In the first year after Virginia expanded Medicaid under the Affordable Care Act (ACA), Virginians living with HIV who newly qualified for coverage still lagged behind peers with other kinds of insurance in achieving viral suppression, according to data published in Open Forum Infectious Diseases.

This contrasts with many studies that have found that, in general, Medicaid expansion is associated with better engagement in care and more people achieving an undetectable viral load. But most of those studies based their findings on overall populations and didn’t differentiate based on age or baseline viral load.

Ryan White clinics and the AIDS Drug Assistance Program (ADAP) cover HIV care, but Medicaid expansion allows people receiving such care to access the gamut of primary care services. This can free up Ryan White resources to offer more wraparound services to people with HIV, which is thought to increase the number of people who then achieve viral suppression.

To study this, Kathleen McManus, MD, an assistant professor of medicine at the University of Virginia School of Medicine, and colleagues used data from 577 people who received HIV care at a single Ryan White clinic in nonurban Virginia in 2018 and 2019. Just over half of the participants (54%) were Black, Latino or otherwise not white, 69% were men and close to half (41%) had incomes below the federal poverty level in 2019: $12,490 for an individual or $25,750 for a four-person household. And while the clinic wasn’t in an urban center, 62% of people who attended the clinic were city residents.

A third of the clients were thought to have qualified for Medicaid expansion in 2019, since they earned $17,236 or less as an individual in 2019 (or 138% of the federal poverty level) and therefore were eligible to be covered by Medicaid in 2019 but not in 2018. Of those, about half, 77 clients, decided to actually enroll in the public health insurance program.

The researchers found that those who did enroll in Medicaid showed up to the clinic on a regular basis (90% versus 78% of those who didn’t enroll in Medicaid), but they had a low rate of viral suppression. At the outset of 2019, 84% of people newly enrolled in Medicaid had an undetectable viral load, compared to 88% of those who didn’t enroll.

At the end of the trial, 94% of clinic clients achieved an undetectable viral load. But that’s among everyone receiving care at the clinic—people who newly qualified for Medicaid, those already receiving Medicaid, those on Medicare, those with ACA marketplace insurance provided through ADAP and other types of insurance. For the 77 clinic clients with new access to Medicaid through expansion in 2019, 85% achieved an undetectable viral load, up 1% from the beginning of the study period. That’s 2% less than those who’d already had Medicaid, 87% of whom had an undetectable viral load.

Meanwhile, people with other kinds of insurance or even no insurance had much higher rates of viral suppression: 99% of those with private employer–based insurance achieved viral suppression, as did 97% of those receiving care through Medicare, 96% of people with no insurance and 95% of those with other private insurance.

This disparity persisted even after adjusting for baseline viral load and age. People with established Medicaid had a 4% lower likelihood of achieving an undetectable viral load, while those newly qualified for Medicaid had a 6% lower likelihood.

The finding was unexpected, wrote McManus and colleagues, who noted that those with new access to Medicaid were doing everything right in terms of showing up for their appointments. Still, the percentage of clients who achieved an undetectable viral load was higher than the overall Ryan White program rate and suggests that people at the study clinic received “robust comprehensive HIV care.” The authors wondered whether the gaps in care that can happen when people switch to new insurance might be responsible for the lower rates of viral suppression in people new to Medicaid.

Still, that didn’t fully explain the gap between people covered by Medicaid and those who weren’t.

“It is concerning in a clinic that supports achievement of [viral suppression] by more than 90% of [people living with HIV] receiving care that there is a disparity in [viral suppression] outcomes for those with Medicaid,” wrote McManus and colleagues. That means “they are not experiencing the associated benefits of viral suppression, including longevity and U=U [Undetectable Equals Untransmittable].”

Click here to read the full study.