Assistant Secretary for Health Howard K. Koh began the briefing by sharing his experience as a physician caring for those with HIV infection in the early 1980s, an experience that established his lifelong commitment to stemming the epidemic in the U.S. Toward this end, he highlighted the promise of recent advances in HIV science and policy that move us closer to an AIDS-free generation, such as the HPTN 052 treatment as prevention findings, Food and Drug Administration approval of Truvada® for HIV pre-exposure prophylaxis, and inclusion of awareness of HIV serostatus as a Leading Health Indicator in Healthy People 2020.
Dr. Koh also underscored that the Affordable Care Act is a structural intervention that offers vast improvements to clinical and public health outcomes yet raises new challenges, such as clarifying that federal rules require qualified health plans to accept third party premium and cost-sharing payments from the Ryan White HIV/AIDS Program. Other promising developments noted by Dr. Koh were the National Institutes of Health plan to allocate $100 million to HIV cure research, the impending release of an updated Viral Hepatitis Action Plan, and the White House Executive Order that seeks to accelerate improvements along the HIV care continuum.
Panel I: Impact of Early Treatment
The first panel examined findings presented in a pair of articles included in the journal’s current issue. University of Southern California’s (USC) Director of the Schaeffer Center for Health Policy and Economics, Dana Goldman, led off with a presentation entitled, “Early HIV treatment led to life expectancy gains valued at $80 billion for people infected in 1996-2009.” In short, he noted that the updated HHS HIV Treatment Guidelines expand the recommendation that antiretroviral therapy should be offered to all HIV-infected individuals irrespective of their CD4+ cell counts. Goldman and colleagues noted that this shift in policy added an estimated 9 years to life expectancy per patient, delivered value to individuals estimated at $141,000, and averted an estimated 188,000 new HIV infections between 1996 and 2009.
John A. Romley, Research Assistant Professor of Public Policy, USC, followed with a presentation entitled, “Early HIV Treatment in the United States Prevented nearly 13,500 Infections per year during 1996-2009,″ which estimated that HIV infection shortens life expectancy by 11.7 years for a person infected at age 35 who initiates combination ART at a CD4+ cell count of less than 350 per mm3 and that each uninfected person who remains so avoids life-years lost valued at $678,000. This translates to an estimated $128 billion in value to society conferred by early treatment and medication adherence.
Panel II: ACA Implementation
In the second panel, Julia Thornton Snider, Senior Research Economist at Precision Health Economics, presented the abstract, “Nearly 60,000 Uninsured and Low-Income People with HIV/AIDS Live in States that are not Moving Forward with Medicaid Expansion.” She estimated that 115,000 low income, uninsured people living with HIV infection would be eligible for Medicaid if all states implemented the expansion. The majority of these people reside in non-expansion states as of January 2014 (e.g., Texas, Florida, and Georgia), many of whom have incomes below the state’s subsidy thresholds. Further, limited antiretroviral formularies available through many state health exchanges will bring challenges to treatment adherence. Snider concluded that full implementation of Medicaid expansion under the ACA would confer significant economic, clinical, and public health benefit, particularly to those in non-expansion states.
Neeraj Sood, USC Associate Professor of Health Economics and Director of Research, presented his abstract, “HIV Care Providers Emphasize the Importance of the Ryan White Program for Access to and Quality of Care,” which describes a national survey of HIV care providers on the continued need for the Ryan White HIV/AIDS Program for persons living with HIV infection. Results indicated that those surveyed believe that even as the ACA transforms the American healthcare system, Ryan White will remain critical to providing high quality, medical and non-medical support services not covered by Medicaid yet necessary to achieve optimal HIV treatment outcomes.
A final presentation in this panel was provided by University of California, Berkeley doctoral student, Zachary Wagner entitled, “The Affordable Care Act may Increase the Number of People Getting Tested for HIV by Nearly 500,000 by 2017.″ Focusing on the 18 states and the District of Columbia that had elected to expand Medicaid as of July 2013, Wagner and colleagues estimated that ACA provisions will enable an additional 466,000 people to be tested for HIV, which they estimated will yield approximately 2,600 new HIV diagnoses by 2017. As a result, they estimated that the share of persons living with undiagnosed HIV infection will decline by 22 percent among those who gain insurance. The investigators noted that these estimated outcomes would be 30 percent higher if all states expanded Medicaid as allowed under the healthcare law.
Panel III: Targeting Resources
In the final panel, Brown University School of Public Health’s Brandon D.L. Marshall offered a talk entitled, “Prevention and Treatment Produced Large Decreases in HIV Incidence in a Model of People who Inject Drugs.” In it, Marshall and colleagues described a mathematical model of the impact of interventions (e.g., increased HIV testing, access to clean needle and syringe programs) on HIV transmission within networks of drug users and non-users in the New York Metropolitan Statistical Area. Findings indicated that although no single strategy eliminated HIV transmission, a combination approach that included HIV testing, substance abuse treatment, clean needle and syringe programs, and early treatment initiation would reduce HIV incidence among injecting drug users by an estimated 62 percent compared to the status quo. Their work provides a compelling case for using modeling to optimize resources in order to effectively respond to local epidemics.
Gery W. Ryan, Senior Behavioral Scientist at Rand Corporation discussed “Data-Driven Decision-Making Tools to Improve Public Resource Allocation for Care and Prevention of HIV/AIDS,” which examined the challenges faced in Los Angeles County in meeting the National HIV/AIDS Strategy goals by maximizing the impact of finite resources. In developing a robust, decision support tool, Ryan and colleagues, in collaboration with key stakeholders, used local data to identify a cost-effective strategy that maximized treatment initiation and adherence support in order to achieve the County’s health policy goals.
Finally, Arleen A. Leibowitz, Professor of Public Policy, University of California, Los Angeles presented, “HIV Tests And New Diagnoses Declined After California Budget Cuts, but Reallocating Funds Helped Reduce Impact,” which discussed an analysis of the impact of the state’s elimination of supplemental HIV prevention funding in 2009. Findings indicated that the budget cuts prompted the redirection of remaining funds from risk reduction education to HIV testing activities, resulting in smaller declines than expected in testing and diagnoses in communities where HIV was most concentrated. Leibowitz noted that although the ACA will stimulate HIV testing, there continues to be a need for free and low-cost HIV testing outside of clinical settings because many of those at highest risk for HIV do not access regular medical care.
Taken together, these presentations made a compelling economic and policy argument for federal and state investment in the HIV care continuum through Medicaid expansion under the ACA. They also underscore the continued need for care completion services provided by the Ryan White HIV/AIDS Program. These data underscore that state-level efforts are increasingly instrumental in achieving the goals of the National HIV/AIDS Strategy, and that state policy decisions about ACA implementation will have particular implications in this regard. Also clear from the presentations was that making the most of the current policy environment will require an ongoing commitment to collaboration and coordination at multiple levels. Further, decision-support tools can help to assure that data-based policy minimizes the number of new infections and maximizes treatment outcomes for those who face the greatest barriers to achieving the full benefit of HIV medical care.