How ACA affects vulnerable Americans living with HIV/AIDS

March 3, 2014

A series of papers in the March issue of Health Affairs examines how the Affordable Care Act could affect two sectors of the most vulnerable Americans—those living with HIV/AIDS and people who have recently cycled through jail.

The issue features several studies by researchers with the USC Schaeffer Center for Health Policy and Economics, one of the nation's premier policy research centers dedicated to promoting health and value in healthcare delivery through innovative research and policy, including:

When it comes to HIV treatment, timing is everything

Dana P. Goldman, Leonard D. Schaeffer Chair and Director of the USC Schaeffer Center for Health Policy and Economics, and coauthors modeled HIV transmission and prevention based on when HIV-positive individuals started combination (cART). The researchers estimate that from 1996 to 2009, early treatment initiation in the United States prevented 188,700 new HIV cases and avoided $128 billion in losses.

In particular, the researchers highlight treatment at "very early" stages as responsible for four-fifths of prevented cases. They define early treatment as when CD4 white blood cell counts are greater than 500, consistent with current treatment guidelines in the United States.

Early treatment both reduces morbidity and mortality in people living with HIV/AIDS, and decreases the transmission of the disease to the uninfected. The authors conclude that early treatment has clear value for both HIV-positive and HIV-negative populations in the United States.

Early treatment of HIV can add valuable years to life—if guidelines are followed

In another study, John A. Romley of the USC Schaeffer Center and coauthors analyze the effects on life expectancy of people initiating combination antiretroviral therapy at early stages of the disease, when CD4 white blood cells are 350 or higher. In recent years, U.S. treatment guidelines have been revised to recommend treatment at all CD4 counts.

The authors found an average gain in life expectancy of 6.1 years for people who initiated therapy when CD4 counts were 350 to 500, and a gain of 9 years for those initiating treatment when CD4 counts were above 500.

The authors found a much higher mortality risk among HIV-positive individuals if treatment was initiated when CD4 counts were less than 350. For HIV-positive individuals whose treatment was initiated when CD4 counts were less than 350, mortality risk was 28 percent higher than those who started treatment when counts were 350 to 500, and 1.16 times higher than those who started when counts were greater than 500.

The researchers estimate the value of survival gains from early initiation from 1996 to 2009 at $80 billion, with each life year valued at $150,000. Those who initiated treatment the earliest—following the current U.S. treatment guidelines—could expect to live another 39.7 years.The authors point to the importance of treatment guideline adherence and to investment in scientific investigation to support rigorous guideline development.

The ACA could help the fight against HIV/AIDS, particularly if more states expand Medicaid

Zachary Wagner and colleagues at the USC Schaeffer Center modeled the effects of the Affordable Care Act and found that by 2017, an additional 466,153 people in the United States will be tested for HIV.

With increased testing among the newly insured under the ACA, the population of HIV-positive people who are unaware of their status will decline by 22 percent, the researchers estimate. By 2017, they estimate 2,598 new cases diagnosed, with the effect potentially magnified by as much as 30 percent if all states expanded their Medicaid programs. The researchers recommend state leaders consider ways to expand insurance coverage to those who remain uninsured.

The authors point to evidence that gaining health insurance can improve testing rates, and that more generous Medicaid benefits can increase the use of by HIV-positive individuals, both important contributors to prevention efforts.

Additional papers in Health Affairs examine jails and health, and reflect ongoing concerns about how to manage the health needs of a population with higher rates of communicable diseases, mental illness, substance abuse and many chronic conditions—and what the return of "jail-involved" individuals to communities will bring as Medicaid expands in many states and the ACA provision ensuring care to them becomes a reality.

Explore further: Older children with HIV may need to start treatment sooner to normalize future CD4 count

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