Medicaid Expansion Helped Detect Undiagnosed HIV Infections

Medicaid expansion under the Affordable Care Act (ACA) led to increases in the identification of undiagnosed HIV infections and the use of HIV prevention services, according to new research out of the University of Illinois Urbana-Champaign.

The research, co-written by a team of University of Illinois Urbana-Champaign public policy and healthcare experts, found that Medicaid expansion was associated with a 13.9 percent increase in HIV diagnoses.

Newly discovered HIV infections were most common in a cohort likely to be affected by Medicaid expansion: low-income individuals engaged in injection drug use from rural counties with high uninsured rates pre-ACA.

The uptick in new HIV diagnoses, awareness of HIV status, and use of preventive services such as preexposure prophylaxis drugs (PrEP) were not a result of an increase in HIV infections or infection risk, but instead an increase in access to care through Medicaid, based on the study’s findings.

Researchers analyzed HIV diagnosis data from 2010 to 2017, awareness of HIV status, and PrEP use, then compared rates between states that expanded Medicaid under the ACA with those that did not.

The study authors found that as access to health insurance improved, HIV testing increased, leading to a higher rate of people living with HIV who were newly aware of their status.

"We find that HIV diagnoses increased in Medicaid expansion states compared with nonexpansion states, and that the general knowledge that HIV can be prevented through prophylaxis drugs also increased," said Bita Fayaz Farkhad, an economist and a postdoctoral researcher in psychology at Illinois, as well as the study’s lead author.

"When we consider these two findings together, our conclusion is that access to health care and health insurance has increased the percentage of people living with HIV who are aware of their status, which is an important finding for HIV prevention efforts,” said Farkhad. “According to 2016 Centers for Disease Control and Prevention estimates, a high proportion of new HIV infections were transmitted by people who were unaware of their HIV-positive status."

Dolores Albarracín, a professor of psychology and business administration at Illinois and co-author of the study, said that the research negates the popular misconception that the ACA is a failed healthcare policy.

“The Medicaid expansion prong of 'Obamacare' has been quite successful, providing evidence that expanding access to health insurance is associated with improvements in several HIV-related outcomes. This is clearly one measure that is not a failure in terms of people's lives and health,” said Albarracín.

The study also found that most new HIV diagnoses are the result of intravenous drug injection, which is not surprising as the country battles an opioid crisis.

"The increase in injection drug use has led to a greater risk of illness due to needle sharing," Farkhad said. "Because there is no evidence that Medicaid expansions affected substance use, the increase in HIV diagnoses attributed to injection is consistent with the improved access to care among those with substance use disorder.”

The researchers said that the study has important health policy implications.

"For COVID-19, public health officials are constantly emphasizing how important it is for people to test, test, test," Farkhad said. "And it's the same idea here. We show how important it is to have insurance coverage to increase testing, and that those extra tests were necessary and have increased the rate of HIV diagnosis.”

"It also speaks to the role of access to affordable health care plans. Expanding insurance coverage to low-income individuals through Medicaid could facilitate HIV prevention and improve HIV-related health outcomes,” Farkhad continued.