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IDU and HIV in the Middle East: a brief window of opportunity?

22 Jul, 14 | by Leslie Goode, Blogmaster

There are regions of the world where intravenous drug use (IDU) is known to have a key role in evolving HIV epidemics.  Information about IDU populations, on the basis of which to motivate and inform public health interventions, can be scant and of poor quality (STI/Aceijas & Hickman).  This deficiency is particularly important to address, given the possibility in some contexts of these populations serving as a bridge into other populations (STI/Reza & Blanchard; STI/Decker & Beyrer), and the practicality and cost-effectiveness of interventions that could make a difference (e.g. needle/syringe exchange programmes) (STI/Demyanenko & Vagaitseva; STI/Boci & Hallkaj).

The Middle East and North Africa (MENA) is among the regions of the world in which IDU might be expected to be a key epidemiological factor – given the availability and cheapness of drugs (US$ 4 per gram of heroine, as against US$ 100 in Europe).  But, as recently as 2005, the region was characterized as “as real hole in terms of HIV/AIDS epidemiological data” – let alone in terms of IDU HIV data.  STI/Reza & Blanchard in an alarming study of epidemiological bridging in Pakistan do not include other MENA countries among the epidemiological parallels to which they refer – perhaps because of the lack of data.

A recent systematic review by Mumtaz & Abu-Raddad (M&R) may go some way to addressing this need, but points to the importance of further research.  M&R review and synthesize data from sources (e.g. international and regional databases, and country-level reports) relevant to actual and potential HIV risk for IDU populations across 23 nations in MENA.  They estimate average IDU over the region at 0.24 per 100 adults, and HIV prevalence in these populations averaging 10-15% (both figures comparable with what we find in other regions).  Among the 10 (23) nations for which good evidence is available, 6 show concentrated epidemics suddenly emerging over the last ten years (Iran, Pakistan, Afghanistan, Egypt, Morocco, Libya), at national (Iran, Pakistan) or local (Afghanistan, Egypt, Morocco, Libya) level; 4-5 others show low level epidemics.

This study delivers a strong message.  Data from countries for which there is evidence of low level IDU HIV epidemics suggests “moderate HIV potential” (i.e. high levels of unsafe practices reflected in prevalence of Hepatitis C and other STIs).  The same, for all anyone knows, may also be true for those 13 countries for which the evidence is not available.  Pakistan saw rocketing levels of HIV (from near 0% to 23% in six months) following introduction of the infection into IDU populations.  Low prevalence countries, including those about which we know little, may have only a brief “window of opportunity” before they experience a comparable explosion of HIV among their own IDU populations.  This, according to M&A makes it imperative to conduct studies in those 13 countries, and to implement further rounds of surveillance in those for which there is already evidence, with a view to making timely and effective interventions.  M&A cite, as evidence of the patchy coverage of IDU by existing prevention services over the region, the very small proportion of the IDU population reporting ever being tested for HIV as indicated by studies conducted in Morocco and Pakistan.

Cultural constraints on the uptake of voluntary medical male circumcision in Eastern and Southern Africa

23 Jun, 14 | by Leslie Goode, Blogmaster

My previous blog spoke of the recent PLoS-Medicine Collection on the progress of a UNAIDS initiative for a five-year scale-up of Voluntary Male Medical Circumcision (VMMC) for HIV prevention in 14 high priority Eastern and Southern African countries.  Among the papers, Ashengo & Njeuhmeli (A&N) and Macintyre & Bertrand (M&B) deal with what the authors of the Collection Review identify as one of the two major obstacles to deployment of the initiative: the insufficiency of demand, especially amongst older (aged 25+) men.  They consider the cultural and social constraints on demand, as these are reflected in the very different cultural contexts of Zimbabwe and Tanzania/Iringa Province (A&N) and Kenya/Turkana County (M&B).

In Tanzania, where circumcision as a cultural practice is widespread, A&N’s figures show a proportion of older men presenting for VMMC through to 2013 of c.6%.  Very few of these were reached through campaigns, as opposed to routine services.  In Zimbabwe, by contrast, where circumcision is not widely practised, the proportion of aged 25+ circumcised through the program was c.33%.  There was much less difference in the age profiles of those accessed by campaign and routine service modalities.  Whereas, in Tanzania there is a cultural perception “that male circumcision is most appropriate before or during puberty” (and older men do not come to VMMC services in a setting that includes mostly adolescent clients) – in Zimbabwe there is less difference between age groups, either in respect to numbers circumcised or preferred mode of access.  Intriguingly, this suggests that the existence of a cultural norm of circumcision may be more of an obstacle than an asset where older clients are concerned.  Of course, this contrast has to be set in the context of the overall advantage in terms of HIV/AIDS prevention conferred on countries like Tanzania by the existence of the cultural norm.  On difficulties of demand in Zimbabwe specifically, see STI/Kaufman & Ross.

A further insight into the potentially negative impact of existing cultural practice is cast by M&B.  Focus group discussions and in-depth interviews in the rural, traditionally non-circumcising area of Turkana County, Kenya, draw attention to perceptions of circumcision amongst older men that are not favourable to their widespread up-take, especially by the older age-group.  The first is the identification of circumcision with the cultural values of other (potentially hostile) groups.  Interestingly, the negative impact of the perception of the practice as imposed from outside, or else non-traditional, has been demonstrated in other non-circumcising cultures (STI/David; STI/Madhivanan & Klausner). The second is the understandable perception that HIV/AIDS is a “new” problem among young urban dwellers (most Turkana sufferers belong in this category) and that circumcision, as a response to this “new” problem, is appropriate for the young, not for older, rural people (see also responses in a study on the acceptability of VMMC in Rwanda: STI/Mbabazi).

The impression that emerges from both studies is that the existence of a cultural practice of circumcision amongst certain groups in a region does not always confer an advantage where potential clients for VMMC are in the older age groups (25+).  In particular, good uptake of VMMC services by adolescents may actually prove an obstacle for older men, reinforcing the cultural perception of VMMC as primarily for younger men.  In this situation service providers may face a choice between strategies that yield the greatest number of circumcisions through an exclusive focus on the younger age-group, and strategies designed to attract a wider diversity of age-groups.

 

The roll-out of UNAIDS voluntary medical male circumcision programmes in sub-Saharan Africa: Is it working?

18 Jun, 14 | by Leslie Goode, Blogmaster

Voluntary medical male circumcision (VMMC) has been demonstrated to reduce HIV acquisition by 60% or more.  WHO and UNAIDS have recommended that VMMC form a part of comprehensive HIV prevention programming in regions of high prevalence, such as sub-Saharan Africa.  Mathematical modelling suggests that the achievement of 80% VMMC coverage within 5 years in 14 countries in Eastern and Southern Africa would avert 3.36m new HIV infections. In the light of this the UNAIDS Joint Strategic Action Framework (JSAF) has set out the goal of circumcising 20.2 million men in five years across these countries. The challenges this represents on both the supply and the demand side are comprehensively discussed by STI/Gray & Kigozi.

A recent PLoS – Medicine Collection considers the progress thus far, and through to 2016, of this initiative.  The Collection Review (Sgaier & Njeuhmeli (S&G)) offers a useful survey. The year preceding the JSAF and the first two years of the initiative have seen yearly VMMC of 0.88m, 1.7m, and 2.9m respectively. If we assume current rates of growth, this would give a cumulative total of 17.5m circumcisions by 2016 – about 3m short of the 20.2m target; if we assume no growth, the cumulative total for this period would be 13.7m.  The scale-up of VMMC over the last three years has been impressive. Still, rates of year-on-year growth have fallen from 109% (2011) to 72% (2013).  S&G identify two factors impeding the achievement of the JSAF goal: first, insufficient funding, largely as a result of the failure of international donors to step in alongside the US President’s Emergency Plan for AIDS Relief (PEPFAR) (which currently bears 80% of the cost); second, the lack of – or failure to create – sufficient demand for VMMC in the targeted countries, especially amongst the older element (i.e. aged 25+) of the population.

The 13 papers in the collection deal with issues around supply of VMMC – such as maintaining quality of service during scale-up (Jennings & Njeuhmeli; Rech & Bertrand; Rech & Njeuhmeli) and optimizing efficiency in service delivery (Rech & Njeuhmeli;  Mahvu & Bertrand; Perry & Bertrand).  But, more interestingly, they also deal with the problem that S&G identify as one of the two main obstacles to achieving the JSAF goal – that of creation of demand (Macintyre & Bertrand; Ashengo & Njeuhmeli).  This important issue will be covered in my next blog.

Gonorrhoea antimicrobial resistance: is UK antibiotic stewarding policy shows “some success”

14 May, 14 | by Leslie Goode, Blogmaster

A widely circulated press release from the Society of General Microbiology’s (SGM) Annual Conference 2014 (April 14th – 17th) reports that Health for England’s Gonorrhoea Resistance Action Plan, according to representative, Dr Catherine Ison, “has shown some success in delaying the onset of treatment failure to the oral antibiotic cefixime”.  At issue here is the policy of switching to intra-muscular ceftriaxone with azithromycin as the first line treatment for gonorrhoea in the face of alarming evidence of an increase in gonococcal resistance to oral cefixime – a policy that aims to delay the emergence of cefixime resistance, and so “steward” our last remaining antibiotic defences against the infection (STI/blogs/Ison & Lowndes).

So the reprieve continues, we are to assume – in the absence from the press-release of even a head-line figure in support of Ison’s bare claim to “some success”.  If we turn to the Gonococcal Resistance to Antimicrobials Surveillance Programme’s last report (GRASP 2012: published October 2013) we find that the prevalence of GUM isolates exhibiting decreased susceptibility to cefixime (MIC ≥0.125 mg/L) declined significantly in MSM from 17% in 2011 to 7% in 2012, and in females from 3% in 2011 to 1.6% in 2012 (though isolates from heterosexual men show little change in cefixime MICs), following alarming increases in resistance from 2007-2010. In June 2013, Ison & Lowndes (I&L) (STI/blogs/Ison & Lowndes) noted a “striking association” between this decline in resistance and the change in UK prescribing practice referred to above, though “causality cannot be attributed to this observation” (Ison: Doctor’s Channel).  (Any argument for causality would, as a minimum, require precise information regarding the timing of the policy change – which is conspicuously absent from the I&L paper).  The SGM press-release appears to indicate a continuation of the same downward trend, and presumably offers further endorsement for the policy adopted at some point in 2011.

The SGM devoted a Report to sexually transmitted infections in 2013 (SGM – 2013). Anti-microbial resistance (most urgently, at present, in gonorrhoea) heads the list of three research challenges.  Recommendations include investment in research to track the impact of new interventions (e.g. optimizing the use of existing antibiotics), and extending lessons learned on gonorrhoea to understand treatment failure in chlamydia and mycoplasma genitalium – as well, of course, as initiating a drug development strategy that addresses the current problems of market failure.  Interestingly, however, the second challenge, that of rapid diagnosis of bacterial STIs, is also highly relevant to the problem of stewarding antibiotic defences.  The future development of enhanced diagnostic point-of-care tests based on genomic rapid sequencing techniques could enable a more “tailored” response to infection, based on profiling antibiotic susceptibility in the individual case, which would facilitate switching back to “abandoned” antibiotics where the their resistance profile disappears from the local population.

Needless to say, the development of new antibiotics (potentially Cempra’s solithromycin or AstraZeneca’s AZD0914), and of rapid sequencing-based diagnostic techniques, are in the future.  Meantime, the reprieve achieved through stewarding of cephalosporins may, says Ison, be short-lived.

 

 

 

Responding appropriately to differentials in HIV care outcomes – are local answers needed?

12 May, 14 | by Leslie Goode, Blogmaster

The recent discovery of the preventative potential of anti-retroviral therapy (ART) (STIs/blog/modelling ART impact)  throws into sharp relief the challenge represented for the US by the very inadequate proportion of its 1.2 million HIV+ citizens (<30%) who are virally suppressed.  Nunn & Mayer  use new geographical mapping tools to bring home forcibly the epidemiological dimension of the problem by visualizing the association which HIV+ incidence/mortality show with social status and ethnicity as reflected in residence.  The picture that emerges is of an enormous concentration of the problem in certain very circumscribed neighbourhoods.  To give just one example of what is best conveyed in the diagrams (figures 1 & 2), age-adjusted death rates rise from <11.2 per 1000 people living with AIDS (PLWHA) to 19.4-32.5 per 1000 PLWHA as one passes from a predominantly white neighbourhood with large gay population and high rates of HIV/AIDS (≥2142 per 100,000 population) to the predominantly Afro-Caribbean neighbourhood of Harlem.

For Nunn & Mayer (N&M), these visualizations raise the question whether either (1.) the allocation of resources to metropolitan areas, or (2.) the nature of the strategies employed by public health interventions, reflects the very geographically focussed nature of the problem of HIV/AIDS incidence and mortality.  Their response to the epidemiological dimension of the problem revealed by their mapping tools is to urge the importance of implementation research as a vital component of HIV initiatives.

N&M’s emphasis on viraemia suppression, rather than just HIV incidence, accords well with their insistence of the epidemiological importance of the local dimension.  Retention in care is a factor that is presumably amenable to initiatives at local level – whereas HIV incidence may owe much to transmission through sexual contacts external to the community (STI/blog/Grabowski & Gray).

Their message is in line with increasing public health interest over recent years in “program impact evaluation methods that take account of the complex interactions among interventions and between intervention packages and the context into which they are introduced” (STIs/Aral & Blanchard).  There is surely a strong argument in favour of designing interventions to take place within an evaluative framework allowing a reflection on the kind of program mix likely to be most effective in a given context.  On the other hand, N&M may be in danger of undervaluing the potential of interventions of a non-localized character that act on the socio-economic determinants of the HIV problem, and especially non-retention in care – for example, the wider provision of medical insurance (STI/blogs/ObamaCare).  It would be interesting to see how far a geographical mapping of the incidence of other health problems in New York or Philadelpia coincided with N&M’s mapping of HIV/AIDS mortality.  How far is the effect of “micro-epidemics”, conjured up by epidemiological language, just a reflection of socio-economic determinants that produce identical results wherever they happen to be present?

 

 

Shared needles for Viagra injection fuel STIs among the Korean elderly

1 May, 14 | by Leslie Goode, Blogmaster

UK BBC radio’s 4’s Korean correspondent, Lucy Williamson refers in last Tuesday’s Crossing Continents to a category of STI transmission through IVDU, which is unlikely to be familiar to our readers.  A recent article in the Korea Times  gives further details.  The individuals at risk are the 16% of South Korean seniors (65+) in Seoul who pay for sex (Korea Herald).  The means of transmission are the syringes used by elderly prostitutes carrying on trade in soft drinks (Korean-style Bacchus) to inject their elderly patients with Viagra, and then “recycled” – according to the interview, “ten or twenty times, or until the needle breaks”.  No surprise, levels of STIs among these elderly partners were found by a recent survey to be as high as 40%.

The proportion of seniors in Seoul who pay for sex (16%) (half of these five times over the last two years) seems high. The percentage of individuals who use sex workers varies enormously between countries, as does the age profile of the typical user (Prostitution: the Johns Chart).  By comparison, rates of use in the US and a number of European countries stand at around 20%, in Spain and Italy nearer 40%, though the typical user is likely to be in his 30s or 40s – not his 60s and 70s.  (For the situation in the UK, see STIs/Ward & Mercer).

Prostitution is illegal in Korea, and most safe-sex counselling is aimed at young people.  “There is a great lack of instructors for sex education for senior citizens”, says a welfare professor at Baekseok University.  “We also need to create quality programs, through which senior citizens can meet friends of the opposite sex and form wholesome relationships” (Korea Herald) .

This problem may currently be local to Seoul.  Commentators  attribute it, however, to rising levels of poverty among seniors – a consequence, they argue, of a fast ageing population in a culture that once placed a high value on Confucian values of filial duty, but has now ceased do so.  If these commentators are right, one can well imagine these conditions being replicated in other Asian countries, as they follow the trajectory of Korea.  In which case, Jong-myo Park may be the shape of things to come (Korea Times).

Are African HIV epidemics sustained by exogenous introduction of infection?

24 Apr, 14 | by Leslie Goode, Blogmaster

What is the relative importance of exogenous and endogenous transmission in sustaining HIV epidemics?  In a study of HIV sub-type distribution in the Middle East, Mumtaz & Abu Raddad (STIs) stress the role of multiple exogenous introductions, as evidenced in the wide diversity of genetic sub-types present in most countries.  At a more local level, the answer to our question will, of course, depend on how “exogenous” and “endogenous” are defined – and may have little meaning where we are concerned with the  HIV transmission networks in gay communities that are the object of a number of studies featured in STIs (Potterat & Muth (STIs); Drumright & Frost (STIs)).  Yet, the situation is surely very different when it comes to the kind of geographical communities that are constituted by the studies designed to evaluate the local epidemiological effect of ART deployment – such as HPTN 071 study in Zambian and South Africa.  Here, the location of the communities targeted by the trial establishes a clear boundary, and gives meaning and importance to our question.  How far are the preventative effects of ART coverage within the community likely to be neutralized by introductions that are exogenous to it?

Grabowski & Ray, in recent analysis of data deriving from the Rakai Community Cohort Study, Round 13 (2008-9), has sought to give some insight into the spatial dynamics of HIV transmission, through investigating a cohort of 14,594 individuals in 46/50 communities in the Rakai region of Uganda.  Its goal: to determine the relative epidemiological importance, in this particular context, of transmissions within the household, across the boundary of the household but within the community, and across boundary of the community.  A difficulty foreseen by the study is that transmissions from outside tend to be less easily traced.  The researchers have therefore adopted a multi-faceted approach:  an analysis of the spatial clustering (1) and a phylogenetic analysis (2) are complemented by an analysis of individual partnerships on the basis of data supplied at interview (3).  The phylogenetic analysis investigated the relationship of phylogenetic clustering (in terms of genetic closeness in the gag and env genes) to geographical location.

The findings of the study suggest the relative importance of repeated introductions of HIV across the community, and indeed, regional boundary, as against the importance of onward transmission through intra-community networks (other than those within the household).  The spatial clustering analysis shows very strong household clustering (RR of HIV+ person, as opposed to non-HIV+ person, being in the same household as another HIV+ person 3.2, and RR 10.8 for incident cases), but practically no clustering outside the household.  The phylogenetic analysis identified 95 clusters, of which 53 (55.8%) spanned households; of these 53, 38 (71.7%) crossed community boundaries; of the 38, 18 (47.4%) spanned geographic regions.  The individual transmission analysis shows 39.5% of new cases from extra-household partners; of these, 62.1% were from partners outside the community; of these (where location of partner was known) 50% outside Rakai district, and geographically dispersed throughout Uganda.

Taken together, the three analyses seem to offer a consistent picture. The surprise is the importance of more exogenous, as against more endogenous, transmissions, with intra-community transmission (excepting within the household) not playing the role that might have been expected.  Of course, these findings may not be generalizable to other sub-Saharan, still less non-African, settings.  But they do raise pertinent questions  to any attempts to evaluate the preventative possibilities of localized ART interventions.

 

HIV/hepatitis C co-infection increases risk of hepatic decompensation

22 Apr, 14 | by Leslie Goode, Blogmaster

A recent study (Lo Re & Vincent (L&J)) presents disquieting findings regarding the relative risk of severe liver complications in HIV/Hepatitis C co-infected patients.

Hepatitis C (HCV) has received particular attention in STIs recently on account of its strong association with HIV sero-positivity in MSM (Yaphe & Klein (STIs)) and because of its growing incidence in some MSM populations (Giraudon & Barton (STIs)).  As for the outcomes of HCV in co-infected patients, there have been studies suggesting the benefit of ART in slowing progression of liver complications; but, L&J claim, theirs is the first to have established a significant difference in the outcomes of HIV co-infected patients.

L&J is a retrospective cohort study involving the records of 10,359 patients receiving care between 1997 and 2010 through the US Veterans Health Administration.  It establishes a relatively higher risk of hepatic decompensation for HCV co-infected, as opposed to HCV mono-infected patients:  HR 1.83 or HR 1.56 (depending on whether death is treated as a “competing risk”).  Cumulative incidence of decompensation at ten years for co-infected and mono-infected was, respectively, 7.4% and 4.8%.

The study also gives an indication of the impact of levels of ART success (in terms of maintenance of HIV RNA levels) on rates of hepatic decompensation in co-infected patients.  Co-infected patients who maintained HIV RNA levels at less than 1000 copies/mL had lower rates of hepatic decompensation than patients who did not, but these rates were still considerably higher than for mono-infected patients: HR 1.44.  Cumulative incidence of decompensation at ten years for co-infected with HIV RNA ≥ 1000 copies/mL was 7.6%.

In addition, the study examined various characteristics associated with higher levels of decompensation in co-infected patients – most interestingly, perhaps CD4 count at the study baseline.  Cumulative incidence of decompensation at ten years for co-infected patients with CD4 <200×106 was 8.1%, as against 6.9% for co-infected with CD4 ≥200×106.

The authors conclude that the considerably greater risk of decompensation in co-infected patients is only somewhat alleviated by effective ART.  They point out that their findings strongly support current guidelines for the earliest possible initiation of ART in co-infected patients, regardless of CD4 count, and may prompt earlier consideration of initiation of HCV to reduce the risk of liver complications

Could Chlamydia treatment failure be the result of genital contamination from persistent gut infection

6 Mar, 14 | by Leslie Goode, Blogmaster

The persistence of Chlamydia trachomatis  (Ct) infection in treated patients is generally attributed either to re-infection or poor treatment adherence.  To some, however, the evidence has suggested the operation of an additional factor – such as treatment failure (STIs/ Goetz & Bruisten; STIs/ Pitt & Ison; STIs/ Horner).

A recent study (Rank & Yeruva (R&Y)) develops an interesting hypothesis, based on evidence of Ct. infection in the gastro-intestinal (GI) tract of mice.  This supports the possibility that Ct. persistence in humans might be a result of ongoing Ct. infection of the gut, and re-infection of the genital via the lower GI tract (Yeruva & Rank).  According to R&Y’s research on animals, Ct. of the GI tract does not elicit an inflammatory response, and never resolves.  It provokes an immune response – but not at a level that would cure the GI infection.  The orthodoxy states that Ct. found in the human GI tract is “non-replicating”.  R&Y claim this not based on evidence.  So they see nothing to exclude the possibility that, in humans, as in mice, treatment failure may be due to auto-innoculation from the lower GI tract.

This hypothesis is highly relevant to discussion of Ct. persistence in this journal, which has arisen around such questions as: whether persistence is due to some factor other than re-infection or poor adherence, such as anti-microbial resistance (STIs/ Goetz & Bruisten; STIs/ Pitt & Ison); how important that factor is, and what it means for Chlamydia screening programs (STIs/ Regan & Hocking).  If R&Y’s hypothesis proves valid for humans as for mice, then that other factor – or, at least, some element of it – is explained, and would certainly need to be taken account of when modelling the effectiveness of screening programs.

The idea that persistence of Ct. in humans results from contamination from persistent GI tract infection seems to be a new one in the STI literature (though apparently cases have been documented by the veterinary literature in numerous animals as early as the 1950s).  It is certainly worthy of further investigation, given the implications that it would have, if proven, for diagnosis and management of human Ct. infection.  In that event, it would be necessary to consider, for example, what importance to attach to the clearing Ct. from the GI tract – and, supposing this to be necessary, how this would affect the nature and duration of treatment given for genital Ct..  In treating rectal Ct., for example, treatment with Azithromycin (≤13%) has been claimed to be inadequate (STIs/ Drummond & Donovan), while Hathorn & Goold find treatment with doxycycline to be a more effective alternative (STIs/ Hathorn & Goold).

HIV impact of ObamaCare reduced by US Supreme Court decision

5 Mar, 14 | by Leslie Goode, Blogmaster

What impact will the roll-out of the US Affordable Care Act (ACA) – ObamaCare – have on health insurance coverage of people with HIV?  A recently published “issue brief” on behalf of the US Centers for Disease Control and Prevention (CDC) offers a first estimate (Kates & Garfield (K&G)).

The ACA includes a provision to expand Medicaid 1. by extending it to non-disabled childless adults (a group at present excluded), and 2. by raising the threshold of eligibility from the present 100% of the Federal Poverty Level (FPL) to 138%.  This would have considerable impact on uninsured HIV infected-people, as a large proportion of them are non-disabled childless adults, and relatively poor.  Thanks to a recent Supreme Court decision, responsibility for the implementation of this ACA provision rests ultimately with state legislatures.  Thus far, only 26 of the 51 states have plans to go ahead with it.  The authors of the brief give estimates, firstly for the impact that the ACA would have had but for the Supreme Court ruling, and, secondly, for the impact it will have, assuming implementation by just the 26 states that of stated their intention to go ahead with it.

In the case of full implementation of Medicaid expansion, say K&G, c.47,000 of the c.70,000 uninsured adults retained in HIV care would immediately be brought under Medicaid, while a further c.20,000 could benefit from the second major ACA provision relevant to the HIV-infected – namely, the subsidized insurance coverage which will be supplied by Health Insurance Marketplaces (HIM).

But, with just 26 states planning to expand Medicaid provision, only c.26,500 additional people will be brought under Medicaid.  Of the c.20,000 who ought to have qualified, but will now fail to do so, some 5,000 may be able to gain subsidized cover with HIM (those at between 100% and 138% of FPL), while the remaining c.15,000 (those under the 100% bar for subsidized coverage by HIM) will remain entirely uninsured.  Many people in this situation will seek coverage under the Ryan White HIV/AIDS program, as they have done in the past.

So the beneficiaries of ACA among the HIV-infected will, according to this brief, be considerably reduced by the Supreme Court ruling.  But does it really matter whether the HIV-infected of the US are treated through an expansion of Medicaid, or through the Ryan White program?

The authors of the brief seem to be in no doubt that ACA would represent an improvement on the present arrangements – and principally for two reasons.  The first has to do the 700,000 HIV-infected (63%) who are undiagnosed, or not linked to – or else not retained in – HIV care.  A proportion of these (the authors reckon as many as 124,000), newly eligible for Medicaid under ACA, could have been brought into regular medical care through the program.  This is the first opportunity missed.  The second has to do with the possibility of addressing the unmet needs of a particularly needy population (i.e. the c.200,000 HIV-infected who are currently uninsured but eligible for cover under ACA) on a more general and ongoing basis than is possible through the Ryan White program.  These, according to K&G, are the benefits which will be largely foregone in states that do not to ratify the expansion of Medicaid.

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