Viral Suppression for People with HIV with Low Incomes: Study of Disparities, Health Equity, and Best Practices

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PROJECT SUMMARY/ABSTRACT People with HIV (PWH) need consistent access to care and antiretroviral therapy (ART) to achieve the sustained viral suppression (VS) critical for individual health (reduced morbidity, comorbidities, and mortality) and public health (preventing transmission of HIV). The United States (US) has significant geographic disparities in HIV VS for PWH with low incomes who rely on state AIDS Drug Assistance Programs (ADAPs), ranging 53% to 99%. ADAPs support 26% of PWH in the US with a $2.4 billion annual budget. As a key part of the US HIV healthcare delivery safety net, ADAPs provide free ART by direct provision or through ADAP-subsidized insurance plans. ADAP implementation varies widely because individual state ADAPs have decision-making flexibilities for health- care delivery programs and policies. Additionally, how ADAPs perform for different subgroups remains unknown. Understanding how ADAPs can optimize VS could reduce healthcare costs, because each HIV infection averted saves $402,000. To support ending the US HIV epidemic, our long-term goal is to use epidemiologic, including causal inference framework, and qualitative methods, to identify how to improve VS for all PWH, including those with low incomes, through healthcare delivery programs. With a focus on disparities and health equity, our over- arching research question is what specific healthcare delivery programs and policies for PWH with low incomes increase sustained VS rates and reduce VS disparities related to race/ethnicity? Our team has studied ADAPs since 2014. Our study results have been used to advocate to successfully change healthcare laws. The Principal Investigator, the only researcher with federal funding to study this aspect of HIV healthcare delivery, and the interdisciplinary team will use expertise in novel causal epidemiology and qualitative methods. We have partner- ships with the National Alliance of State & Territorial AIDS Directors (NASTAD) and six state health departments providing access to multistate individual-level data (comprising 20% of ADAP clients; including ADAPs at VS rate extremes), and for a national study, we will interview AIDS/ADAP leadership. We will complete the following: Aim 1: we will decompose disparities in sustained VS related to race/ethnicity. We will quantify the mediating effect of a modifiable factor, ADAP healthcare delivery programs. Aim 2: we will quantify potential improvements in sustained VS for individual state ADAPs informed by state ADAP client mix. Using simulation for all state ADAPs, we will estimate the impact on sustained VS of ADAP clients changing to specific ADAP programs. Aim 3: we will perform interviews of AIDS/ADAP Directors across the nation. Using qualitative analyses, we will iden- tify the ADAP programs and policies that improve VS and improve health equity. Successful completion of this work will provide evidence to inform state/federal regulation and resource prioritization toward the goal of helping people achieve VS and interrupting HIV transmission. Our findings would allow state ADAPs, advocates, policy- makers, and Ending the HIV Epidemic initiative leaders to adopt best practices identified from our study and to develop new interventions (laws, guidance, funding) to optimize VS- translating data into policy and action.