Clients in Uganda accessing preferred differentiated antiretroviral therapy models achieve higher viral suppression and are less likely to miss appointments: a cross-sectional analysis.

INTRODUCTION: The Uganda Ministry of Health recommends facility- and community-based differentiated antiretroviral therapy (DART) models to support person-centred care for eligible clients receiving antiretroviral therapy (ART). Healthcare workers assess client eligibility for one of six DART models upon initial enrolment; however, client circumstances evolve, and their preferences are not routinely adjusted. We developed a tool to understand the proportion of clients accessing preferred DART models and compared the outcomes of clients accessing preferred DART models to the outcomes of clients not receiving preferred DART models. METHODS: We conducted a cross-sectional study. A sample of 6376 clients was selected from 113 referrals, general hospitals and health centres purposely selected from 74 districts. Clients receiving ART accessing care from the sampled sites were eligible for inclusion. Healthcare workers interviewed clients (caretakers of clients under 18), over a 2-week period between January and February 2022 using a client preference tool to elicit whether clients were receiving DART services through their preferred model. Treatment outcomes of viral load test, viral load suppression and missed appointment date were extracted from clients' medical files before or immediately after the interview and de-identified. The descriptive analysis determined the interaction between client preferences and predefined treatment outcomes by comparing outcomes of clients whose care aligned with their preferences to outcomes of clients whose care misaligned with their preferences. RESULTS: Of 25% (1573/6376) of clients not accessing their preferred DART model, 56% were on facility-based individual management and 35% preferred fast-track drug refills model. Viral load coverage was 87% for clients accessing preferred DART models compared to 68% among clients not accessing their preferred model. Viral load suppression was higher among clients who accessed the preferred DART model (85%) compared to (68%) clients who did not access their preferred DART model. Missed appointments were lower at 29% for clients who accessed preferred DART models compared to 40% among clients not enrolled in the DART model of their choice. CONCLUSIONS: Clients who accessed their preferred DART model have better clinical outcomes. Preferences should be integrated throughout health systems, improvement interventions, policies and research efforts to ensure client-centred care and client autonomy.

Medicaid Expansion's Impact on Human Immunodeficiency Virus Outcomes in a Nonurban Southeastern Ryan White HIV/AIDS Program Clinic.

BACKGROUND: Although the Ryan White HIV/AIDS Program supports high-quality human immunodeficiency virus (HIV) care, Medicaid enrollment provides access to non-HIV care. People with HIV (PWH) with Medicaid historically have low viral suppression (VS) rates. In a state with previously high Qualified Health Plan coverage of PWH, we examined HIV outcomes by insurance status during the first year of Medicaid expansion (ME). METHODS: Participants were PWH ages 18-63 who attended ≥1 HIV medical visit/year in 2018 and 2019. We estimated associations of sociodemographic characteristics with ME enrollment prevalence and associations between insurance status and engagement in care and VS. RESULTS: Among 577 patients, 151 (33%) were newly eligible for Medicaid, and 77 (51%) enrolled. Medicaid enrollment was higher for those with incomes <100% federal poverty level (adjusted prevalence ratio, 1.67; 95% confidence interval [CI], 1.00-1.86) compared with others. Controlling for age, income, and 2018 engagement, those with employment-based private insurance (adjusted risk difference [aRD], -8.5%; 95% CI, -16.9 to 0.1) and Medicare (aRD, -12.5%; 95% CI, -21.2 to -3.0) had lower 2019 engagement than others. For those with VS data (n = 548), after controlling for age and baseline VS, those with Medicaid (aRD, -4.0%; 95% CI, -10.3 to 0.3) and with Medicaid due to ME (aRD, -6.2%; 95% CI, -14.1 to -0.8) were less likely to achieve VS compared with others. CONCLUSIONS: Given that PWH who newly enrolled in Medicaid had high engagement in care, the finding of lower VS is notable. The discordance may be due to medication access gaps associated with changes in medication procurement logistics.