The Ryan White HIV/AIDS Program: Supplementary Service Provision Post-Affordable Care Act

Abstract

The Ryan White HIV/AIDS program (RWHAP) provides essential primary and supplementary health services to people living with HIV (PLWH). We examined the relationship between supplementary RWHAP services (Part B) and two outcomes: viral suppression (VS) and two separate measures of retention in care (RiC) based on kept- and missed-visits. We used purposive sampling to identify adult patients who received primary medical care at an academically-affiliated HIV/AIDS clinic in the southeastern United States (N = 1159) and who attended at least one scheduled HIV primary care appointment at the study site during 2015. Unadjusted and adjusted logistic regression models were fit, in which RWHAP supplementary services were the primary independent variables of interest. Age, race, gender, education level, and income were control variables. Among 1159 PLWH, 45.3% received RWHAP supplementary services in addition to public insurance, private insurance, or primary RWHAP. Among participants, 91.4% were virally suppressed, 87.4% were retained in care using the Institute of Medicine (IOM) kept-visits measure, and 60% were retained in care using the missed-visits measure. In multivariable models, patients with RWHAP supplementary services had significantly higher odds of (1) VS [adjusted odds ratio (AOR) = 1.91], (2) RiC using the IOM kept-visits measure (AOR = 2.56), and (3) RiC using the missed-visits measure (AOR = 1.58). Receipt of supplementary RWHAP services is associated with increased odds of VS and two measures of RiC when adjusting for key sociodemographic variables. Policymakers should consider the vital role of RWHAP as continued funding is uncertain.

Introduction

When the Patient Protection and Affordable Care Act (ACA) was signed into law by President Obama on March 23, 2012 and fully implemented on January 1, 2014,¹ this prompted discussion among HIV researchers and policymakers about how the ACA would affect healthcare coverage for people living with HIV (PLWH). HIV providers were of the opinion that the Ryan White HIV/AIDS Program (RWHAP), providing primary medical care and wraparound supplementary social services to over 50% of the 1.1 million PLWH in the United States (US),^2,3 would remain vital as a payer of last resort.^4
–6 Moreover, some HIV providers voiced concern that Congress would no longer fund the program, which depends on annual appropriations, if policymakers falsely assumed that expanded health coverage under the ACA would displace the need for continued RWHAP funding.^7,8 A recent report from the Henry J. Kaiser Family Foundation illustrates that reliance on RWHAP has actually increased post-ACA, particularly in its provision of supplementary services,⁹ which are defined as “non-medical wraparound, enabling and coordinative services designed to address health and human service needs that fall outside the normal purview of medical care.”¹⁰ Examples of these crucial services include mental healthcare, transportation assistance, and case management.¹¹ The Kaiser Family Foundation report reflects a growing trend in the way RWHAP interfaces with insurance providers: state AIDS Drug Assistance Programs (ADAPs), funded by RWHAP Part B, often purchase insurance plans on behalf of their clients as this is more cost-effective than paying medication costs directly.¹² In fact, between 2002 and 2015, PLWH receiving ADAP-purchased insurance increased by 1162%.¹² In addition to Part B funding, for which every state is eligible, the RWHAP also provides funding to large urban areas (Part A), clinics (Part C), and services specific to women, children, and youth (Part D).²

The RWHAP is unique in its subsidization of nonmedical wraparound supplementary services, which likely contributes to its association with positive HIV health outcomes in extant research.^13

–16 Findings from nationally representative Medical Monitoring Project data collected from 2009 to 2013 suggested that PLWH who have RWHAP as their primary medical payer are more likely to be virally suppressed than PLWH with a public or private insurance provider. Moreover, patients with both private or public insurance and RWHAP supplementary services were significantly more likely to be virally suppressed than those with public or private insurance only, during this study period before the advent of the ACA.¹³

Maintaining viral suppression (VS) has implications for both personal and public health, as it is associated with decreased risk of mortality and inadvertent transmission.¹⁷ Moreover, it has been estimated that 91.5% of all new HIV infections are attributable to PLWH who are either undiagnosed or who are diagnosed but not retained in care.¹⁸ Given that approximately 40,000 people were diagnosed in 2016 alone and the rate of new infections has increased in some groups (e.g., black/African American and Hispanic/Latino gay and bisexual men),¹⁹ it is clear that effective, accessible services are needed to link and retain PLWH in care.

Against this current backdrop of fluctuating healthcare access, a timely research question is how the receipt of supplementary RWHAP services—regardless of primary payer type—impacts HIV-related health outcomes. To our knowledge, no studies to date have focused specifically on RWHAP's supplementary role using post-ACA implementation health services data. In the current analysis, we sought to examine the relationship between receipt of RWHAP supplementary services and HIV health outcomes (VS, and two different measures of retention in care, RiC) post-ACA implementation.

Methods

Analytic sample

The analytic sample included 1159 persons living with HIV who received primary medical care at a large, urban, academically affiliated HIV/AIDS clinic in the southeastern United States, which receives RWHAP Parts B and C funding. All patients were of adult age, as the study site only treats PLWH who are 18 years of age or older.

Using purposive sampling, we obtained de-identified, patient-level, sociodemographic, and clinical data for all PLWH who attended at least one scheduled HIV primary care appointment at the study site during the 2015 calendar year and who had data recorded for all variables of interest. The observation window for viral load (VL) and RiC outcomes included the 12 months between January 1, 2016 and December 31, 2016. A primary care visit was defined as one that addresses routine medical care and is scheduled in advance; this does not include emergency or walk-in visits or specialty care appointments. We used primary care visit data from 2015 to establish which patients were active in care before the 12-month observation window of 2016. An additional criterion for the analytic sample was that patients did not die during the observation window. The reason for excluding patients who died during the observation window (n = 35) is that (1) they had a truncated observation window and (2) their cause of death was not systematically listed in their medical records (i.e., they may have died from non-AIDS-related causes).

Independent variables

RWHAP supplementary services served as the independent variable of interest. This dichotomous measure referred to whether or not patients received documented nonmedical wraparound supplementary services (e.g., case management, transportation assistance). All patients were eligible for supplementary RWHAP services with (1) paystubs or other documentation of an annual income ≤400% of the federal poverty level and (2) documentation of physical address of permanent state residency or a Statement of Temporary Housing. In addition, per federal guidelines, all RWHAP enrollees must recertify for RWHAP every 6 months to maintain eligibility.²⁰ Given its status as a payer of last resort, only uninsured patients were eligible for RWHAP as a primary payer; however, patients with all possible primary payer types (private insurance, public insurance, RWHAP, or uninsured/no RWHAP) who met the aforementioned eligibility criteria could receive supplementary RWHAP services.

Several sociodemographic measures collected in the electronic medical record (EMR) served as control variables, including the continuous variables, age and monthly income, and the categorical variables, gender (male, female), race (black, white, other), and education level (less than high school, high school or GED, some college, or college and higher). Although gender may be conceptualized outside of the traditional male/female dichotomy, these were the only two categories listed in the EMR available for analysis. In addition, patients' primary payer type, which was independent of whether patients received supplemental RWHAP services, was included as a control variable and consisted of four possible categories: private insurance, public insurance, primary RWHAP, and uninsured (no RWHAP). These variables, which were chosen based on existing literature,^21

–24 were provided by patients' self-reports and, except for gender and race, reflected the latest value recorded during the observation window.

Dependent variables

There were two different dichotomous measures for RiC, a core HIV health indicator that describes patients' level of engagement in medical care services.²⁵ Since previous research has shown that different aspects of retention are differentially associated with VS²⁶ and that missed-visits-based measures are associated with increased mortality risk,²⁷ both kept-visits and missed-visits measures were included to more comprehensively capture the RiC construct. For the kept-visits measure, retained patients must have at least two (2) primary care visits, at least 90 days apart, during a 12-month observation window, in accordance with the Institute of Medicine (IOM) indicator and National HIV/AIDS Strategy for the United States²⁸ (hereafter referred to as the IOM kept-visits measure). Any patients who attended fewer than two visits, or who attended two visits that were less than 90 days apart, were considered not retained in care. For the missed-visits measure, retained patients must have attended all scheduled primary care visits within the observation window. Consistent with the literature, the missed-visits measure captures “no show” visits, or appointments that were not cancelled by the patient or provider in advance.²⁷ All patients who missed one or more visits during the observation window were considered not retained in care.

The other dependent variable was VS, a preeminent indicator of HIV control and clinical health.²⁸ Patients' last VL measurement collected during the observation window was assessed for suppression. The VL measure was dichotomized into suppressed (<200 copies/mL) and unsuppressed (≥200 copies/mL), in line with the standard measure recognized by the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration HIV/AIDS Bureau.^29,30

Statistical analyses

All analyses were cross-sectional. Descriptive statistics for independent and dependent variables, including means, standard deviation, frequencies, and percentages, were conducted (Table 1). In addition, frequencies and percentages were found for patients who had RWHAP supp and achieved study outcomes (Table 2). Binary logistic regression models were conducted to assess relationships between the primary independent variable of interest and the dependent variables (Table 3), and multivariable logistic regression models were fit to adjust for control variables (Table 4). A significance level (α) of p < 0.05 was used to define statistical significance in all models. All analyses were conducted using Stata 14.2.³¹

Table 1.

Characteristics for Patients Receiving HIV Primary Care Services in 2016

Characteristic	n (%)	Mean (SD); min.-max.
RWHAP supplementary
Yes	525 (45.3)
No	643 (54.7)
Primary payer type
Private insurance	659 (56.9)
Public insurance	379 (32.7)
RWHAP	44 (3.8)
Uninsured (no RWHAP)	77 (6.6)
Combination payer type
Public insurance + RWHAP	157 (13.5)
Private insurance + RWHAP	266 (23.0)
Public insurance only	222 (19.2)
Private insurance only	393 (33.9)
RWHAP only	102 (8.8)
Uninsured (no RWHAP)	19 (1.6)
Gender
Male	835 (72.0)
Female	324 (28.0)
Race/ethnicity
Black	897 (77.4)
White	221 (19.1)
Other	41 (3.5)
Monthly income	1159	$963.77 ($804.86)
		$0–$5572
Age (in years)	1159	44.4 (12.5)
		20–83
Highest ed. level
Less than high school	264 (22.8)
High school or GED	607 (52.4)
Some college	190 (16.4)
College or higher	98 (8.5)
Viral suppression
Yes	1059 (91.4)
No	100 (8.6)
Retention in care: IOM kept-visits
Yes	1022 (87.4)
No	147 (12.6)
Retention in care: missed-visits
Yes	698 (60.0)
No	461 (40.0)

Percentages may not sum to 100 due to rounding.

IOM, Institute of Medicine; RWHAP, the Ryan White HIV/AIDS program.

Table 2.

Percentages for Being Retained in Care and Virally Suppressed by Receipt of Ryan White HIV/AIDS Program Supplementary Services Among Patients Receiving HIV Primary Care Services in 2016

	Viral suppression n (%)		Retention in care IOM kept-visits n (%)		Retention in care missed-visits n (%)
	Yes	No	Yes	No	Yes	No
RWHAP supplementary services
Yes	487 (92.8)	38 (7.2)	485 (92.4)	40 (7.6)	335 (63.8)	190 (36.2)
No	572 (90.2)	62 (9.8)	535 (84.4)	99 (15.6)	363 (57.3)	271 (42.7)

Table 3.

Unadjusted Odds Ratios for Being Retained in Care and Virally Suppressed by Receipt of Ryan White HIV/AIDS Program Supplementary Services Among Patients Receiving HIV Primary Care Services in 2016

	Viral suppression, VS		Retention in care, RiC: IOM kept-visits		Retention in care, RiC: missed-visits
Characteristic	OR (95% CI)	p	OR (95% CI)	P	OR (95% CI)	p
RWHAP supplementary services
Yes	1.39 (0.91–2.12)	0.13	2.24 (1.52–3.30)	<0.001	1.32 (1.14–1.57)	0.02
No	Referent		Referent		Referent

OR, odds ratio; CI, confidence interval.

Table 4.

Adjusted Odds Ratios for Being Retained in Care and Virally Suppressed By Receipt of Ryan White HIV/AIDS Program Supplementary Services Among Patients Receiving HIV Primary Care Services in 2016

	Viral suppression, VS		Retention in care, RiC: IOM kept-visits		Retention in care, RiC: missed-visits
Characteristic	AOR (95% CI)	p	AOR (95% CI)	P	AOR (95% CI)	p
RWHAP supplementary
Yes	1.91 (1.18–3.07)	0.01	2.56 (1.68–3.90)	<0.001	1.58 (1.22–2.07)	0.001
No	Referent		Referent		Referent
Primary payer type
Private Insurance	4.29 (2.14–8.60)	<0.001	2.94 (1.56–5.52)	0.001	2.12 (1.25–3.58)	0.01
Public Insurance	1.73 (0.84–3.55)	0.14	2.40 (1.21–4.76)	0.01	1.42 (0.82–2.48)	0.21
RWHAP	2.07 (0.61–6.97)	0.24	11.07 (1.39–88.12)	0.02	1.44 (0.65–3.21)	0.37
Uninsured (no RWHAP)	Referent		Referent		Referent
Gender
Male	1.28 (0.79–2.06)	0.31	0.80 (0.51–1.26)	0.34	0.94 (0.71–1.25)	0.69
Female	Referent		Referent		Referent
Race/ethnicity
White	1.89 (0.94–3.79)	0.08	0.74 (0.47–1.18)	0.21	1.22 (0.87–1.71)	0.24
Other	2.73 (0.59–12.59)	0.20	1.24 (0.35–4.39)	0.74	2.54 (1.15–5.61)	0.02
Black	Referent		Referent		Referent
Highest education
≥College	0.89 (0.31–2.53)	0.83	0.84 (0.39–1.81)	0.65	3.16 (1.72–5.80)	<0.001
Some college	1.49 (0.69–3.18)	0.31	1.17 (0.62–2.18)	0.63	1.81 (1.20–2.73)	0.01
High school/GED	0.98 (0.59–1.64)	0.94	0.93 (0.58–1.48)	0.91	1.32 (0.96–1.80)	0.08
<High school	Referent		Referent		Referent
Monthly income (Per $100)	1.06 (1.03–1.10)	<0.001	1.02 (1.00–1.04)	0.20	1.04 (1.02–1.06)	<0.001
Age (in years)	1.04 (1.02–1.06)	<0.001	1.03 (1.02–1.05)	<0.001	1.03 (1.02–1.05)	<0.001

AOR, adjusted odds ratio; CI, confidence interval.

Results

Descriptive statistics for independent and dependent variables are provided in Table 1, along with frequencies and percentages for combination payer type (which consisted of various combinations of insurance and RWHAP). Among study participants, just under half (45.3%) received RWHAP supplementary services in addition to public insurance, private insurance, or primary RWHAP coverage. A little over half of patients had private insurance (56.9%), and about one-third had public insurance (32.7%). An overwhelming majority of participants (91.4%) were virally suppressed. Also, while over three-fourths of patients (87.4%) were considered retained in care using the IOM kept-visits retention measure, just 60% of patients were considered retained in care using the missed-visits measure, having attended all scheduled clinic visits (Table 1).

Patients ranged in age from 20 to 83 years, and approximately three-quarters (72%) were male and black (77.4%). Half (52.4%) of patients reported a high school degree or its equivalent as the highest education level attained, and the mean income was $963.77 per month (ranging from $0 to $5572) (Table 1). Among patients who received supplementary RWHAP services, approximately 93% were virally suppressed, 92% were retained in care by the IOM kept-visits measure, and 64% were retained in care by the missed-visits measure.

In unadjusted models (Table 3), patients with RWHAP supplementary services had significantly higher odds of being retained in care using the IOM kept-visits measure than patients without RWHAP supplementary services (OR = 2.24, 95% CI = 1.52–3.30). This relationship was similarly found in the adjusted model (AOR = 2.56, 95% CI = 1.68–3.90) (Table 4). Older patients and patients who had private insurance, public insurance, or RWHAP as their primary payer type (compared with patients who were uninsured and did not have RWHAP) were also more likely to be retained in care (Table 4).

When the missed-visits measure was used, patients with RWHAP supplementary services had significantly higher odds of RiC in the unadjusted (AOR = 1.32, 95% CI = 1.14–1.57) and adjusted (AOR = 1.58, 95% CI = 1.22–2.07) models. In addition, older patients, patients with higher incomes, patients with an “other” as opposed to black race, patients with private insurance, and patients with at least some college attendance (compared to patients without a high school degree) were more likely to be retained in care (Table 4).

For VS, the association with RWHAP supplementary services was significant in the adjusted, but not unadjusted, models. In the adjusted model (Table 4), patients who received RWHAP supplementary services had nearly twice the odds of being virally suppressed than those who did not receive supplementary services through the program (AOR = 1.91, 95% CI = 1.18–3.07). Also, older age, higher income, private insurance, and white race were associated with increased odds of VS (Table 3).

Discussion

RWHAP supplementary services were significantly associated with both RiC and VS among a large sample of PLWH in medical care, independent of primary health insurance/payer. These results have particular relevance for PLWH whose health may be impacted by the fluctuating healthcare landscape in the United States. In particular, receiving RWHAP supplementary services was associated with increased odds of VS and IOM kept-visits and missed-visits measures of RiC, even when controlling for multiple sociodemographic characteristics associated with HIV health outcomes.

These results, while consistent with previous research,^13

–16 also contribute novel findings to the literature. It is the first analysis, to our knowledge, to examine the relationship between healthcare payer type and using kept-visits as well as missed-visits measures of RiC. This research is also novel in its use of patient-level data collected post-ACA implementation, which highlights RWHAP's critical and still-expanding role as a supplementary healthcare provider. As the RWHAP has not been reauthorized since 2009 and the President's Budget for Fiscal Year 2018 would defund three components of the program (the Special Projects of National Significance Program, the AIDS Education and Training Centers program, and the Minority HIV/AIDS Initiative),³² it is important that all stakeholders have access to data that help inform policy decisions that have a direct impact on the health of PLWH. Careful attention to patient-level data can potentially shed some light on how insurance programs and RWHAP can best complement each other in providing PLWH with the best possible care.

In all multivariable models, older patients had higher odds of achieving outcome variables. This finding has been echoed in the literature, which suggests that older age is positively and significantly correlated with better HIV health outcomes.^33,34 However, Doshi et al. have posited that survivorship bias may be a salient factor with age, in which older PLWH who have been retained in care and virally suppressed over time are less likely to succumb to premature mortality.³⁴

Income retained a significant association in multivariable models with VS and missed-visits RiC outcomes, but not the IOM kept-visits RiC outcome. Income may have served to enhance the association between RWHAP supplementary services and the outcome measures in these models. Yet, for the IOM kept-visit RiC measure, results suggest that RWHAP may have a unique association with HIV health that is separate from socioeconomic status. Education level was not significantly associated with VS or with RiC when using the IOM kept-visits measure. However, when using the missed-visits measure, all patients who had, at minimum, attended some college were significantly more likely to be retained in care than patients who had not completed high school.

Race was not significantly associated with the VS or IOM kept-visits RiC outcomes. For the missed-visits RiC outcome, patients with an “other” race, but not white patients, had significantly higher odds of RiC compared with black patients. This is a salient finding, as it suggests that the health disparities between black or African American and white patients, consistently observed in health services research, may be attenuated by RWHAP supplementary services, at least for RiC. In fact, when the IOM kept-visits measure of RiC was used, black patients actually had higher odds of RiC than white patients, although the difference was not statistically significant. This suggests support for RWHAP's ability to mitigate racial health disparities among PLWH as a supplementary service provider. Future research should attend more closely to the interface between race and RWHAP services and how this interaction affects RiC. In particular, PLWH who are younger, low-income, and nonwhite may benefit from targeted, culturally competent interventions.

Interestingly, primary payer type was largely unassociated with two of the three study outcomes. For VS and missed-visits RiC, patients with private insurance had significantly higher odds of achieving VS and RiC compared with patients who were uninsured and did not have RWHAP, but no significant differences were found between uninsured patients and patients with public insurance or RWHAP. Yet, for the IOM kept-visits RiC outcome, significant differences were found between each payer type and the uninsured reference group. In fact, patients with RWHAP had 11 times the odds of RiC compared with patients who were uninsured. These impressive odds illustrate the importance of differentiating between patients who are uninsured and who do not have RWHAP versus patients who are uninsured but who do have RWHAP. While we are unable to identify in the current study why this group of uninsured PLWH were not receiving RWHAP-funded services, it is clear that they represent a distinct subpopulation at risk for poor HIV health outcomes. Future research should attend to this group of uninsured PLWH to better understand their eligibility for and utilization of HIV primary care services.

Overall, these results not only suggest that having supplementary RWHAP services is more strongly associated with VS and RiC outcomes than primary payer/insurance type, but they also suggest that, as a primary payer, RWHAP is uniquely associated with the IOM kept-visits measure of RiC, but not the missed-visits RiC measure or VS. In addition, our findings suggest that there is a stronger association between RWHAP supplementary services and RiC versus VS. This may be due to the nature of these HIV health indicators: VS reflects laboratory measures only, while retention indicators depend on appointment attendance and consistent involvement in care.

This study has several limitations. First, this research was cross-sectional and could not capture temporal trends. There is research suggesting that that cross-sectional analyses may overestimate achievement of RiC and VS, which are outcomes that may fluctuate over a period of several patient-years.¹⁴ More studies are needed that measure RiC and VS on a continuous basis. Second, the analytic sample contains some missing data. The 35 patients who died during the observation window were excluded from the analytic sample based on an incomplete observation window and an inability to determine whether they died from AIDS-related causes. Also, while several key patient-level characteristics were controlled for in analyses, there may be unexplained, uncaptured variance related to unmeasured characteristics. Finally, the analytic sample comes from one HIV/AIDS clinic in one southeastern state. Although the sample included over 1500 patients, the findings may not be generalizable to PLWH at other clinics or in other states/regions.

The current analysis reveals that receipt of supplementary RWHAP services is associated with increased odds of VS and two measures of RiC when adjusting for key sociodemographic variables. As was recently noted in a Ryan White Policy Project issue brief, there is “increasing urgency” to position RWHAP as a supplementary provider, as its payer of last resort status dictates that PLWH who are eligible for insurance must receive primary coverage through an insurance provider.³⁵ Since healthcare in the United States will likely be in-flux for the foreseeable future, it is important to continually reexamine the impact of policy on the health of PLWH and to make this data available to policymakers and HIV providers.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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