Meia-Idade , Participação do Paciente , Prevalência , Estudos Prospectivos , Qualidade de Vida , Estados Unidos/epidemiologiaRESUMO
Our objective was to evaluate the impact of insurance coverage on access to sexual health services among at-risk men. Data were collected from Hispanic/Latino and non-Hispanic White male patients at a publicly funded sexually transmitted disease clinic in a Medicaid expansion state from February to July 2017, using in-depth, semistructured interviews. A coding scheme was applied to interview transcripts with iterative revisions until a final coding scheme was achieved. Data were analyzed using Nvivo 10 software. Three key themes emerged from qualitative analysis: Most participants reported (a) financial barriers, (b) fluctuations in insurance status and challenges with insurance re-enrollment, and (c) lack of access to a provider and discomfort discussing sexual health as barriers to accessing HIV/sexually transmitted disease care in primary care settings. Hispanic/Latino men more frequently cited these barriers compared with non-Hispanic White men. Insurance status and out-of-pocket costs are barriers to sexual health care for at-risk men.
Assuntos
Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Hispânico ou Latino/psicologia , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/economia , Saúde Sexual , População Branca/psicologia , Adulto , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde/economia , Humanos , Entrevistas como Assunto , Masculino , Medicaid , Pesquisa Qualitativa , Serviços de Saúde Reprodutiva , Estados UnidosRESUMO
In the last decade, reductions in HIV incidence have been observed across the United States. However, HIV continues to disproportionately impact gay, bisexual, and other men who have sex with men (MSM). In Rhode Island, rates of HIV diagnoses have decreased by 44% across all groups over the last decade. This success has been the result of close collaboration across multiple sectors. Different prevention approaches, including syringe exchange programs, community-based HIV testing, condom distribution, HIV care and treatment, and pre-exposure prophylaxis (PrEP) have all contributed to the decline in HIV diagnoses across the state. In 2015, Rhode Island became one of the first states to sign on to the Joint United Nations Programme on HIV/AIDS "90-90-90" campaign to end the HIV epidemic by 2030. Intensified and innovative initiatives are needed to improve progress in HIV prevention and treatment, especially in populations who are most at risk.
Assuntos
Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Formulação de Políticas , Serviços Preventivos de Saúde/métodos , Saúde Pública/tendências , Diagnóstico Precoce , Feminino , Infecções por HIV/transmissão , Heterossexualidade/estatística & dados numéricos , Homossexualidade Masculina/estatística & dados numéricos , Humanos , Incidência , Masculino , Rhode Island/epidemiologiaRESUMO
BACKGROUND: Place of residence has been associated with HIV transmission risks. Social capital, defined as features of social organization that improve efficiency of society by facilitating coordinated actions, often varies by neighborhood, and hypothesized to have protective effects on HIV care continuum outcomes. We examined whether the association between social capital and 2 HIV care continuum outcomes clustered geographically and whether sociocontextual mechanisms predict differences across clusters. METHODS: Bivariate Local Moran's I evaluated geographical clustering in the association between social capital (participation in civic and social organizations, 2006, 2008, 2010) and [5-year (2007-2011) prevalence of late HIV diagnosis and linkage to HIV care] across Philadelphia, PA, census tracts (N = 378). Maps documented the clusters and multinomial regression assessed which sociocontextual mechanisms (eg, racial composition) predict differences across clusters. RESULTS: We identified 4 significant clusters (high social capital-high HIV/AIDS, low social capital-low HIV/AIDS, low social capital-high HIV/AIDS, and high social capital-low HIV/AIDS). Moran's I between social capital and late HIV diagnosis was (I = 0.19, z = 9.54, P < 0.001) and linkage to HIV care (I = 0.06, z = 3.274, P = 0.002). In multivariable analysis, median household income predicted differences across clusters, particularly where social capital was lowest and HIV burden the highest, compared with clusters with high social capital and lowest HIV burden. DISCUSSION: The association between social participation and HIV care continuum outcomes cluster geographically in Philadelphia, PA. HIV prevention interventions should account for this phenomenon. Reducing geographic disparities will require interventions tailored to each continuum step and that address socioeconomic factors such as neighborhood median income.
Assuntos
Infecções por HIV/epidemiologia , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Disparidades nos Níveis de Saúde , Capital Social , Análise por Conglomerados , Diagnóstico Tardio/estatística & dados numéricos , Feminino , Infecções por HIV/economia , Infecções por HIV/terapia , Conhecimentos, Atitudes e Prática em Saúde , Inquéritos Epidemiológicos , Humanos , Renda , Masculino , Adesão à Medicação/estatística & dados numéricos , Características de Residência , Apoio Social , Fatores Socioeconômicos , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: In Rhode Island, the Patient Protection and Affordable Care Act has led to over 95% of the state's population being insured. We evaluated insurance coverage and barriers to insurance use among patients presenting for services at the Rhode Island sexually transmitted disease (STD) clinic. METHODS: We analyzed factors associated with insurance coverage and utilization among patients presenting for STD services between July and December 2015. RESULTS: A total of 692 patients had insurance information available; of those, 40% were uninsured. Patients without insurance were more likely than those with insurance to be nonwhite (50% among uninsured, compared with 40% among insured; P = 0.014) and Hispanic or Latino/a (25%, compared with 16%; P = 0.006), and less likely to be men who have sex with men (27%, compared with 39%; P = 0.001). Of those with health insurance, 26% obtained coverage as a result of the Affordable Care Act, and 56% of those were previously uninsured. Among uninsured individuals, barriers to obtaining health insurance included cost and unemployment. Among those with insurance, 43% reported willingness to use insurance for STD services. Barriers to insurance use included concerns about anonymity and out-of-pocket costs. CONCLUSIONS: Despite expanded insurance access, many individuals presenting to the Rhode Island STD Clinic were uninsured. Among those who were insured, significant barriers still existed to using insurance. STD clinics continue to play an important role in providing safety-net STD services in states with low uninsured rates. Both public and private insurers are needed to address financial barriers and optimize payment structures for services.
Assuntos
Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Patient Protection and Affordable Care Act/estatística & dados numéricos , Infecções Sexualmente Transmissíveis/prevenção & controle , Adulto , Instituições de Assistência Ambulatorial/economia , Instituições de Assistência Ambulatorial/estatística & dados numéricos , Feminino , Reforma dos Serviços de Saúde , Gastos em Saúde , Acessibilidade aos Serviços de Saúde , Necessidades e Demandas de Serviços de Saúde , Humanos , Cobertura do Seguro/economia , Seguro Saúde/economia , Masculino , Medicaid/economia , Patient Protection and Affordable Care Act/economia , Rhode Island/epidemiologia , Provedores de Redes de Segurança/economia , Provedores de Redes de Segurança/estatística & dados numéricos , Infecções Sexualmente Transmissíveis/economia , Estados Unidos/epidemiologia , Adulto JovemRESUMO
BACKGROUND: Many of the five million Americans chronically infected with hepatitis C (HCV) are unaware of their infection and are not in care. OBJECTIVE: We implemented and evaluated HCV screening and linkage-to-care interventions in a community setting. DESIGN: We developed a comprehensive, community-based HCV screening and linkage-to-care program in a medically underserved neighborhood with high rates of HCV infection in Philadelphia, Pennsylvania. We provided patient navigation services to enroll uninsured patients in insurance programs, facilitate referrals from primary care physicians and link patients to an HCV infectious disease specialist with intention to treat and cure. PATIENTS: Philadelphia residents were recruited through street outreach. MAIN MEASURES: We measured anti-HCV seroprevalence and diagnosis, linkage and retention in care outcomes for chronically infected patients. KEY RESULTS: We screened 1,301 participants for HCV; anti-HCV seroprevalence was 3.9 % and 2.8% of all patients were chronically infected. Half of chronically infected patients were newly diagnosed; the remaining patients were aware of infection but not in care. We provided confirmatory RNA testing and results, assisted patients with attaining insurance and linked most chronically infected patients to a primary care provider. The biggest barrier to retaining patients in care was obtaining referrals for subspecialty providers; however, we obtained referrals for 64% of chronically infected participants and have retained most in subspecialty HCV care. Several have commenced treatment. CONCLUSIONS: Non-clinical screening programs with patient navigator services are an effective means to diagnose, link, retain and re-engage patients in HCV care. Eliminating referral requirements for subspecialty care might further enhance retention in care for patients chronically infected with HCV.
Assuntos
Serviços de Saúde Comunitária/organização & administração , Hepatite C Crônica/diagnóstico , Navegação de Pacientes/organização & administração , Adulto , Idoso , Administração de Caso/organização & administração , Feminino , Pesquisa sobre Serviços de Saúde/métodos , Humanos , Seguro Saúde/estatística & dados numéricos , Masculino , Programas de Rastreamento/organização & administração , Área Carente de Assistência Médica , Pessoa de Meia-Idade , Pennsylvania , Atenção Primária à Saúde/organização & administração , Avaliação de Programas e Projetos de Saúde , Encaminhamento e Consulta/organização & administração , Assunção de Riscos , Fatores SocioeconômicosRESUMO
OBJECTIVES: We sought to determine the preventive healthcare needs of incarcerated women in the following areas: cervical cancer and breast cancer screening, sexually transmitted infection (STI) screening, hepatitis screening and vaccination, and smoking cessation. METHODS: A cross-sectional interview survey of a random sample of 100 incarcerated women at the Rhode Island Department of Corrections (RIDOC) in Cranston, Rhode Island, was conducted. RESULTS: Participants were 62% white, 11% African American, 13% Hispanic, and 14% of mixed race. Mean age was 35 years. Of those surveyed, 67% reported having had a Papanicolou (Pap) smear in the past year, the strongest predictor of which was having received a Pap smear while incarcerated. Of the inmates >40 years old, 58% reported having had a mammogram in the past 2 years. The majority (88%) reported testing for STIs in the past, and 39% desired testing during their current incarceration. As for hepatitis C, 70% had been tested previously and 37% of those reported testing positive. Hispanics were less likely than whites to have been tested for hepatitis C (OR 0.1). Over half (54%) of the women who reported testing positive for hepatitis C also reported having completed the hepatitis A and B vaccine series. Among smokers (80% of all survey participants), 61% were interested in quitting. Those who had been incarcerated multiple times were less likely to want to quit smoking (OR 0.1). CONCLUSIONS: Incarceration presents a unique opportunity to provide preventive healthcare to high-risk, medically underserved women.
Assuntos
Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde , Serviços Preventivos de Saúde/estatística & dados numéricos , Prisões/estatística & dados numéricos , Populações Vulneráveis/estatística & dados numéricos , Adolescente , Adulto , Estudos Transversais , Feminino , Pessoas Mal Alojadas/psicologia , Pessoas Mal Alojadas/estatística & dados numéricos , Humanos , Cobertura do Seguro/estatística & dados numéricos , Saúde Mental/estatística & dados numéricos , Análise Multivariada , Serviços Preventivos de Saúde/métodos , Rhode Island/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/psicologia , Populações Vulneráveis/etnologia , Adulto JovemRESUMO
BACKGROUND: Little is known about the long-term drug costs associated with treating AIDS in developing countries. Brazil's AIDS treatment program has been cited widely as the developing world's largest and most successful AIDS treatment program. The program guarantees free access to highly active antiretroviral therapy (HAART) for all people living with HIV/AIDS in need of treatment. Brazil produces non-patented generic antiretroviral drugs (ARVs), procures many patented ARVs with negotiated price reductions, and recently issued a compulsory license to import one patented ARV. In this study, we investigate the drivers of recent ARV cost trends in Brazil through analysis of drug-specific prices and expenditures between 2001 and 2005. METHODS AND FINDINGS: We compared Brazil's ARV prices to those in other low- and middle-income countries. We analyzed trends in drug expenditures for HAART in Brazil from 2001 to 2005 on the basis of cost data disaggregated by each ARV purchased by the Brazilian program. We decomposed the overall changes in expenditures to compare the relative impacts of changes in drug prices and drug purchase quantities. We also estimated the excess costs attributable to the difference between prices for generics in Brazil and the lowest global prices for these drugs. Finally, we estimated the savings attributable to Brazil's reduced prices for patented drugs. Negotiated drug prices in Brazil are lowest for patented ARVs for which generic competition is emerging. In recent years, the prices for efavirenz and lopinavir-ritonavir (lopinavir/r) have been lower in Brazil than in other middle-income countries. In contrast, the price of tenofovir is US$200 higher per patient per year than that reported in other middle-income countries. Despite precipitous price declines for four patented ARVs, total Brazilian drug expenditures doubled, to reach US$414 million in 2005. We find that the major driver of cost increases was increased purchase quantities of six specific drugs: patented lopinavir/r, efavirenz, tenofovir, atazanavir, enfuvirtide, and a locally produced generic, fixed-dose combination of zidovudine and lamivudine (AZT/3TC). Because prices declined for many of the patented drugs that constitute the largest share of drug costs, nearly the entire increase in overall drug expenditures between 2001 and 2005 is attributable to increases in drug quantities. Had all drug quantities been held constant from 2001 until 2005 (or for those drugs entering treatment guidelines after 2001, held constant between the year of introduction and 2005), total costs would have increased by only an estimated US$7 million. We estimate that in the absence of price declines for patented drugs, Brazil would have spent a cumulative total of US$2 billion on drugs for HAART between 2001 and 2005, implying a savings of US$1.2 billion from price declines. Finally, in comparing Brazilian prices for locally produced generic ARVs to the lowest international prices meeting global pharmaceutical quality standards, we find that current prices for Brazil's locally produced generics are generally much higher than corresponding global prices, and note that these prices have risen in Brazil while declining globally. We estimate the excess costs of Brazil's locally produced generics totaled US$110 million from 2001 to 2005. CONCLUSIONS: Despite Brazil's more costly generic ARVs, the net result of ARV price changes has been a cost savings of approximately US$1 billion since 2001. HAART costs have nevertheless risen steeply as Brazil has scaled up treatment. These trends may foreshadow future AIDS treatment cost trends in other developing countries as more people start treatment, AIDS patients live longer and move from first-line to second and third-line treatment, AIDS treatment becomes more complex, generic competition emerges, and newer patented drugs become available. The specific application of the Brazilian model to other countries will depend, however, on the strength of their health systems, intellectual property regulations, epidemiological profiles, AIDS treatment guidelines, and differing capacities to produce drugs locally.
Assuntos
Síndrome da Imunodeficiência Adquirida/tratamento farmacológico , Antirretrovirais/economia , Terapia Antirretroviral de Alta Atividade/economia , Custos de Medicamentos/tendências , Programas Nacionais de Saúde/economia , Brasil , Redução de Custos , Países em Desenvolvimento/economia , Medicamentos Genéricos/economia , Fundações/economia , Acessibilidade aos Serviços de Saúde , Humanos , InternacionalidadeRESUMO
Little is known about the long-term drug costs associated with treating AIDS in developing countries.Brazils AIDS treatment program has been cited widely as the developing worlds largest and mostsuccessful AIDS treatment program. The program guarantees free access to highly active antiretroviraltherapy (HAART) for all people living with HIV/AIDS in need of treatment. Brazil produces non-patentedgeneric antiretroviral drugs (ARVs), procures many patented ARVs with negotiated price reductions, andrecently issued a compulsory license to import one patented ARV. In this study, we investigate the driversof recent ARV cost trends in Brazil through analysis of drug-specific prices and expenditures between 2001and 2005.