Economic Barriers to Antiretroviral Therapy in Nursing Homes

Abstract

OBJECTIVES Our aim was to clarify if persons living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) have adequate economic access to antiretroviral therapy (ART) when admitted to nursing homes (NHs). Medicare Part A pays NHs a bundled skilled nursing rate that includes prescription drugs for up to 100 days, after which individuals are responsible for the costs. DESIGN A cross‐sectional study. SETTING NHs. PARTICIPANTS A total of 694 newly admitted long‐stay (>100 d) NH residents with HIV. MEASUREMENTS We used Minimum Dataset v.3.0, pharmacy dispensing data, NH provider surveys, and Medicare claims from 2011 to 2013. We assessed receipt of any HIV antiretrovirals or recommended combinations (ART), as defined by national care guidelines, and the source of payment. We identified predictors of antiretroviral use with risk‐adjusted generalized estimating equation logistic models. RESULTS All study persons living with HIV/AIDS in NHs had prescription drug coverage through Medicare's Part D program, and ART was 100% covered. However, only 63.9% received recommended ART, and 15.2% never received any antiretrovirals during their NH stay. The strongest predictor of not receiving antiretrovirals was the first 100 days of a long NH stay (odds ratio [OR] = .44; 95% confidence interval [CI] = .24‐.80). The strongest predictor of receiving recommended ART was health acuity (OR = 1.51; 95% CI = 1.20‐1.88). CONCLUSION People living with HIV in NHs do not always receive lifesaving ART, but the reasons are unclear and appear unrelated to economic barriers. J Am Geriatr Soc 68:777–782, 2020

Use of antiretroviral therapy in nursing home residents with HIV

“…We observed that receiving care under the Medicare skilled nursing benefit at baseline was a strong predictor of non‐ART use during NH stays, which confirms previous evidence 8 . People who are admitted to short‐term SNF for post‐acute care are typically covered by Medicare Part A.…”

“…We observed that white residents had a lower likelihood of receiving an ART use compared with black residents. Although this runs counter to prior community‐based studies, 28,29 it is consistent with another NH study 8 . Although we hypothesized whites were more likely to reside in facilities with low HIV experience, our supplementary analyses did not support this explanation.…”

“…Although this runs counter to prior community-based studies, 28,29 it is consistent with another NH study. 8 Although we hypothesized whites were more likely to reside in facilities with low HIV experience, our supplementary analyses did not support this explanation. Further studies are needed to identify other factors contributing to the low use of ART in NH residents.…”

“…Note that when one of the previous papers examined only "preferred" ART regimens, their findings were very similar to ours. 9 Additionally, the one previous study that looked only at long-stay residents, making it directly comparable to our study, included only 694 patients, 8 as compared with 4171 PLWH in our study.…”

“…We observed that receiving care under the Medicare skilled nursing benefit at baseline was a strong predictor of non-ART use during NH stays, which confirms previous evidence. 8 SNF to long-term care, and has medication coverage through Medicare Part D, this disincentive is no longer present. One explanation for our findings is that patients may be discharged from the hospital with an ART, but the ART is not continued during the SNF stay during Medicare Part A coverage, and when the patient subsequently transfers to long-term care and resumes Part D coverage, providers continue the medication regimen that they were on during the SNF stay, missing the ART.…”