New research has found that the Medicaid expansion facilitated by the Affordable Care Act (ACA) led to increases in the identification of undiagnosed HIV infections as well as gains in the use of HIV prevention services, such as preexposure prophylaxis (PrEP) drugs, according to a press release from the University of Illinois Urbana-Champaign.

Expanding Medicaid was associated with a 13.9% increase in HIV diagnoses, according to the press release. The newly discovered infections were concentrated among individuals likely to be affected by the health insurance expansion, including those who use injectable drugs in low-income and rural counties with a high share uninsured rates before implementation of the ACA.

These changes were not simply due to an increase in infections or in infection risk, the authors said, but are attributable to the expanded access to health insurance through the Medicaid program. They also noted an increase in awareness of HIV status and additional PrEP use.

“We find that HIV diagnoses increased in Medicaid expansion states compared with non-expansion states, and that the general knowledge that HIV can be prevented through prophylaxis drugs also increased,” said Bita Fayaz Farkhad, PhD, an economist and postdoctoral researcher in psychology at the university, in a press release. “When we consider these 2 findings together, out conclusion is that access to health care and health insurance has increased the percentage of people living with HIV who are aware of their status, which is an important finding for HIV prevention efforts. According to 2016 Centers for Disease Control and Prevention estimates, a high proportion of new HIV infections were transmitted by people who were unaware of their HIV-positive status.”

The investigators analyzed the effects of the Medicaid expansion using data from 2010 to 2017 on HIV diagnoses per 100,000, as well as awareness of HIV status and PrEP use before and after states adopted the expansions. They compared the differences between all counties in states that expanded Medicaid and control counties in states that did not expand Medicaid.

As access to health insurance and HIV testing improved with the health insurance expansions, they found that a higher percentage of people living with HIV were newly aware of their status, as reflected in rising numbers of diagnoses.

“Although many social factors contribute to rural-urban and other social-health disparities, health insurance accounts for much of the variation in access to care,” Farkhad said in the press release. “Hence, expanding health insurance coverage has important implications for HIV prevention and disease transmission.”

The study authors also found that the main increase in new HIV diagnoses was from intravenous drug injection.

“This finding is not surprising given that the US is in the midst of an opioid crisis, and the increase in injection drug use has led to a greater risk of illness due to needle sharing,” Farkhad explained. “Because there is no evidence that Medicaid expansions affected substance use, the increase in HIV diagnoses attributed to injection is consistent with the improved access to care among those with substance use disorder. Also, people with substance use disorders were more likely to be uninsured prior to the ACA than the general population, which further reinforces the idea that expanding Medicaid is a good thing for public health.”

The investigators said their findings have important health policy implications. In order to eradicate HIV, they said increasing health coverage will be essential. Without that, HIV will continue to spread and individuals will be unaware of their status.

“For [coronavirus disease 2019], public health officials are constantly emphasizing how important it is for people to test, test, test,” Farkhad said in the press release. “And it’s the same idea here. We show how important it is to have insurance coverage to increase testing, and that those extra tests were necessary and have increased the rate of HIV diagnosis.”

Medicaid expansion helps uncover undiagnosed HIV infections [news release]. University of Illinois at Urbana-Champaign; January 26, 2021. Accessed January 29, 2021.