Financial Barriers and Lapses in Treatment and Care of HIV-Infected Adults in a Southern State in the United States

Abstract

Antiretroviral (ARV) adherence has largely been considered from the perspective of an individual's behavior with less attention given to potential structural causes for lapses in treatment, such as the cost of medications and care. HIV medication expense is typically covered by third party payers. However, private insurance premiums and deductibles may rise, or policies terminated such as with a change in employment. Likewise, a patient's eligibility for publicly funded coverage like state AIDS Drug Assistance Programs (ADAP) or Medicaid can also be lost. We conducted a one-time survey of a sample of 300 patients receiving HIV care at a single large academic center in the south of United States to examine lapses in HIV therapy due to financial reasons. We found that during the prior year, financial issues including medication cost or coverage led to a lapse in ARVs in 10% (n = 31) of participants. However, of the 42% (n = 125) participants who had been enrolled in ADAP at any time during the prior year, 21% (n = 26) reported an ARV lapse due to problems with ADAP or medication cost. Respondents cited ADAP's required semi-annual renewal process and other administrative issues as the cause of ARV lapses. The median duration of missed ARVs was 2 weeks (range of <1-23 weeks). Non-HIV medication and transportation to and from clinic costs were also identified as financial burdens to care by respondents. In conclusion, although conducted at a single medical center and one state, this study suggests that a significant minority of HIV-infected patients encounter financial barriers to ARV access, and this is paradoxically more common among those enrolled in the state ADAP. Streamlining, supporting, and simplifying ADAP renewal procedures will likely reduce lapses in ARV adherence and persistence.

Postpartum HIV care continuum outcomes in the southeastern USA

“…(30) Other programs designed to provide affordable HIV treatment exist, however, in a recent study conducted in our source study population, patients reported ongoing financial barriers preventing them from accessing HIV care and ART. (31) In this study, WLWH with longer time on prenatal ART were more likely to receive recommended postpartum HIV care. A number of studies have observed that care received prenatally is associated with postpartum care outcomes.…”

“…Among 1416 women participating in the UCHCC, 141 had a live birth between 1996 and 2014 and met study inclusion criteria. The median maternal age at delivery was 28 years (interquartile range [IQR], [24][25][26][27][28][29][30][31][32]. Most women were either non-Hispanic Black (62%) or non-Hispanic White (21%), with 18% of other race/ethnicity including 13% Hispanic ( Table 1).…”

Despite early Medicaid expansion, decreased durable virologic suppression among publicly insured people with HIV in Washington, DC: a retrospective analysis

“…Mental health and substance use comorbidities are additional well-established barriers to medication adherence [15][16][17]. Despite improved access to government-sponsored health insurance, publicly-insured PWH also face structural barriers to health care such as medication copays (a one dollar copay for each DC Medicaid prescription can be a significant financial obstacle for some), decreased health literacy, difficulty renewing public insurance in a timely manner to prevent medication discontinuation, and lack of transportation to pharmacies for medication retrieval [18,19]. Clinical indicators endorsed by the IOM are a one-sizefits-all approach and do not account for insurance status, which may act as a direct marker of socioeconomic status [20].…”

Despite Early Medicaid Expansion, Decreased Durable Virologic Suppression Among Publicly Insured People with HIV in Washington, DC

“…Mental health and substance use comorbidities are additional well-established barriers to medication adherence (15)(16)(17). Despite improved access to government-sponsored health insurance, publicly-insured PWH also face structural barriers to health care such as medication copays (a one dollar copay for each DC Medicaid prescription can be a significant financial obstacle for some), decreased health literacy, difficulty renewing public insurance in a timely manner to prevent medication discontinuation, and lack of transportation to pharmacies for medication retrieval (18,19).…”