The first time someone newly diagnosed with HIV takes antiretroviral medication in his office—two pills, swallowed together—Dr. Jason Halperin holds their hand. It’s a gesture of support, of hope, that seems to happen naturally. It conveys not only that this is the first step to living an entirely normal life despite this diagnosis, but that he, their doctor, is going to be right beside them as they begin to get better.
Halperin works in New Orleans, the city with the fourth-highest new HIV infection rate in America, in Louisiana, a state with the third-highest rate overall, and in the South, the region with far and away the most new HIV diagnoses in the nation, more than the rest of the country combined. But as a doctor in Louisiana, he has two tools available that are uncommon to some other states with such high HIV case rates: A special program that rapidly places new patients on antiretroviral medication, often within 24 hours of diagnosis, and expanded Medicaid, a federal program under the Affordable Care Act that allowed states to widen the eligibility for Medicaid coverage.
The first, the CrescentCare Start Initiative, is a cutting-edge strategy for disseminating medication proven to be the fastest way to reduce HIV viral loads in a patient, thereby quickening the time it takes for the disease to be undetectable in their blood and thus scientifically untransmittable. Miami, San Francisco, and New York all employ similar programs. The second, Medicaid, which covers a wide range of HIV medication and services, is seen as key to curbing the epidemic by decreasing the number of uninsured people with HIV. Halperin says Medicaid is an especially vital component of rapid HIV treatment.
Yet as President Donald Trump promises to end the epidemic in a decade, he’s left out one of the most effective tools to fight the disease.
“Together, we will defeat AIDS in America and beyond," Trump declared in his State of the Union address Tuesday night. The goal is to reduce new HIV infections by 75 percent in five years and by at least 90 percent in 10 years. The plan will funnel an unspecified amount of funding to counties and regions with the highest rates of new HIV infections. But Medicaid, or health insurance of any kind, is absent from the proposal.
Almost 40 percent of people with HIV live in states without expanded Medicaid, a statistic that’s more politics than policy: Many of those states are controlled by the GOP. Trump and most of the Republican Party campaigned heavily on repealing the Affordable Care Act in 2016, and his administration has been looking for ways to undermine the law ever since, including pushing back against expanded Medicaid. In the latest effort, GOP leaders in Utah and Idaho are currently working to restrict access to expanded Medicaid in their states through work requirements or lowering the income threshold, reportedly with the “encouragement” of the Trump administration, after voters approved the expansions in ballot measures in November.
According to research from the Kaiser Family Foundation, a nonprofit research firm, Medicaid is the single largest source of health coverage for people with HIV in America. In states that expanded Medicaid under the Affordable Care Act, the rate of uninsured HIV patients in care halved in just two years, dropping from 14 percent in 2012 down to 7 percent in 2014. The law removed a major barrier to HIV care by raising the qualifying income levels to at or below 138 percent of the federal poverty level ($28,676 for a family of three in 2018) and removing the requirement that HIV-positive people had to be disabled by the disease, says Jennifer Kates, director of global health and HIV at the Kaiser Family Foundation. (In Louisiana, it halved the number of uninsured adults.) Kates calls Medicaid a “fundamental” part of fighting HIV.
Halperin agrees. Rapid HIV treatment programs rely on ongoing access to medication, a process streamlined by Medicaid, he says. The demographics of Medicaid patients also match the populations who are at highest risk for HIV, he says. New infections are highest among African-American and Latino men who have sex with men and those between the ages of 25 and 34. “We know these communities of color that identify as gay or bisexual are at a significantly lower socioeconomic status, and most often will meet the criteria for Medicaid.”
When new patients visit CrescentCare, the HIV/AIDS clinic where Halperin works, they’re typically assessed that day for whether they qualify for Medicaid, and if they do, staff help them apply for it on the spot. The CrescentCare Start Initiative has seen 150 patients within one to three days of a diagnosis since launching in 2016. At the start of treatment, 40 percent of patients are already on Medicaid. After one month of treatment, that number jumps to 78 percent.
Instead of paying for care through health insurance, the Trump administration's plan appears to rely heavily on boosting funding via the Ryan White HIV/AIDS Program, named after a young teenager who fought HIV/AIDS stigma after contracting the disease through a blood transfusion. The program provides HIV/AIDS healthcare and other supports through federal grants and has been crucial to fighting the disease. Halperin says that before expanded Medicaid, Ryan White grants provided the main source of funding for patient medications, but that in epidemic hot spots like New Orleans, it wasn’t always enough. The grants are a set amount of money and don’t operate indefinitely.
“It was not that long ago in Louisiana, go back five or 10 years, that we had waiting lists to access medication through Ryan White,” he says. Expanded Medicaid lets the clinic use Ryan White funding for more expansive services and supports and to fund the care of undocumented immigrants, he adds.
The president’s plan also focuses heavily on expanding the use of PrEP—a drug that, taken once a day, is more than 90 percent effective at preventing HIV infections, and which hasn’t been covered by Ryan White funding. Its widespread use is considered essential among at-risk populations, and two recent studies show that states with expanded Medicaid, which does cover PrEP, have significantly boosted the use of the drug. In one, patients with health insurance were four times more likely to take PrEP. In another, states with expanded medicaid had twice the number of PrEP users compared to HIV infections.
For Kates, “the biggest question for the plan is how much money will be provided.”
If the funds are great enough, that could offset the absence of including the use of health insurance, she says. The program might be able to provide enough money in counties without expanded Medicaid to counteract that significant drawback. But “in those places where there’s no Medicaid expansion, the success might be slower or less,” Kates adds. And if expanded Medicaid is rolled back in some way, that would change the equation again.
In New York, expanded Medicaid has been part of a multi-pronged approach to fund healthcare for HIV-positive people, and its success is clear, notes Johanne Morne, the director of the AIDS Institute at the New York State Department of Health. "You look at the numbers of individuals who have been diagnosed, the number of individuals in care, the number of individuals who are virally suppressed.” But she stresses that states without expanded Medicaid can still do important work. “The bigger conversation here is that there’s great opportunity across the country to end this epidemic,” she says.