The Role of Government-Funded Assistance Programs on HIV Testing Among Poor U.S. Adults

Abstract

Government-funded assistance program enrollment may play an important role in the overall increase of HIV testing among low-income U.S. adults. We pooled data from the 2016–2018 National Health Interview Survey and limited analyses to respondents aged 18 to 64 years with incomes less than 100% of the U.S. poverty threshold (N = 9,497). The outcome of interest was ever testing for HIV. Prevalence ratios were used to assess the likelihood of ever testing for HIV and were adjusted for sociodemographic covariates including whether the respondent was a beneficiary of any government-funded assistance programs (e.g., Medicaid; job-placement/training/human services; or Temporary Assistance for Needy Families). After adjusting for significant sociodemographic covariates, government-funded assistance beneficiaries were significantly more likely to ever test for HIV (adjusted prevalence ratio = 1.3; 95% CI = [1.2, 1.4], p < .0001) than adults with incomes less than 100% of the U.S. poverty threshold who did not receive government assistance. Beneficiaries of government-funded assistance programs are more likely to test for HIV.

Keywords

government-funded assistance programs HIV poverty testing

An estimated 1.2 million people in the United States are living with HIV, including over 160,000 people who are unaware of their status (Centers for Disease Control and Prevention [CDC], 2020). Approximately 40% of persons with HIV do not know they have it, are not in care, and account for 80% of new infections (CDC, 2020). HIV testing is an important tool for preventing, finding, and linking HIV-positive individuals to life-saving care. In addition, research has shown that early treatment after diagnosis increases antiretroviral therapy benefits, which has a profound impact on reducing HIV transmission (Cohen et al., 2016). The socioeconomically disadvantaged are among the groups with late HIV diagnoses, putting them at a disadvantage for receiving HIV treatment and care (Pellowski et al., 2013). A previous study has shown that HIV testing among populations with incomes less than 100% of the U.S. poverty threshold is higher than those living in more affluent populations (Gai & Marthinsen, 2019). An increased knowledge regarding the possible reasons for the higher rate of testing may be used to improve current HIV prevention initiatives. Government-funded assistance programs may play an important role in the overall increased testing among this population. These programs provide social support services and health benefits to enrolled members. Participants in these programs are connected to health-care systems that increase access to preventive care and insurance services (Kaiser Family Foundation [KFF], 2014). For example, adults enrolled in Medicaid programs have insurance coverage and access to preventive care including HIV testing (Simon et al., 2017). Thus, HIV testing nested in government-funded assistance programs may increase routine preventive HIV screening and diagnostic testing to enable early treatment initiation (KFF, 2014). This may aid in meeting Ending the HIV Epidemic in the U.S. (EHE) goal of reducing HIV infections by 90% within 10 years (U.S. Department of Health and Human Services, 2019). Our objective was to assess the association between government-funded assistance programs and HIV testing among U.S. adults with incomes less than 100% of the U.S. poverty threshold.

Method

Secondary data analysis was conducted from data collected through the National Health Interview Survey (NHIS), an in-person, annual health survey of the civilian, noninstitutionalized population of the United States. A complete description of the NHIS data collection methodology is available elsewhere (National Center for Health Statistics, 2018). A representative sample of households and noninstitutional quarters was included via multistage probability sampling. Hispanic/Latino, Black or African American, and Asian households were oversampled to allow for more precise estimation of these groups. Analyses were limited to respondents aged 18 to 64 years with incomes less than 100% of the U.S. poverty threshold (N = 9,497). The federal poverty level was calculated using imputed family income and household size according to federal poverty thresholds (<100% of the U.S. poverty threshold [below poverty level], ≥100% of the U.S. poverty threshold [above poverty level]) published by the U.S. Census Bureau (Semega et al., 2019). The average conditional response rate was 54%, and analyses accounted for the complex survey design and weights were calibrated to U.S. Census Bureau population projections and American Community Survey 1-year estimates for age, sex, race, and ethnicity. Design weight did not account for census division and metropolitan statistical area (MSA) status prior to 2019. The outcome of interest was ever testing for HIV (yes/no). Prevalence ratios (PRs) and 95% CIs calculated from multivariable logistic regression models were used to determine the correlates of ever testing for HIV and enrollment in any of the following government-funded assistance programs: (1) Medicaid, (2) Human Services, or (3) Temporary Assistance for Needy Families (TANF). Medicaid included persons who had Medicaid coverage or other state-sponsored health plans, including the Children’s Health Insurance Program. Human services included an affirmative response to receiving other government assistance (e.g., job-placement/training, transportation, or childcare). TANF recipients included an affirmative response to receiving income from a state or county welfare program.

Results

According to the analysis results in Table 1, an estimated 46.8% of U.S. adults have ever tested for HIV. An estimated 15.4% of the sample were experiencing poverty and nearly half have ever tested for HIV (49.9%) or were government-funded assistance program beneficiaries (45.0%). Table 2 presents the adjusted prevalent ratios of ever testing for HIV among the population. After adjusting for significant sociodemographic covariates, the prevalence of ever testing for HIV was significantly associated with beneficiaries of government-funded assistance (adjusted prevalence ratio [APR] = 1.3; 95%CI = [1.2, 1.4], p < .0001) than adults with incomes less than 100% of the U.S. poverty threshold who were nonbeneficiaries. Also, adults with incomes less than 100% of the U.S. poverty threshold between the ages of 30 and 49 years (APR = 1.3; 95%CI = [1.2, 1.4], p < .0001), who were female (APR = 1.2; 95%CI = [1.1, 1.3], p < .0001), non-Hispanic Blacks (APR = 1.5; 95%CI = [1.4, 1.6], p < .0001), and self-identified as gay/bisexual (APR = 1.3; 95%CI = [1.2, 1.5], p < .0001) were significantly associated with ever testing for HIV. The prevalence of ever testing for HIV among recipients of government assistance with incomes less than 100% of the U.S. poverty threshold are displayed in Figure 1. The prevalence of ever testing for HIV was significantly higher among recipients of Medicaid (57.9% vs. 49.0%), Human Services (65.1% vs. 49.4%), and TANF (67.1% vs. 49.2%) compared with adults with incomes less than 100% of the U.S. poverty threshold who were not enrolled in those respective programs.

Table 1.

Sociodemographic and Health-Related Characteristics of U.S. Adults Aged 18 to 64 Years With Income Less Than 100% U.S. Poverty Threshold; National Health Interview Survey 2016–2018.

Independent variables	N = 9,497
Independent variables	Unweighted N	Weighted %	95% CI
Age (years)
18–29	3,583	39.5	[37.6, 41.5]
30–49	3,583	35.8	[34.3, 37.4]
50–64	3,583	24.7	[23.5, 259]
Gender
Male	3,803	42.5	[41.2, 44.0]
Female	5,694	57.5	[56.0, 59.0]
Race/ethnicity
Hispanic	1,949	26.4	[23.4, 29.0]
Non-Hispanic White	4,791	42.7	[40.3, 45.1]
Non-Hispanic Black	1,997	22.9	[21.0, 25.0]
Non-Hispanic Asian	451	5.4	[4.6, 6.4]
Non-Hispanic other	308	2.6	[1.7, 3.9]
Marital status
Married/cohabiting	7,194	64.4	[62.8, 66.0]
Unmarried/not cohabitating	2,285	35.6	[34.0, 37.2]
Highest level of education
<High school	2,272	26.9	[25.4, 28.6]
High school	2,734	30.4	[29.0, 31.9]
Some college	2,632	24.5	[23.0, 26.1]
≥4-year college	1,804	18.1	[16.9, 19.4]
Sexual orientation
Gay/bisexual	469	4.7	[4.2, 5.3]
Straight	8,538	95.3	[94.7, 95.9]
Region
Northeast	1,432	16.4	[14.5, 18.5]
Midwest	2,059	20.0	[18.1, 21.9]
South	3,945	41.6	[38.8, 44.5]
West	2,061	22.0	[19.5, 24.7]
Received any government assistance^a
Yes	4,257	45.0	[43.0, 47.0]
No	5,239	55.1	[53.0, 57.1]
Ever tested for HIV
Yes	4,460	49.9	[48.1, 51.7]
No	4,524	50.1	[48.3, 51.9]

Government assistances includes a “Yes” response to any of the following: (1) insured through Medicaid or other public insurance; (2) job-placement/training, transportation, or child care; (3) TANF [Temporary Assistance for Needy Families] or welfare.

Table 2.

Unadjusted and Adjusted Prevalence Ratios of Ever Testing for HIV Among U.S. Adults Aged 18 to 64 Years With Income Less Than 100% U.S. Poverty Threshold; National Health Interview Survey 2016–2018.

Sociodemographic variables	Ever tested for HIV^a
Sociodemographic variables	Prevalence %	PR	PR [95% CI]	p	APR	APR [95% CI]	p value Wald F
Age (years)
18–29	40.0	0.8	[0.8, 0.9]	<.0001	0.9	[0.8, 0.93]	<.0001
30–49	62.1	1.3	[1.2, 1.4]		1.3	[1.2, 1.4]
50–64	48.4	Reference			Reference
Gender
Male	42.3	Reference		<.0001	Reference		<.0001
Female	55.5	1.3	[1.2, 1.4]	<.0001	1.2	[1.1, 1.3]	<.0001
Race/ethnicity
Hispanic	49.0	1.1	[1.0, 1.2]	<.0001	1.1	[1.0, 1.2]	<.0001
Non-Hispanic White	44.1	Reference			Reference
Non-Hispanic Black	66.7	1.5	[1.4, 1.6]		1.5	[1.4, 1.6]
Non-Hispanic Asian	30.2	0.7	[0.6, 0.8]		0.7	[0.6, 0.9]
Non-Hispanic other	45.1	1.0	[0.8, 1.3]		1.1	[0.8, 1.3]
Marital status
Married/cohabiting	52.1	Reference		.0386	Reference		.0359
Unmarried/not cohabitating	48.6	0.9	[0.9, 1.0]	.0386	0.9	[0.9, 1.0]	.0359
Highest level of education
<High school	49.1	0.9	[0.8, 1.0]	<.0001	0.8	[0.7, 0.8]	<.0001
High school	49.6	0.9	[0.8, 1.0]		0.8	[0.7, 0.9]
Some college	46.5	0.8	[0.8, 0.9]		0.9	[0.8, 1.0]
≥4-year college	56.6	Reference			Reference
Sexual orientation			49.3
Gay/bisexual	64.7	1.3	[1.2, 1.4]	<.0001	1.3	[1.2, 1.5]	<.0001
Straight	49.3	Reference		<.0001	Reference		<.0001
Region
Northeast	51.0	1	[0.9, 1.1]	.0011	1.0	[0.9, 1.1]	<.0001
Midwest	46.9	0.9	[0.8, 1.0]		1.0	1.0
South	53.6	Reference			Reference
West	44.9	0.8	[0.8, 0.9]		0.9	[0.8, 1.0]
Received any government assistance^a
Yes	58.2	1.4	[1.3, 1.4]	<.0001	1.3	[1.2, 1.4]	<.0001
No	43.1	Reference		<.0001	Reference		<.0001

Bold-faced values in Table 2 indicate confidence intervals that show statistical significance.

Figure 1.

Prevalence of ever testing for HIV among various forms of government assistance received by U.S. adults with income less than 100% U.S. poverty threshold; National Health Interview Survey 2016–2018.

Discussion

Government-funded assistance beneficiaries were 30% more likely to ever test for HIV than adults with incomes less than 100% of the U.S. poverty threshold who were nonbeneficiaries. Given the sparse amount of literature on HIV testing among this population, the findings from this study provide statistically reliable, nationally representative estimates to highlight the role those programs may play in HIV prevention.

Government-funded assistance programs aim to provide equity to the socioeconomically disadvantaged households by ensuring that basic nutrition, housing, and health care needs are met. These programs also have unintended benefits that affect other dimensions of health. For example, most states in the United States now cover routine HIV screenings as part of benefits for enrolled members (KFF, 2014). Our findings show that recipients of Medicaid, Human Services, and TANF significantly tested for HIV more than adults with incomes less than 100% of the U.S. poverty threshold who were not on those programs. Differences in HIV testing rates among these programs highlight the potential pathways to improve HIV prevention efforts among the socioeconomically disadvantaged populations. Participants on these programs qualify based on income (<100% U.S. poverty threshold) and most states now cover routine HIV testing (KFF, 2014). This may lead to higher rate of testing among this population. Our findings show that young minorities, females, and gay/bisexual adults with incomes less than 100% of the U.S. poverty threshold who are on government assistance programs were more likely to ever test for HIV than adults with incomes less than 100% of the U.S. poverty threshold who were not on those programs. These findings corroborate with a recent report by Nash on the EHE which emphasizes the need to develop metrics that address HIV-related disparities by race/ethnicity, sociodemographic factors, gender minority status, and geographic location (Nash, 2020).

Factors that may increase testing within this population include routine HIV screening for Medicaid beneficiaries, perinatal services, and provider incentives. Our results show that Medicaid beneficiaries were more likely to ever test for HIV. A previous report by KFF on state Medicaid coverage showed that more than two thirds of all states now cover routine HIV screenings for Medicaid beneficiaries (KFF, 2014). Thus, the coverage of routine HIV screening could result in increased testing among beneficiaries as indicated in this study. Moreover, routine HIV preventive screening and diagnostic testing for Medicaid beneficiaries may offer the opportunity to reduce the risk of HIV infection, increase access to care, and rapidly identify and treat those diagnosed with HIV.

Females in our study were more likely to test for HIV than males, perhaps due to the prenatal services they receive through public assistance programs. This finding is consistent with a study among minority women participating on Medicaid in the Women, Infants, and Children and TANF programs, which showed that women on those programs receive HIV testing education as part of their family planning services (Nguyen et al., 2018). Another contributing factor may be the influence of insurance health-care quality initiatives. For example, providers in Tennessee who coordinate mental and physical preventive health care screenings were awarded up to a fourth of what was saved by the Medicaid program (Farmer, 2019). Therefore, an increase in HIV testing could be the result of providers promoting and encouraging HIV testing. Although perinatal services, Medicaid routine HIV screening for members, and provider stimulus are not the only possible contributing factors for increased HIV testing among persons participating in government assistance programs, they provide insight into the potential role government-funded programs may have on preventive HIV screening and diagnostic testing among U.S. adults with incomes less than 100% of the U.S. poverty threshold.

This analysis is subject to several limitations. The NHIS data are cross-sectional; therefore, causal relationships between enrollment in government assistance programs and HIV testing cannot be determined. Self-reported data are subject to recall bias. Second, there may be temporal misalignment in periods between ever testing for HIV and enrollment in government-funded assistance programs for the study period. Third, due to the use of secondary data and lack of indicator variables to determine variations within states, state fixed effect, time effect, and health system features that enable HIV testing could not be accounted for in this study. Fourth, given that the comparison group is also eligible for these programs, we cannot rule out selection bias in our estimates stemming from something other than just program participation. Finally, NHIS survey items are limited in scope; therefore, expanded analysis of the duration of time that respondents received government assistance or behaviors that may increase risk of HIV could not be included in the analysis. Despite these limitations, an overarching strength of this study is its use of nationally representative, probability-based data that describe the association between government-funded assistance programs and HIV testing among U.S. adults with incomes less than 100% of the U.S. poverty threshold.

Conclusion

Our findings indicate that enrollment in government assistance programs like Medicaid, human services, or TANF is significantly correlated with having ever been tested for HIV. Further research is needed to understand the internal processes that mediate this association. Because HIV testing is the most crucial step in eliminating HIV, any public assistance program that incorporates HIV testing should be supported. Adults with incomes less than 100% of the U.S. poverty threshold who are vulnerable to HIV, concerns of employment, affordable housing, and affordable health care outweigh the potential fears of an HIV infection (Kapadia & Landers, 2020). Thus, HIV testing that is nested within public assistance programs will not only help reduce health disparities but may also increase HIV preventive screening and diagnostic testing to eventually make it part of routine primary care services. This will be consistent with CDC’s recommendation of incorporating HIV screening as part of routine medical care for all patients between 13 and 64 years of age (Branson et al., 2006). Moreover, collaborating with government-funded assistance programs can provide health departments and community-based organizations the opportunity to leverage their limited resources to reach members of populations at risk, and ensure that activities critical to the success of EHE are conducted.

Footnotes

Acknowledgements

We thank the ICF research team, Stacie Deaton and Kate Musgrove, for their assistance in editing this manuscript.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Iddrisu Abdallah

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