National Hospitalization Rates and In-Hospital Mortality Rates of HIV-related Opportunistic Infections in the United States, 2011-2018.

BACKGROUND: HIV-related opportunistic infections (OIs) cause substantial morbidity and mortality among people with HIV (PWH). US hospitalization and in-hospital mortality rates associated with OIs have not been published using data from the past decade. METHODS: We analyzed the National Inpatient Sample (NIS) for the years 2011 through 2018. We used sociodemographic, financial, and hospital-level variables and identified hospitalizations for PWH and OI diagnoses. Using survey-weighted methods, we estimated all OI-related US hospitalization rates and in-hospital mortality per 100,000 PWH and modeled associated factors using survey-based multivariable logistic regression techniques. FINDINGS: From 2011-2018, there were an estimated 1,710,164 (95% CI 1,659,566-1,760,762) hospital discharges for PWH with 154,430 (95% CI 148,669-159,717; 9.2%) associated with an OI, of which 9,336 (95% CI 8,813-9,857; 6.0%) resulted in in-hospital mortality. Variables associated with higher odds of OI-related hospitalizations (compared to without an OI) included younger age (Likelihood Ratio (LR) p < 0.001), male sex (LR p < 0.001), non-white race/ethnicity (LR p < 0.001) and being uninsured (LR p < 0.001). Higher OI-related mortality was associated with older age (LR p < 0.001), male sex (LR p = 0.001), Hispanic race/ethnicity (LR p < 0.001), and being uninsured (LR p = 0.009). The OI-related hospitalization rate fell from 2,725.3 (95% CI 2,266.9-3,183.7) per 100,000 PWH in 2011 to 1,647.3 (95% CI 1,492.5-1,802.1) in 2018 (p < 0.001), but the proportion of hospitalizations with mortality was stable (5.9% in 2011 and 2018). INTERPRETATION: Our findings indicate an ongoing need for continued funding of HIV testing, health insurance for all PWH, OI screening initiatives, review of current prophylaxis guidelines, and recruitment of more HIV clinicians.

Development of an Interdisciplinary Telehealth Model of Provider Training and Comprehensive Care for Hepatitis C and Opioid Use Disorder in a High-Burden Region.

BACKGROUND: Hepatitis C virus (HCV) and the opioid epidemic disproportionately affect the Appalachian region. Geographic and financial barriers prevent access to specialty care. Interventions are needed to address the HCV-opioid syndemic in this region. METHODS: We developed an innovative, collaborative telehealth model in Southwest Virginia featuring bidirectional referrals from and to comprehensive harm reduction (CHR) programs and office-based opioid therapy (OBOT), as well as workforce development through local provider training in HCV management. We aimed to (1) describe the implementation process of provider training and (2) assess the effectiveness of the telehealth model by monitoring patient outcomes in the first year. RESULTS: The provider training model moved from a graduated autonomy model with direct specialist supervision to a 1-day workshop with parallel tracks for providers and support staff followed by monthly case conferences. Forty-four providers and support staff attended training. Eight providers have begun treating independently. For the telehealth component, 123 people were referred, with 62% referred from partner OBOT or CHR sites; 103 (84%) attended a visit, 93 (76%) completed the treatment course, and 61 (50%) have achieved sustained virologic response. Rates of sustained virologic response did not differ by receipt of treatment for opioid use disorder. CONCLUSIONS: Providers demonstrated a preference for an in-person training workshop, though further investigation is needed to determine why only a minority of those trained have begun treating HCV independently. The interdisciplinary nature of this program led to efficient treatment of hepatitis C in a real-world population with a majority of patients referred from OBOTs and CHR programs.

Evidence From a Multistate Cohort: Enrollment in Affordable Care Act Qualified Health Plans' Association With Viral Suppression.

BACKGROUND: Healthcare delivery changes associated with viral suppression (VS) could contribute to the United States' "Ending the HIV Epidemic" (EtHE) initiative. This study aims to determine whether Qualified Health Plans (QHPs) purchased by AIDS Drug Assistance Programs (ADAPs) are associated with VS for low-income people living with HIV (PLWH) across 3 states. METHODS: A multistate cohort of ADAP clients eligible for ADAP-funded QHPs were studied (2014-2015). A log-binomial model was used to estimate the association of demographics and healthcare delivery factors with QHP enrollment prevalence and 1-year risk of VS. A number needed to treat/enroll (NNT) for 1 additional person to achieve viral suppression was calculated. RESULTS: Of the cohort (n = 7776), 52% enrolled in QHPs. QHP enrollment in 2015 was associated with QHP coverage in 2014 (adjusted PR [aPR], 3.28; 95% confidence intervals [CIs], 3.06-3.53) and engagement in care in 2014 (aPR, 1.16; 1.04-1.28). PLWH who were engaged in care (n = 4597) and had QHPs had a higher VS rate than those who received medications from Direct ADAP (86.0% vs 80.2%). QHPs' NNT for an additional person to achieve VS is 20 (14.1-34.5). Starting undetectable (adjusted risk ratio [aRR], 1.39; 1.28-1.52) and enrolling in QHPs in 2015 (aRR, 1.06; 0.99-1.14) was associated with VS. CONCLUSIONS: Once enrolled in ADAP-funded QHPs, ADAP clients stay enrolled. Enrollment is associated with VS across states/demographic groups. ADAPs, especially in the South and in Medicaid nonexpansion states, should consider investing in QHPs because increased enrollment could improve VS rates. This evidence-based intervention could be part of EtHE.

A qualitative study of perceived barriers to hepatitis C care among people who did not attend appointments in the non-urban US South.

BACKGROUND: Most people diagnosed with hepatitis C virus (HCV) have not linked to care, despite the availability of safe and effective treatment. We aimed to understand why people diagnosed with HCV have not pursued care in the non-urban Southern United States. METHODS: We conducted a survey and semi-structured interview with participants referred to an HCV clinic who did not attend an appointment between 2014 and 2018. Our clinic is located in a non-urban region of Virginia at a university hospital. Qualitative data collection was guided by the Health Belief Model (HBM). Data was analyzed using qualitative content analysis to identify key factors influencing patient perceptions regarding HCV and pursuit of care. RESULTS: Over half of previously referred patients (N = 200) could not be reached by phone. Eleven participants enrolled, including 7 men and 4 women. Based on survey responses, unreliable transportation, unstable housing, substance use, and lack of insurance were common. Participants demonstrated good knowledge of HCV disease, complications, and treatment. On qualitative analysis of semi-structured interviews, final themes emerged from within and between HBM constructs. Emerging themes influencing patient perceptions included (1) structural barriers, (2) stigma, (3) prior experiences of HCV disease and treatment, (4) discordance between the recognized severity of HCV and expected impacts on one's own health, and (5) patient-provider relationship. Substance use was not identified to be a barrier to care. CONCLUSIONS: Participants perceived individual and structural barriers to linking to care. A strong HCV knowledge base was not sufficient to motivate pursuit of care. Efforts to improve linkage to care must address barriers at multiple levels, and system-level changes are needed. As the majority of previously referred patients could not be contacted by phone, current approaches to patient engagement are not effective for reaching these populations. Expansion of HCV care to primary care settings with an established patient-provider relationship or co-located treatment within substance use treatment programs may serve to increase access to HCV treatment.

National Survey of United States Human Immunodeficiency Virus Medical Providers' Knowledge and Attitudes About the Affordable Care Act.

Background: The Affordable Care Act (ACA) affects United States' healthcare by offering Medicaid expansion and tax subsidies to persons with low incomes, and its interaction with the current human immunodeficiency virus (HIV) healthcare delivery system is complex. The objective was to explore HIV medical providers' knowledge and attitudes about the ACA. Methods: HIV medical providers were emailed a weblink to a survey. Descriptive statistics, Mann-Whitney U tests, and binary logistic regression were performed. Results: Of the 253 survey participants, the majority (61%) answered all 4 knowledge questions correctly. About 70% knew whether or not their state had decided to expand Medicaid. About 1 in 10 did not know if the ACA eliminated the Ryan White Program. When rating whether the ACA would improve their patients' HIV outcomes from 1-5 with 5 as "strongly agree," the providers' mean responses varied by state Medicaid status: 3.78 (standard deviation [SD], 0.83) for Medicaid expansion compared with 3.37 (SD, 1.00) for Medicaid nonexpansion (P = .002). Adjusting for medical provider type, years of HIV practice, and sources of ACA information, correct ACA knowledge was associated with providing care in a Medicaid nonexpansion state (adjusted odds ratio [aOR], 2.07; 95% confidence interval [CI], 1.11-3.88), obtaining knowledge from case managers (aOR, 1.89; 95% CI, 1.03-3.48), and obtaining knowledge from newspapers/magazines (aOR, 1.94; 95% CI, .99-3.81). Conclusions: Medical providers in Medicaid expansion states were more optimistic about the ACA's likelihood to improve their patients' HIV outcomes. There are gaps in HIV medical providers' understanding of the ACA. Education could enhance systems-based practice.

Erratum to: Hospital days attributable to immune reconstitution inflammatory syndrome in persons living with HIV before and after the 2012 DHHS HIV guidelines.

[This corrects the article DOI: 10.1186/s12981-017-0152-0.].

Affordable Care Act Qualified Health Plan Coverage: Association With Improved HIV Viral Suppression for AIDS Drug Assistance Program Clients in a Medicaid Nonexpansion State.

BACKGROUND: With the Patient Protection and Affordable Care Act, many state AIDS Drug Assistance Programs (ADAPs) shifted their healthcare delivery model from direct medication provision to purchasing qualified health plans (QHPs). The objective of this study was to characterize the demographic and healthcare delivery factors associated with Virginia ADAP clients' QHP enrollment and to assess the relationship between QHP coverage and human immunodeficiency virus (HIV) viral suppression. METHODS: The cohort included persons living with HIV who were enrolled in the Virginia ADAP (n = 3933). Data were collected from 1 January 2013 through 31 December 2014. Multivariable binary logistic regression was conducted to assess for associations with QHP enrollment and between QHP coverage and viral load (VL) suppression. RESULTS: In the cohort, 47.1% enrolled in QHPs, and enrollment varied significantly based on demographic and healthcare delivery factors. In multivariable binary logistic regression, controlling for time, age, sex, race/ethnicity, and region, factors significantly associated with achieving HIV viral suppression included QHP coverage (adjusted odds ratio, 1.346; 95% confidence interval, 1.041-1.740; P = .02), an initially undetectable VL (2.809; 2.174-3.636; P < .001), HIV rather than AIDS disease status (1.377; 1.049-1.808; P = .02), and HIV clinic (P < .001). CONCLUSIONS: QHP coverage was associated with viral suppression, an essential outcome for individuals and for public health. Promoting QHP coverage in clinics that provide care to persons living with HIV may offer a new opportunity to increase rates of viral suppression.

PPACA and Low-Income People Living with HIV: 2014 Qualified Health Plan Enrollment in a Medicaid Nonexpansion State.

People living with human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) often are uninsured or underinsured, and they may benefit from the Patient Protection and Affordable Care Act (PL 111-148) and its improved access to medical care. Safety net programs, such as AIDS Drug Assistance Programs (ADAP) funded through the Ryan White HIV/AIDS Program, which serve low-income people living with HIV, are incorporating Patient Protection and Affordable Care Act Marketplace-qualified health plans (QHPs) and helping to fund patients' participation. This changing landscape differs from state to state, and one main element contributing to the differing situations is whether a state elected to expand Medicaid. This review examines QHP enrollment of ADAP clients in Virginia, a Medicaid nonexpansion state, and explores some issues that affect people living with HIV in other Medicaid nonexpansion states. Virginia is a leader in the shift of ADAP healthcare delivery from direct medication provision to purchasing QHPs. Virginia ADAP clients accounted for approximately 2% of ADAP clients nationally, but they represent 17% of ADAP clients enrolled in QHPs nationwide. Ensuring good HIV care of the ADAP population is important to each patient's personal longevity, the public health, and the efficient use of healthcare dollars. As healthcare delivery models shift, the effects on patients and health outcomes achieved should be monitored, particularly for chronic diseases such as HIV.

Spatial Accessibility and Uptake of Pediatric COVID-19 Vaccinations by Social Vulnerability.

BACKGROUND AND OBJECTIVES: Geographic accessibility predicts pediatric preventive care utilization, including vaccine uptake. However, spatial inequities in the pediatric coronavirus disease 2019 (COVID-19) vaccination rollout remain underexplored. We assessed the spatial accessibility of vaccination sites and analyzed predictors of vaccine uptake. METHODS: In this cross-sectional study of pediatric COVID-19 vaccinations from the US Vaccine Tracking System as of July 29, 2022, we described spatial accessibility by geocoding vaccination sites, measuring travel times from each Census tract population center to the nearest site, and weighting tracts by their population demographics to obtain nationally representative estimates. We used quasi-Poisson regressions to calculate incidence rate ratios, comparing vaccine uptake between counties with highest and lowest quartile Social Vulnerability Index scores: socioeconomic status (SES), household composition and disability (HCD), minority status and language (MSL), and housing type and transportation. RESULTS: We analyzed 15 233 956 doses administered across 27 526 sites. Rural, uninsured, white, and Native American populations experienced longer travel times to the nearest site than urban, insured, Hispanic, Black, and Asian American populations. Overall Social Vulnerability Index, SES, and HCD were associated with decreased vaccine uptake among children aged 6 months to 4 years (overall: incidence rate ratio 0.70 [95% confidence interval 0.60-0.81]; SES: 0.66 [0.58-0.75]; HCD: 0.38 [0.33-0.44]) and 5 years to 11 years (overall: 0.85 [0.77-0.95]; SES: 0.71 [0.65-0.78]; HCD: 0.67 [0.61-0.74]), whereas social vulnerability by MSL was associated with increased uptake (6 months-4 years: 5.16 [3.59-7.42]; 5 years-11 years: 1.73 [1.44-2.08]). CONCLUSIONS: Pediatric COVID-19 vaccine uptake and accessibility differed by race, rurality, and social vulnerability. National supply data, spatial accessibility measurement, and place-based vulnerability indices can be applied throughout public health resource allocation, surveillance, and research.

Managing Modern Antiretroviral Therapy in the Intensive Care Unit: Overcoming Challenges for Critically Ill People With Human Immunodeficiency Virus.

People with human immunodeficiency virus (HIV) have a 50% excess risk for intensive care unit (ICU) admission, often for non-HIV-related conditions. Despite this, clear guidance for managing antiretroviral therapy (ART) in this setting is lacking. Selecting appropriate ART in the ICU is complex due to drug interactions, absorption issues, and dosing adjustments. Continuing ART in the ICU can be challenging due to organ dysfunction, drug interactions, and formulary limitations. However, with careful consideration, continuation is often feasible through dose adjustments or alternative administration methods. Temporary discontinuation of ART may be beneficial depending on the clinical scenario. Clinicians should actively seek resources and support to mitigate adverse events and drug interactions in critically ill people with HIV. Navigating challenges in the ICU can optimize ART and improve care and outcomes for critically ill people with HIV. This review aims to identify strategies for addressing the challenges associated with the use of modern ART in the ICU.

Access to a novel first-line single-tablet HIV antiretroviral regimen in Affordable Care Act Marketplace plans, 2018-2020.

BACKGROUND: A pillar of the United States' Ending the HIV Epidemic (EHE) initiative is to rapidly provide antiretroviral therapy (ART) in order to achieve HIV viral suppression. However, insurance benefit design can impede ART access. The primary objective of this study is to understand how Affordable Care Act (ACA) Marketplace qualified health plan (QHP) formularies responded to two new ART single tablet regimens (STRs): dolutegravir/abacavir/lamivudine (DTG/ABC/3TC; approved in 2014) and bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF; approved in 2018). METHODS: We conducted a descriptive study of individual and small group QHPs to assess coverage, cost sharing (coinsurance vs. copay), specialty tiering, prior authorization, and out-of-pocket (OOP) costs for DTG/ABC/3TC and BIC/FTC/TAF. All individual and small group QHPs offered in state ACA Marketplaces from 2018-2020 were identified using plan-level formulary data from Ideon linked to end-of-year data from Robert Wood Johnson Foundation's Individual Market Health Insurance Exchange (HIX). RESULTS: For 2018, 2019, and 2020, respectively, we identified 19,533, 17,007, and 21,547 QHPs. While DTG/ABC/3TC coverage was above 91% from 2018-2020, BIC/FTC/TAF coverage improved from 60 to 86%. Coverage of BIC/FTC/TAF improved in EHE priority jurisdictions from 73 to 90% driven by increased coverage with coinsurance. Although BIC/FTC/TAF had a higher wholesale acquisition cost than DTG/ABC/3TC, monthly OOP cost trends differed regionally in the Midwest but did not differ by EHE priority jurisdiction status. CONCLUSIONS: QHP coverage of STRs is heterogeneous across the US. While coverage of BIC/FTC/TAF increased over time, many QHPs in EHE priority jurisdictions required coinsurance. Access to new ART regimens may be slowed by delayed QHP coverage and benefit design.

Geographic Variation in Qualified Health Plan Coverage and Prior Authorization Requirements for HIV Preexposure Prophylaxis.

Importance: HIV preexposure prophylaxis (PrEP) is a key component of the Ending the HIV Epidemic (EHE) Initiative to curb new HIV diagnoses. In October 2019, emtricitabine/tenofovir alafenamide was added as an approved formulation for PrEP in addition to emtricitabine/tenofovir disoproxil fumarate; despite availability of another formulation with a similar prevention indication, variations in coverage may limit access. Objective: To assess qualified health plan (QHP) coverage, prior authorization (PA) requirements, and specialty tiering for emtricitabine/tenofovir disoproxil fumarate and emtricitabine/tenofovir alafenamide following emtricitabine/tenofovir alafenamide approval as a PrEP treatment. Design, Setting, and Participants: This cross-sectional study analyzed QHPs in the US that were compliant with the Patient Protection and Affordable Care Act from 2018 to 2020. QHPs were categorized by region and EHE priority jurisdictions. Data analysis occurred from March 2022 to March 2023. Exposures: Enrollment in a qualified health plan certified by the Patient Protection and Affordable Care Act. Main Outcome and Measures: Annual variation in QHP coverage and PA requirement for emtricitabine/tenofovir disoproxil fumarate and/or emtricitabine/tenofovir alafenamide. Descriptive statistics were reported for all outcomes. A secondary outcome was whether the PrEP formulation was determined by the QHP to be placed on a specialty drug tier. Results: A total of 58 087 QHPs (19 533 for 2018; 17 007 for 2019; and 21 547 for 2020) were analyzed. QHPs covered emtricitabine/tenofovir disoproxil fumarate (19 165 QHPs [98.1%] in 2018; 16 970 QHPs [99.8%] in 2019; 20 045 QHPs [94.8%] in 2020) at a higher rate than emtricitabine/tenofovir alafenamide (17 391 QHPs [91.9%] in 2018; 15 757 QHPs [92.7%] in 2019; 18 836 QHPs [87.4%] in 2020). QHPs in the South required exclusive PA (ie, PA for 1 of the formulations even if the QHP covered both) for emtricitabine/tenofovir disoproxil fumarate and emtricitabine/tenofovir alafenamide at the highest rates in all 3 years. In the South, the rate of PA for emtricitabine/tenofovir disoproxil fumarate increased from 806 of 8023 QHPs (10.0%) in 2018 to 3466 of 7401 QHPs (46.8%) in 2020. QHPs with exclusive PA requirement for emtricitabine/tenofovir disoproxil fumarate were higher in EHE jurisdictions than non-EHE jurisdictions (difference: 2018, 0.9 percentage points; 2019, 3.5 percentage points; 2020, 29.1 percentage points). QHPs were more likely to place emtricitabine/tenofovir disoproxil fumarate on a specialty tier compared with emtricitabine/tenofovir alafenamide (difference: 2018, 1.8 percentage points; 2019, 3.7 percentage points; 2020, 4.1 percentage points). Conclusions and Relevance: In this cross-sectional study, despite similar indications for biomedical prevention, QHPs were more likely to cover emtricitabine/tenofovir disoproxil fumarate than emtricitabine/tenofovir alafenamide, and QHPs were also more likely to subject emtricitabine/tenofovir disoproxil fumarate to PA or place it on a specialty tier despite the broader clinical indication. QHP PA requirements of emtricitabine/tenofovir disoproxil fumarate following emtricitabine/tenofovir alafenamide approval does not reflect clinical guidelines. The requirements could reflect differences in clinical indication, manufacturer discounts, or anticipation of a changing regulations and emerging generics. High rates of exclusive PA for emtricitabine/tenofovir disoproxil fumarate in areas where rates of HIV diagnoses are highest and PrEP is most needed (eg, the South and EHE priority jurisdictions) is concerning; policy solutions to address the growing PrEP health equity crisis could include regulator actions and a national PrEP program.

Ryan White HIV/AIDS Part B and AIDS Drug Assistance Programs during COVID-19: safety net public health programs' challenges and innovations.

Introduction: We characterized the challenges and innovations of states' Ryan White HIV/AIDS Program (RWHAP) Part B programs, including AIDS Drug Assistance Programs (ADAPs), during the COVID-19 pandemic. In the United States, these are important safety net programs for HIV healthcare, providing essential medical and support services, and medications, to people with HIV with low incomes who are uninsured/underinsured. Methods: Data were collected via the 2021-2022 NASTAD National RWHAP Part B and ADAP Monitoring Project Report, a cross-sectional survey of state, district, and territorial programs through a mixed method study design. For quantitative data, we used descriptive statistics. Qualitative responses were coded and analyzed using content analysis. Results: Forty-seven RWHAP Part B and ADAPs responded (92% response rate). The majority of respondents reported that maintaining client eligibility (78%) and working remotely (70%) were the most challenging aspects of the pandemic, particularly in regards to implementing new telehealth and e-certification platforms. In response to COVID-19, programs introduced enrollment "grace periods" (19%), bolstered client outreach (11%), allowed more than a 30 day supply of medications (79%), and supported medication home delivery for clients (80%). Discussion: Despite the challenges of the COVID-19 pandemic, RWHAP Part B and ADAPs implemented several operational innovations in order to continue providing essential medicines and services. Other public health programs may adopt similar innovations, including digital innovations, for greater public health benefit. Future studies should assess the retention of policy innovations over time, their impact on the individual client level satisfaction or health outcomes, and what factors may improve the acceptability of telehealth and e-certification platforms.

Access to Medications for Opioid Use Disorder for Persons With Human Immunodeficiency Virus in the United States: Gaps in Coverage by State AIDS Drug Assistance Programs.

Life-saving medications for opioid use disorder are inaccessible for people with human immunodeficiency virus relying on the AIDS Drug Assistance Programs (ADAP) in 40% of jurisdictions. Funding/policies should address this through increasing access through ADAP and the Ryan White HIV/AIDS Program (RWHAP), partnerships between RWHAP and substance use programs, and other state/federal initiatives.

Economic benefits of the United States' AIDS drug assistance Program: A systematic review of cost analyses to guide research and policy priorities.

As part of the Ryan White HIV/AIDs Program, the federally-funded, state-administered AIDS Drug Assistance Program (ADAP) provides prescription drug medications, including antiretroviral therapy, for people with HIV (PWH) who are uninsured/underinsured and have a low income. ADAP expenditures are ∼$2.4 billion annually, but there is a dearth of formal economic analysis supporting the societal perspective. We conducted a systematic review of economic analyses of the United States' AIDS Drug Assistance Program to establish future research priorities based on gaps in knowledge. We searched six electronic databases for articles published before January 2022 that met inclusion criteria. We used the 2022 Consolidated Health Economic Evaluation Reporting Standards to assess the quality of reporting of the economic evaluations. We extracted data into categories to assess gaps and needs for future economic evaluation. Seven studies met inclusion criteria. Two used the same modeling approaches but were published with slightly different outcomes. The few economic analyses that focused solely on ADAP were conducted using 2008 or older data. The most recent study modeled the net cost per quality-adjusted life-year (QALY) secondary to reducing new HIV cases among those virally suppressed, but did not include the economic or health benefits for PWH. ADAP programs' delivery of antiretroviral therapy has shifted from primarily direct provision to subsidizing insurance plans. None of the models take these shifts into account. Updated person-centered cost effectiveness models assessing ADAP are needed on a national and state-by-state level to guide policy decisions and coverage determinations.

Patient Perspective of People with HIV Who Gained Medicaid Through Medicaid Expansion: A Cross-Sectional Qualitative Study.

Given the large numbers of people with HIV (PWH) with Medicaid coverage, it is important to understand the patient experience with Medicaid. Understanding experiences with and attitudes around the program have important policy and clinical implications. The objective was to understand the patient perspective of PWH in Virginia, who transitioned to Medicaid in 2019 due to Medicaid expansion. English-speaking PWH who gained Medicaid due to Medicaid expansion in 2019 were recruited at one Virginia Ryan White HIV/AIDS Program clinic. The goal was to enroll >33% of those who newly were on Medicaid for 2019. Participants were surveyed about demographic characteristics, and semistructured interviews were performed. Descriptive analyses were performed for cohort characteristics. Using qualitative description and an open coding strategy, codebooks were generated for the interviews and themes were identified. The cohort (n = 28) met our recruitment goal. Most participants had positive feelings about Medicaid before enrollment (general: 68%; good for general health: 75%, and good for HIV care: 67%) and after enrollment (general: 93% and good for HIV care: 93%). All participants expressed incomplete understanding about Medicaid before enrollment. Seventy-nine percent needed outside help to complete enrollment. Approximately 40% described overlaps of Medicaid with other insurance/payers or gaps in insurance coverage when transitioning from one insurance/payer (such as AIDS Drug Assistance Program [ADAP] medication provision and ADAP-subsidized insurance) to Medicaid. Participants suggested more access or easier access to information about Medicaid and more explanation of Medicaid benefits would be helpful. Our findings indicate participants had mostly positive perceptions of Medicaid before and after enrollment. Even with enrollment help, participants voiced that dealing with insurance is hard. Medicaid and other programs should prioritize more access to information, smoother processes, and less burdensome enrollment/re-enrollment.

A Missed Opportunity: Extragenital Screening for Gonorrhea and Chlamydia Sexually Transmitted Infections in People With HIV in a Southeastern Ryan White HIV/AIDS Program Clinic Setting.

Background: Guidelines recommend annual screening for gonorrhea/chlamydia in sexually active people with HIV at multiple sites (urogenital, oropharyngeal, rectal). In the first year of multisite screening at our Ryan White HIV/AIDS Program clinic, we studied (1) sexual history documentation rate, (2) sexually transmitted infection (STI) screening rate, (3) characteristics associated with STIs, and (4) the percentage of extragenital STIs that would have been missed without multisite screening. Methods: Participants were ≥14 years old with ≥1 in-person medical visit at our clinic in 2019. Descriptive analyses were performed, and adjusting for number of sites tested, a log-binomial model was used to estimate the association between characteristics and STI diagnosis in men. Results: In this cohort (n = 857), 21% had no sexual history recorded. Almost all STI diagnoses were among males (99.3%). Sixty-eight percent (253/375) received appropriate urogenital testing, 63% (85/134) received appropriate oropharyngeal testing, and 69% (72/105) received appropriate rectal testing. In male participants with ≥1 STI test (n = 347), Hispanic ethnicity and having a detectable HIV viral load were associated with an STI diagnosis. Of those diagnosed with an STI who had multisite testing, 96% (n = 25/26) were positive only at an extragenital site. Conclusions: Screening rates were similar across all anatomical sites, indicating no obvious bias against extragenital testing. In males, STIs were more frequently diagnosed in people who identify as Hispanic and those with detectable viral loads, which may indicate more condomless sex in these populations. Based on infections detected exclusively at extragenital sites, our clinic likely underdiagnosed STIs before implementation of multisite screening.

Worsening Disparities in State-Level Uptake of Human Immunodeficiency Virus Preexposure Prophylaxis, 2014-2018.

Retrospective analysis of human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) use among individuals with PrEP indications demonstrates worsening disparities in uptake between early- and late-adopting states from 2014 to 2018. To end the HIV epidemic, federal and state governments must close gaps by translating successful policies from early-adopting states to late-adopting states.