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After the Affordable Care Act went into effect in the U.S., some states that did not immediately expand Medicaid — Virginia, South Carolina and Nebraska — allowed residents with HIV to get therapy and medications through state-run programs that used federal funds to create ACA-compliant health plans.

These programs, though they did not offer as many residents the full health benefits that could have been available through Medicaid expansion, improved health outcomes and saved costs, a new study from the University of Virginia suggests.

Dr. Kathleen McManus, a doctor at UVa’s Ryan White HIV/AIDS Clinic who researches HIV outcomes, built on previous research to calculate how many people must be enrolled in a state-run health insurance plan — rather than just receiving medication — in order to avoid a new transmission of the disease.

The findings suggest that for every 20 new people enrolled, one additional person likely will reach viral suppression, when the presence of HIV is reduced to undetectable levels in the blood and is unlikely to be transmitted.

“Sometimes we have to treat thousands of people in medicine to begin to make a difference in disease outcomes,” McManus said. “To just have to treat 20 to improve outcomes for one is actually a really small ratio that could make a big difference.”

While the federal government offers a program, known as ADAP, that gives eligible people with HIV access to medication, McManus found that the state-run insurance plans, which also give access to primary and preventative care, were more effective at improving HIV outcomes.

“There’s something about the wraparound services of having insurance that improved outcomes,” she said.

In total, the researchers found, if every person in the country receiving medication during the period also enrolled in a health plan, the United States could avert 103 HIV infections and avoid more than $41 million in healthcare costs.

“As the United States focuses on ending HIV as an epidemic, we need to ensure that our health policies and laws support the goal of getting to zero new HIV diagnoses,” McManus said.

The researchers looked at 7,776 patients in Nebraska, South Carolina and Virginia — states that had not expanded Medicaid during the period studied (Virginia’s Medicaid expansion took effect in 2019 and Nebraska will expand later this year).

More than 70% of patients in the study had incomes less than 138% of the federal poverty line, meaning they would have been eligible for Medicaid had their state expanded it at that time.

In Virginia, 63% of patients enrolled in the plans, while 51% enrolled in Nebraska and 34% enrolled in South Carolina. Once enrolled, the study found, patients tended to stay enrolled.

In a 2015 study that just focused on Virginians with HIV, McManus already had noted positive outcomes from the plans — but found that African American patients, people with AIDS and people ages 25 to 44 were less likely to enroll in the health plans.

In the next year, she said, Virginia Department of Health officials made a substantial effort to increase outreach, and this study found that the intervention now seemed to benefit people with HIV across all demographic groups.

The researchers have published their findings in the scientific journal Clinical Infectious Diseases.

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