Publications
Health Conditions, Health Services Use, and Viral Suppression Patterns in an HIV Special Needs Plan
2024
Kaufman, J.E., Manalel, J., Fusaris, E., Correa, A., Ernst, J., Brennan-Ing, M. (2024, June 30). Health conditions, health services use, and viral suppression patterns in an HIV special needs plan [Poster presentation]. AcademyHealth Annual Research Meeting, Baltimore, MD.
Jennie Kaufman, Jasmine Manalel and Mark Brennan-Ing
Research objective: The purpose of this study was to identify how health conditions and health care use were associated with unsuppressed viral load in a clinical population of people living with HIV.
Study design: This study involved a retrospective analysis of claims data from members of a Medicaid Special Needs Plan in New York City. We used cluster analysis to classify viral suppression patterns among plan members across a four-year period. To examine factors associated with viral suppression patterns, we conducted bivariate analyses and used multinomial logistic regression.
Population studied: We used data from adults age 18 or older who had received a diagnosis of HIV and who were continuously enrolled in the Medicaid plan from 2016 through 2019 (N=3,265). Of these, 2,677 plan members had sufficient viral load data for the current analysis. About half (53%) of the sample identified as non-Hispanic Black, 37% as Hispanic, and 8% as non-Hispanic White. The sample was 61% cisgender male, 32% cisgender female, and 7% transgender/nonbinary. Plan members were classified into five groups: Consistently Suppressed (45%), Became Suppressed (12%), Fluctuated (16%), Became Unsuppressed (12%), and Consistently Unsuppressed (15%).
Principal findings: Sustained viral suppression was negatively associated with the number of physical and behavioral health conditions, and with eligibility for supportive programs, such as Adult Day Health Care (ADHC). Health care use differed significantly by viral suppression category; the Consistently Unsuppressed (CU) group averaged three times as many emergency department (ED) visits per year as the Consistently Suppressed (CS) group, as well as more primary care visits (M=34, compared with M=25 in the CS group). The average annual medical care cost was higher for the CU group ($59,653 per year) than for the other groups, with the lowest average cost ($50,973) in the CS group. The average annual medication cost was lowest in the CU group ($35,198, compared with $38,408 in the CS group), but median medication costs did not differ between the two groups. In the regression analysis, unsuppressed viral load was significantly associated with a nadir CD4 count below 200, drug use, alcohol use, opioid use, ED visits, number of pharmacies used, low HIV medication adherence, and ADHC eligibility, as well as younger age and non-Hispanic Black and Hispanic race/ethnicity.
Conclusions: Given the strong associations between viremia and physical and behavioral health multimorbidity, failure to maintain durable viral suppression appears to be part of a syndrome of poor health in this population, accounting for increased use of health services. Many struggle with HIV medication adherence and viral suppression even while engaged in care.
Implications for policy or practice: Ending the HIV epidemic will require improving the effectiveness of behavioral health care for people living with HIV. Providers and policymakers should support evidence-based approaches, such as case management and peer support, as well as initiatives to address social drivers of health, such as housing stability. Moreover, some people in care may benefit from long-acting injectable antiretroviral medications, which are currently available only to those who have achieved durable viral suppression.