Insurance coverage and financing landscape for HIV treatment and prevention in the USA.

In 2010, the US health insurance system underwent one of its most substantial transformations with the passage of the Affordable Care Act, which increased coverage for millions of people in the USA, including those with and at risk of HIV. Even so, the system of HIV care and prevention services in the USA is a complex patchwork of payers, providers, and financing mechanisms. People with HIV are primarily covered by Medicaid, Medicare, private insurance, or a combination of these; many get care through other programmes, particularly the Ryan White HIV/AIDS Program, which serves as the nation's safety net for people with HIV who remain uninsured or underinsured but offers modest to no support for prevention services. While uninsurance has drastically declined over the past decade, the USA trails other high-income countries in key HIV-specific metrics, including rates of viral suppression. In this paper in the Series, we provide an overview of the coverage and financing landscape for HIV treatment and prevention in the USA, discuss how the Affordable Care Act has changed the domestic health-care system, examine the major programmes that provide coverage and services, and identify remaining challenges.

The G20 and development assistance for health: historical trends and crucial questions to inform a new era.

One of the most important gatherings of the world's economic leaders, the G20 Summit and ministerial meetings, takes place in June, 2019. The Summit presents a valuable opportunity to reflect on the provision and receipt of development assistance for health (DAH) and the role the G20 can have in shaping the future of health financing. The participants at the G20 Summit (ie, the world's largest providers of DAH, emerging donors, and DAH recipients) and this Summit's particular focus on global health and the Sustainable Development Goals offers a unique forum to consider the changing DAH context and its pressing questions. In this Health Policy perspective, we examined trends in DAH and its evolution over time, with a particular focus on G20 countries; pointed to persistent and emerging challenges for discussion at the G20 Summit; and highlighted key questions for G20 leaders to address to put the future of DAH on course to meet the expansive Sustainable Development Goals. Key questions include how to best focus DAH for equitable health gains, how to deliver DAH to strengthen health systems, and how to support domestic resource mobilisation and transformative partnerships for sustainable impact. These issues are discussed in the context of the growing effects of climate change, demographic and epidemiological transitions, and a global political shift towards increasing prioritisation of national interests. Although not all these questions are new, novel approaches to allocating DAH that prioritise equity, efficiency, and sustainability, particularly through domestic resource use and mobilisation are needed. Wrestling with difficult questions in a changing landscape is essential to develop a DAH financing system capable of supporting and sustaining crucial global health goals.

Assessing the impact of the president's emergency plan for AIDS relief on all-cause mortality.

This study estimated the impacts of PEPFAR on all-cause mortality (ACM) rates (deaths per 1,000 population) across PEPFAR recipient countries from 2004-2018. As PEPFAR moves into its 3rd decade, this study supplements the existing literature on PEPFAR 's overall effectiveness in saving lives by focusing impact estimates on the important subgroups of countries that received different intensities of aid, and provides estimates of impact for different phases of this 15-year period study. The study uses a country-level panel data set of 157 low- and middle-income countries (LMICs) from 1990-2018, including 90 PEPFAR recipient countries receiving bilateral aid from the U.S. government, employing difference-in-differences (DID) econometric models with several model specifications, including models with differing baseline covariates, and models with yearly covariates including other donor spending and domestic health spending. Using five different model specifications, a 10-21% decline in ACM rates from 2004 to 2018 is attributed to PEPFAR presence in the group of 90 recipient countries. Declines are somewhat larger (15-25%) in those countries that are subject to PEPFAR's country operational planning (COP) process, and where PEPFAR per capita aid amounts are largest (17-27%). Across the 90 recipient countries we study, the average impact across models is estimated to be a 7.6% reduction in ACM in the first 5-year period (2004-2008), somewhat smaller in the second 5-year period (5.5%) and in the third 5-year period (4.7%). In COP countries the impacts show decreases in ACM of 7.4% in the first period attributed to PEPFAR, 7.7% reductions in the second, and 6.6% reductions in the third. PEPFAR presence is correlated with large declines in the ACM rate, and the overall life-saving results persisted over time. The effects of PEFAR on ACM have been large, suggesting the possibility of spillover life-saving impacts of PEPFAR programming beyond HIV disease alone.

Analysis of economic and educational spillover effects in PEPFAR countries.

The United States President's Emergency Plan for AIDS Relief (PEPFAR) has been credited with saving millions lives and helping to change the trajectory of the global human immunodeficiency virus (HIV) epidemic. This study assesses whether PEPFAR has had impacts beyond health by examining changes in five economic and educational outcomes in PEPFAR countries: the gross domestic product (GDP) per capita growth rate; the share of girls and share of boys, respectively, who are out of school; and female and male employment rates. We constructed a panel data set for 157 low- and middle-income countries between 1990 and 2018 to estimate the macroeconomic impacts of PEPFAR. Our PEPFAR group included 90 countries that had received PEPFAR support over the period. Our comparison group included 67 low- and middle-income countries that had not received any PEPFAR support or had received minimal PEPFAR support (<$1M or <$.05 per capita) between 2004 and 2018. We used differences in differences (DID) methods to estimate the program impacts on the five economic and educational outcome measures. This study finds that PEPFAR is associated with increases in the GDP per capita growth rate and educational outcomes. In some models, we find that PEPFAR is associated with reductions in male and female employment. However, these effects appear to be due to trends in the comparison group countries rather than programmatic impacts of PEPFAR. We show that these impacts are most pronounced in COP countries receiving the highest levels of PEPFAR investment.

Analysis of maternal and child health spillover effects in PEPFAR countries.

OBJECTIVES: This study examined whether the US President's Emergency Plan for AIDS Relief (PEPFAR) funding had effects beyond HIV, specifically on several measures of maternal and child health in low-income and middle-income countries (LMICs). The results of previous research on the question of PEPFAR health spillovers have been inconsistent. This study, using a large, multicountry panel data set of 157 LMICs including 90 recipient countries, adds to the literature. DESIGN: Seven indicators including child and maternal mortality, several child vaccination rates and anaemia among childbearing-age women are important population health indicators. Panel data and difference-in-differences estimators (DID) were used to estimate the impact of the PEPFAR programme from inception in 2004 to 2018 using a comparison group of 67 LMICs. Several different models of baseline (2004) covariates were used to help balance the comparison and treatment groups. Staggered DID was used to estimate impacts since all countries did not start receiving aid at PEPFAR's inception. SETTING: All 157 LMICs from 1990 to 2018. PARTICIPANTS: 90 LMICs receiving PEPFAR aid and cohorts of those countries, including those required to submit annual country operational plans (COP), other recipient countries (non-COP), and three groupings of countries based on cumulative amount of per capita aid received (high, medium, low). INTERVENTIONS: PEPFAR aid to combat the HIV epidemic. PRIMARY OUTCOME MEASURES: Maternal mortality and child mortality rates, vaccination rates to protect children for diphtheria, whooping cough and tetanus, measles, HepB3, and tetanus, and prevalence of anaemia in women of childbearing age. RESULTS: Across PEPFAR recipient countries, large, favourable PEPFAR health effects were found for rates of childhood immunisation, child mortality and maternal mortality. These beneficial health effects were large and significant in all segments of PEPFAR recipient countries studied. We also found significant and favourable programme effects on the prevalence of anaemia in women of childbearing age in PEPFAR recipient countries receiving the most intensive financial support from the PEPFAR programme. Other recipient countries did not demonstrate significant effects on anaemia. CONCLUSIONS: This study demonstrated that important health indicators, beyond HIV, have been consistently and favourably influenced by PEPFAR presence. Child and maternal mortality have been substantially reduced, and childhood immunisation rates increased. We also found no evidence of 'crowding out' or negative spillovers in these resource-poor countries. These findings add to the body of evidence that PEPFAR has had favourable health effects beyond HIV. The implications of these findings are that foreign aid for health in one area may have favourable health effects in other areas in recipient countries. More research is needed on the influence of the mechanisms at work that create these spillover health effects of PEPFAR.

Unmet needs for HIV ancillary care services by healthcare coverage and Ryan White HIV/AIDS program assistance.

OBJECTIVE: To investigate unmet needs for HIV ancillary care services by healthcare coverage type and Ryan White HIV/AIDS Program (RWHAP) assistance among adults with HIV. DESIGN: We analyzed data using the 2017-2019 cycles of the CDC Medical Monitoring Project, an annual, cross-sectional study designed to produce nationally representative estimates of characteristics among adults with diagnosed HIV. METHODS: Unmet need was defined as needing, but not receiving, one or more HIV ancillary care services. We estimated prevalence ratios (PRs) and 95% confidence intervals (CIs) using predicted marginal means to examine associations between healthcare coverage type and unmet needs for HIV ancillary care services, adjusting for age. Associations were stratified by receipt of RWHAP assistance. RESULTS: Unmet needs for HIV ancillary care services were highest among uninsured persons (58.7%) and lowest among those with private insurance living with at least 400% of the federal poverty level (FPL; 21.7%). Uninsured persons who received RWHAP assistance were less likely than those who did not receive RWHAP assistance to have unmet needs for HIV clinical support services (aPR: 0.21; 95% CI: 0.16-0.28) and other medical services (aPR: 0.75; 95% CI: 0.59-0.96), but not subsistence services (aPR: 0.97; 95% CI: 0.74-1.27). Unmet needs for other medical services and subsistence services did not differ by RWHAP assistance among those with Medicaid, Medicare, or other healthcare coverage. CONCLUSIONS: RWHAP helped reduce some needs for uninsured persons. However, with growing socioeconomic inequities following the coronavirus disease 2019 pandemic, expanding access to needed services for all people with HIV could improve key outcomes.

The cost of reaching the 90-90-90 targets: are current investments enough?

PURPOSE OF REVIEW: The 90-90-90 targets were launched with the aim of reaching specific milestones by 2020. To support these targets, modeling has shown that additional resources are needed. This review examines what is known about current investments for HIV in low and middle-income countries, resource needs, and the potential for additional investment. RECENT FINDINGS: Reaching the 90-90-90 targets would place the global community on track to end the AIDS epidemic by 2030, significantly improving health outcomes and reducing future spending needs. Recent analyses indicate, however, that funding has slowed and there is a significant gap in resources needed to reach targets. While some studies have modeled the potential for additional HIV spending based on normative and theoretical benchmarks, there are limitations to such approaches. Others have looked at the potential to increase efficiencies. Even if spending continues at recent rates, there would still be a gap of $6.4 billion in 2020. SUMMARY: There is a significant gap in resources needed to reach the 90-90-90 targets by 2020. It may be possible to reduce the gap through more efficient allocation of resources. In addition, there are efforts underway to mobilize more investment. Ultimately, any gap that remains has implications for health outcomes and future spending.

Potential for additional government spending on HIV/AIDS in 137 low-income and middle-income countries: an economic modelling study.

BACKGROUND: Between 2012 and 2016, development assistance for HIV/AIDS decreased by 20·0%; domestic financing is therefore critical to sustaining the response to HIV/AIDS. To understand whether domestic resources could fill the financing gaps created by declines in development assistance, we aimed to track spending on HIV/AIDS and estimated the potential for governments to devote additional domestic funds to HIV/AIDS. METHODS: We extracted 8589 datapoints reporting spending on HIV/AIDS. We used spatiotemporal Gaussian process regression to estimate a complete time series of spending by domestic sources (government, prepaid private, and out-of-pocket) and spending category (prevention, and care and treatment) from 2000 to 2016 for 137 low-income and middle-income countries (LMICs). Development assistance data for HIV/AIDS were from Financing Global Health 2018, and HIV/AIDS prevalence, incidence, and mortality were from the Global Burden of Disease study 2017. We used stochastic frontier analysis to estimate potential additional government spending on HIV/AIDS, which was conditional on the current government health budget and other finance, economic, and contextual factors associated with HIV/AIDS spending. All spending estimates were reported in 2018 US$. FINDINGS: Between 2000 and 2016, total spending on HIV/AIDS in LMICs increased from $4·0 billion (95% uncertainty interval 2·9-6·0) to $19·9 billion (15·8-26·3), spending on HIV/AIDS prevention increased from $596 million (258 million to 1·3 billion) to $3·0 billion (1·5-5·8), and spending on HIV/AIDS care and treatment increased from $1·1 billion (458·1 million to 2·2 billion) to $7·2 billion (4·3-11·8). Over this time period, the share of resources sourced from development assistance increased from 33·2% (21·3-45·0) to 46·0% (34·2-57·0). Care and treatment spending per year on antiretroviral therapy varied across countries, with an IQR of $284-2915. An additional $12·1 billion (8·4-17·5) globally could be mobilised by governments of LMICs to finance the response to HIV/AIDS. Most of these potential resources are concentrated in ten middle-income countries (Argentina, China, Colombia, India, Indonesia, Mexico, Nigeria, Russia, South Africa, and Vietnam). INTERPRETATION: Some governments could mobilise more domestic resources to fight HIV/AIDS, which could free up additional development assistance for many countries without this ability, including many low-income, high-prevalence countries. However, a large gap exists between available financing and the funding needed to achieve global HIV/AIDS goals, and sustained and coordinated effort across international and domestic development partners is required to end AIDS by 2030. FUNDING: The Bill & Melinda Gates Foundation.

Insurance coverage and access to HIV testing and treatment: considerations for individuals at risk for infection and for those with undiagnosed infection.

The Centers for Disease Control and Prevention estimates that of the approximately 1.2 million people with human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome in the United States, approximately 500,000 are not receiving care for their disease, including approximately 250,000 who do not know they are HIV positive. Although little is known about these 2 subgroups of HIV-infected people, they are likely to be reflective of the larger population of people with HIV infection; that is, they are predominantly racial minorities, more likely to be unemployed and/or poor, and much more likely to be uninsured or dependent on public insurance programs such as Medicaid, compared with the US population overall. In addition, many persons receive a diagnosis of HIV infection late during the course of the disease, and those who are difficult to reach are less likely to receive standard-of-care antiretroviral therapy. New testing initiatives attempting to diagnose infection in persons who do not know their HIV infection status have raised important questions about the funding and program capacity of the current system to handle new patients. Given these challenges and questions, measuring the success of new testing initiatives will be critical but difficult.

HIV incidence and CDC's HIV prevention budget: an exploratory correlational analysis.

BACKGROUND: The central evaluative question about a national HIV prevention program is whether that program affects HIV incidence. Numerous factors may influence incidence, including public investment in HIV prevention. Few studies, however, have examined the relationship between public investment and the HIV epidemic in the United States. METHODS: This 2006 exploratory analysis examined the period from 1978 through 2006 using a quantitative, lagged, correlational analysis to capture the relationship between national HIV incidence and Centers for Disease Control and Prevention's HIV prevention budget in the United States over time. RESULTS: The analyses suggest that early HIV incidence rose in advance of the nation's HIV prevention investment until the mid-1980s (1-year lag correlation, r=0.972, df=2, p <0.05). From that point on, it appears that the nation's investment in HIV prevention became a strong correlate of HIV incidence (1-year lag correlation, r=-0.905, df=18, p <0.05). CONCLUSIONS: This exploratory study provides correlational evidence of a relationship between U.S. HIV incidence and the federal HIV prevention budget over time, and calls for further analysis of the role of funding and other factors that may influence the direction of a nation's HIV epidemic.

Use of a telephone screener to identify a probability sample of gays, lesbians, and bisexuals.

OBJECTIVES: To examine public response to a telephone screener used to identify a probability sample of lesbians, gays, and bisexuals. METHODS: A telephone screener was designed to provide a representative sample of self-identified lesbians, gays, and bisexuals (LGB) in the 30 central cities of the 15 largest Consolidated Metropolitan Areas. RESULTS: Of 14,458 households contacted, 11,612 completed at least part of the survey. Of these, only 2.6% refused or responded "don't know" to the sexual orientation screener question. Respondents from the northeast were more reluctant to answer than respondents from the west. CONCLUSIONS: The use of a screener on a national telephone survey to screen households for self-identified lesbian, gay, and bisexual adults was a successful way to generate a representative sample.

Delivering HIV services to vulnerable populations: an evaluation and research agenda.

In May 2000, the HIV/AIDS Bureau of the Health Resources and Services Administration convened HIV experts from throughout the country to identify new and emerging areas of research needed to guide policy and programmatic decisions on HIV service delivery to vulnerable populations. This article describes the process used to develop an evaluation/research agenda, discusses key findings and recommendations of the conference, and proposes a set of principles to guide the design and conduct of future investigations. Conference participants identified nine major evaluation/research themes that span the continuum of HIV behavioral prevention services and treatment. They recommended focusing future research on questions relevant to populations experiencing rapid rates of increase in HIV infection (for example, women, people of color, and adolescents and young adults) and considering explanatory factors at multiple levels of analysis (individual, clinician, organization, service delivery system, and environment).

Implications of the Affordable Care Act for people with HIV infection and the Ryan White HIV/AIDS Program: what does the future hold?

There are numerous aspects of the Patient Protection and Affordable Care Act that will be important for people in the United States with HIV infection, including consumer protections and private insurance reforms, establishment of health care marketplaces in every state, new benefit standards, Medicare fixes, prevention enhancements, expansion of Medicaid, and health system improvements. However, it is unlikely that these changes will address all the needs of people with HIV infection in the United States. The Ryan White HIV/AIDS Program will thus remain crucial for the provision of adequate health care to HIV-infected individuals, but it will need to change. Changes in the role of the Ryan White HIV/AIDS Program will depend largely on state decisions on Medicaid expansion and health care marketplaces. This article summarizes a presentation by Jennifer Kates, PhD, at the IAS-USA continuing education program held in New York, New York, in April 2013.

Global health diplomacy: advancing foreign policy and global health interests.

Attention to global health diplomacy has been rising but the future holds challenges, including a difficult budgetary environment. Going forward, both global health and foreign policy practitioners would benefit from working more closely together to achieve greater mutual understanding and to advance respective mutual goals.

The role of treaties, agreements, conventions, and other international instruments in global health.

As nations become more reliant on each other for cohesive development of global health policies and practice, and globalization increasingly makes health challenges in one part of the world concerns for all nations, the importance and use of international agreements in framing policy and national commitments have increased. This article reviews international agreements, looking specifically at multilateral instruments or partnerships, to identify those that either directly focus on or encompass health. It defines the different types of agreements, describes the process through which governments enter into these agreements, evaluates the legality of agreements under international law, and assesses participation by member states.