Antiretroviral Therapy Changes for Medicare Beneficiaries With HIV Transitioning to Long-Term Care

JAMA Network Open · 2025-12-12

Importance: Studies of nursing home (NH) residents show lower than expected antiretroviral therapy (ART) use, but it is unclear whether ART use changes across the transition from the community to long-term NH stay. Objective: To examine changes in ART use across the transition from the community to long-term NH stay. Design, Setting, and Participants: This retrospective cohort study examined long stays in US NHs for people with HIV in a sample of 5% of Medicare claims from 2014 to 2019. Stays were at least 30 days long, had at least 3 months between multiple stays, and were for those continuously enrolled in Medicare for the stay and 6 months before. Analysis was completed in May 2025. Exposures: Admission year demographics included age, race and ethnicity (non-Hispanic Black, non-Hispanic White, and other [American Indian or Alaska Native, Asian or Pacific Islander, other, and unknown]), binary sex, Medicaid eligibility, whether the stay was preceded by a skilled nursing stay, and whether disability was Medicare original eligibility. NH characteristics included for-profit status, census region, and facility quality rating. Main Outcomes and Measures: Linear regression estimated changes in the proportion of days covered by 3-drug ART, and hierarchical multinomial logistic regression estimated the risk of never having, losing, or gaining ART vs always having it, across the transition from the community to long-term NH stay. Results: There were 713 long NH stays for 657 people with HIV (mean [SD] age, 61.0 [11.4] years) across 598 facilities; 271 stays (38%) were for people aged 65 years and older. Only 23 individuals lost ART (3%), 97 individuals (14%) gained ART, 185 individuals (26%) never had ART, and 408 individuals (57%) always had ART across the transition. Excluding those who lost ART, all other groups were mostly men (never, 132 men [71%]; always, 289 men [71%]; gained, 72 men [74%]) and Black (never, 85 individuals [46%]; always, 237 individuals [58%]; gained, 58 individuals [60%]). There was an increase in the proportion of days covered (mean intercept α = 13.92; 95% CI, 9.57-18.29). Compared with always having ART, Black race (relative risk [RR], 0.52; 95% CI, 0.35-0.77), polypharmacy (RR, 0.41; 95% CI, 0.23-0.74), and disability as original Medicare eligibility (RR, 0.47; 95% CI, 0.29-0.77) were associated with lower risk of never having ART. For-profit facilities were associated with higher risk (RR, 1.63; 95% CI, 1.03-2.59) of never having ART. Polypharmacy was associated with lower risk of gaining ART (RR, 0.15; 95% CI, 0.05-0.49). Conclusions and Relevance: These findings suggest that long-term NH stays may be associated with improved ART use among people with HIV because most stays without ART never had ART before admission.

Association Between Medicaid Prescription Drug Caps And Antiretroviral Adherence Among People Living With HIV

Health Affairs · 2025-12-01 · 1 citations

To control spending, some state Medicaid agencies "cap" the number of prescriptions that a beneficiary can fill each month, presenting a potential barrier to medication adherence for people with chronic health conditions. To evaluate the association between Medicaid prescription drug cap policies and antiretroviral therapy (ART) adherence among people living with HIV, we compared beneficiaries in four states with caps to beneficiaries in eight states without caps during the period 2016-19. In three of four cap states, cap status was associated with a 9 percent relative reduction in the percentage of days covered by ART over the course of twelve months compared to noncap states, and a 24 percent relative reduction in the likelihood of achieving optimal ART adherence (90 percent or higher) over the course of twelve months. The association was stronger for people with higher baseline ART adherence or more baseline comorbidities. We also identified racial and ethnic disparities, where the magnitude of ART adherence reduction associated with caps was significantly greater for Black and Hispanic people than for White people. Medicaid prescription drug cap policies appear to be both a potential source of racial and ethnic disparity and an impediment to achieving clinical targets for optimal ART adherence among people with HIV.

Frailty, Latent Health Profiles, and Antiretroviral Therapy: Predicting Success of Skilled Nursing Facility Care in an HIV Population

Journal of the American Medical Directors Association · 2025-06-24 · 1 citations

Impact of a Pharmacy Copayment Increase on Medication Use in the Military Health System

Medical Care · 2025-07-01

BACKGROUND: We analyzed the impact of a copayment increase instituted February 1, 2018 for persons covered by the retail or mail order Military Health System (MHS) pharmacy benefit. METHODS: We compared medication use in 2 cohorts in the 12 months before and after the copayment increase: MHS beneficiaries between 18 and 64 years old (MHS cohort), and MHS beneficiaries older than or equal to 65 years old with Medicare (Medicare cohort). Subjects with diabetes, hypertension and hypercholesterolemia were eligible. Using propensity score matching, we compared the control group of those who obtained medications at military pharmacies ($0 copay) to those who experienced a copay increase. The outcome variable was any use of condition-specific medication. RESULTS: In the MHS cohort there were 30,753, 46,965, and 59,783 non-unique persons with diabetes, hyperlipidemia, and hypertension, respectively, in the intervention and control groups. In the Medicare cohort there were 45,977, 205,363, and 365,628 non-unique persons, respectively. The post-period mPDC differences for the MHS cohort were 0.02 (95% CI: 0.01, 0.03), 0.03 (95% CI: 0.02, 0.03), and 0.03 (95% CI: 0.01, 0.03) for the diabetes, hyperlipidemia, and hypertension cohorts, respectively. The post-period mPDC differences for the Medicare cohort were 0.01 (95% CI: 0.01, 0.02), 0.03 (95% CI: 0.03, 0.04), and 0.01 (95% CI: 0.01, 0.02), respectively. CONCLUSIONS: The small (1-3 percentage point) copayment increases are unlikely to have had adverse clinical effects. Insurers and policy-makers should understand that even small copayment increases can impact the use of clinically important medications and should carefully consider the tradeoffs.

The relationship of age and comorbid conditions to hospital and nursing home days in Medicaid recipients with HIV

AIDS · 2024-02-21 · 2 citations

OBJECTIVE: To determine how aging impacts healthcare utilization in persons with HIV (PWH) compared with persons without HIV (PWoH). DESIGN: Matched case-control study. METHODS: We studied Medicaid recipients in the United States, aged 18-64 years, from 2001 to 2012. We matched each of 270 074 PWH to three PWoH by baseline year, age, gender, and zip code. Outcomes were hospital and nursing home days per month (DPM). Comorbid condition groups were cardiovascular disease, diabetes, liver disease, mental health conditions, pulmonary disease, and renal disease. We used linear regression to examine the joint relationships of age and comorbid conditions on the two outcomes, stratified by sex at birth. RESULTS: We found small excesses in hospital DPM for PWH compared with PWoH. There were 0.03 and 0.07 extra hospital DPM for female and male individuals, respectively, and no increases with age. In contrast, excess nursing home DPM for PWH compared with PWoH rose linearly with age, peaking at 0.35 extra days for female individuals and 0.4 extra days for male individuals. HIV-associated excess nursing home DPM were greatest for persons with cardiovascular disease, diabetes, mental health conditions, and renal disease. For PWH at age 55 years, this represents an 81% increase in the nursing home DPM for male individuals, and a 110% increase for female individuals, compared PWoH. CONCLUSION: Efforts to understand and interrupt this pronounced excess pattern of nursing home DPM among PWH compared with PWoH are needed and may new insights into how HIV and comorbid conditions jointly impact aging with HIV.

Attitudes of Black American Christian church leaders toward Opioid Use Disorder, overdoses, and harm reduction: a qualitative study

Frontiers in Psychiatry · 2024-04-03 · 4 citations

Introduction: Black American Christian church leaders are trusted community members and can be invaluable leaders and planners, listeners, and counselors for Opioid Use Disorder (OUD) sufferers in the opioid overdose crisis disproportionately affecting the Black community. This qualitative study examines the extent to which the knowledge, attitudes, practices, and beliefs of Black American church leaders support medical and harm reduction interventions for people with OUD. Methods: A semi-structured interview guide was used to conduct in-depth interviews of 30 Black Rhode Island church leaders recruited by convenience and snowball sampling. Results: Thematic analysis of the interviews identified four themes: Church leaders are empathetic and knowledgeable, believe that hopelessness and inequity are OUD risk factors, are committed to helping people flourish beyond staying alive, and welcome collaborations between church and state. Conclusion: Black American Christian church leaders are a critical resource in providing innovative and culturally sensitive strategies in the opioid overdose crisis affecting the Black American communities. As such, their views should be carefully considered in OUD policies, collaborations, and interventions in the Black American community.

Antiretroviral Therapy Use Was Not Associated with Stillbirth or Preterm Birth in an Analysis of U.S. Medicaid Pregnancies to Persons with HIV

Women s Health Reports · 2023-02-01

Background: Using a U.S. based, nationally representative sample, this study compares stillbirth and preterm birth outcomes between women living with HIV (WWH) who did and did not use antiretroviral therapy (ART) during pregnancy, additionally assessing ART duration and regimen type. Methods: Using 2001 to 2012 Medicaid Analytic eXtract (MAX) data from the 14 states with the highest prevalence of HIV. We estimated two, propensity score matched, multivariate logistic regression models for both outcomes of stillbirth and preterm birth: (1) any ART use and (2) the number of months on ART during pregnancy for ART users, adjusting for patient-level covariates. Results: Only 34.6% of pregnancies among WWH had a history of ART use and among those, the proportions of stillbirth and preterm birth were 0.9% and 7.9%, respectively. Any ART use was not significantly associated with either outcome of stillbirth (marginal effects [MEs]: 0.06%, 95% confidence interval [CI]: -0.17 to 0.28) or preterm birth (ME: -0.12%, 95% CI: -0.79 to 0.55). For ART users, duration of ART was not significantly associated with either outcome. Black race was a strong independent predictor in both models (stillbirth: 0.80% and 0.84%, preterm birth: 4.19% and 3.76%). Neither protease inhibitor (PI) nor boosted PI regimens were more strongly associated with stillbirth or preterm birth than nucleoside reverse transcriptase inhibitor-based regimens. Conclusion: ART use during pregnancy was low during this period. Our findings suggest that ART use and ART regimen are not associated, positively or negatively, with stillbirth or preterm birth for mothers with Medicaid. Additionally, our findings highlight a persisting need to address disparities in these outcomes for Black women.

Does the Quality of Behavior Change Counseling in Routine HIV Care Vary According to Topic and Demand?

AIDS and Behavior · 2023-10-04 · 1 citations

Comparing ambulatory commercial spending in Rhode Island and Massachusetts, 2016–2019

Health Services Research · 2023-05-12 · 1 citations

OBJECTIVE: To evaluate trends and drivers of commercial ambulatory spending and price variation. DATA SOURCES AND STUDY SETTING: Commercial claims data from the Massachusetts and Rhode Island All-Payer Claims Databases from 2016 to 2019. STUDY DESIGN: Observational study of spending in major ambulatory care settings. We calculated per member per year spending, average price, and utilization rates to consider drivers of spending, and constructed site-specific price indices to evaluate price variation. DATA COLLECTION/EXTRACTION METHODS: We analyzed commercial claims data from All-Payer Claims Databases in the two states. PRINCIPAL FINDINGS: Ambulatory spending levels in Massachusetts were 38.0% higher than those in Rhode Island in 2019. Overall utilization rates were similar, but Massachusetts had a 6.2 percentage point higher share of visits occurring in hospital outpatient departments (HOPD). Average prices were 31.5% higher in Massachusetts in 2016 and 36.4% higher in 2019. We observed extensive price variation in both states across both office and HOPD settings. CONCLUSIONS: States seeking to address increases in health care spending, including those with cost growth benchmarks and rate review policies, should consider additional interventions that mitigate market failures in the establishment of commercial health care prices.

Does the Quality of Behavior Change Counseling in Routine HIV Care Vary According Topic and Demand?

Patient Education and Counseling · 2023-03-03 · 1 citations