Geographic Variation in Qualified Health Plan Coverage and Prior Authorization Requirements for HIV Preexposure Prophylaxis.

Importance: HIV preexposure prophylaxis (PrEP) is a key component of the Ending the HIV Epidemic (EHE) Initiative to curb new HIV diagnoses. In October 2019, emtricitabine/tenofovir alafenamide was added as an approved formulation for PrEP in addition to emtricitabine/tenofovir disoproxil fumarate; despite availability of another formulation with a similar prevention indication, variations in coverage may limit access. Objective: To assess qualified health plan (QHP) coverage, prior authorization (PA) requirements, and specialty tiering for emtricitabine/tenofovir disoproxil fumarate and emtricitabine/tenofovir alafenamide following emtricitabine/tenofovir alafenamide approval as a PrEP treatment. Design, Setting, and Participants: This cross-sectional study analyzed QHPs in the US that were compliant with the Patient Protection and Affordable Care Act from 2018 to 2020. QHPs were categorized by region and EHE priority jurisdictions. Data analysis occurred from March 2022 to March 2023. Exposures: Enrollment in a qualified health plan certified by the Patient Protection and Affordable Care Act. Main Outcome and Measures: Annual variation in QHP coverage and PA requirement for emtricitabine/tenofovir disoproxil fumarate and/or emtricitabine/tenofovir alafenamide. Descriptive statistics were reported for all outcomes. A secondary outcome was whether the PrEP formulation was determined by the QHP to be placed on a specialty drug tier. Results: A total of 58 087 QHPs (19 533 for 2018; 17 007 for 2019; and 21 547 for 2020) were analyzed. QHPs covered emtricitabine/tenofovir disoproxil fumarate (19 165 QHPs [98.1%] in 2018; 16 970 QHPs [99.8%] in 2019; 20 045 QHPs [94.8%] in 2020) at a higher rate than emtricitabine/tenofovir alafenamide (17 391 QHPs [91.9%] in 2018; 15 757 QHPs [92.7%] in 2019; 18 836 QHPs [87.4%] in 2020). QHPs in the South required exclusive PA (ie, PA for 1 of the formulations even if the QHP covered both) for emtricitabine/tenofovir disoproxil fumarate and emtricitabine/tenofovir alafenamide at the highest rates in all 3 years. In the South, the rate of PA for emtricitabine/tenofovir disoproxil fumarate increased from 806 of 8023 QHPs (10.0%) in 2018 to 3466 of 7401 QHPs (46.8%) in 2020. QHPs with exclusive PA requirement for emtricitabine/tenofovir disoproxil fumarate were higher in EHE jurisdictions than non-EHE jurisdictions (difference: 2018, 0.9 percentage points; 2019, 3.5 percentage points; 2020, 29.1 percentage points). QHPs were more likely to place emtricitabine/tenofovir disoproxil fumarate on a specialty tier compared with emtricitabine/tenofovir alafenamide (difference: 2018, 1.8 percentage points; 2019, 3.7 percentage points; 2020, 4.1 percentage points). Conclusions and Relevance: In this cross-sectional study, despite similar indications for biomedical prevention, QHPs were more likely to cover emtricitabine/tenofovir disoproxil fumarate than emtricitabine/tenofovir alafenamide, and QHPs were also more likely to subject emtricitabine/tenofovir disoproxil fumarate to PA or place it on a specialty tier despite the broader clinical indication. QHP PA requirements of emtricitabine/tenofovir disoproxil fumarate following emtricitabine/tenofovir alafenamide approval does not reflect clinical guidelines. The requirements could reflect differences in clinical indication, manufacturer discounts, or anticipation of a changing regulations and emerging generics. High rates of exclusive PA for emtricitabine/tenofovir disoproxil fumarate in areas where rates of HIV diagnoses are highest and PrEP is most needed (eg, the South and EHE priority jurisdictions) is concerning; policy solutions to address the growing PrEP health equity crisis could include regulator actions and a national PrEP program.

Access to a novel first-line single-tablet HIV antiretroviral regimen in Affordable Care Act Marketplace plans, 2018-2020.

BACKGROUND: A pillar of the United States' Ending the HIV Epidemic (EHE) initiative is to rapidly provide antiretroviral therapy (ART) in order to achieve HIV viral suppression. However, insurance benefit design can impede ART access. The primary objective of this study is to understand how Affordable Care Act (ACA) Marketplace qualified health plan (QHP) formularies responded to two new ART single tablet regimens (STRs): dolutegravir/abacavir/lamivudine (DTG/ABC/3TC; approved in 2014) and bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF; approved in 2018). METHODS: We conducted a descriptive study of individual and small group QHPs to assess coverage, cost sharing (coinsurance vs. copay), specialty tiering, prior authorization, and out-of-pocket (OOP) costs for DTG/ABC/3TC and BIC/FTC/TAF. All individual and small group QHPs offered in state ACA Marketplaces from 2018-2020 were identified using plan-level formulary data from Ideon linked to end-of-year data from Robert Wood Johnson Foundation's Individual Market Health Insurance Exchange (HIX). RESULTS: For 2018, 2019, and 2020, respectively, we identified 19,533, 17,007, and 21,547 QHPs. While DTG/ABC/3TC coverage was above 91% from 2018-2020, BIC/FTC/TAF coverage improved from 60 to 86%. Coverage of BIC/FTC/TAF improved in EHE priority jurisdictions from 73 to 90% driven by increased coverage with coinsurance. Although BIC/FTC/TAF had a higher wholesale acquisition cost than DTG/ABC/3TC, monthly OOP cost trends differed regionally in the Midwest but did not differ by EHE priority jurisdiction status. CONCLUSIONS: QHP coverage of STRs is heterogeneous across the US. While coverage of BIC/FTC/TAF increased over time, many QHPs in EHE priority jurisdictions required coinsurance. Access to new ART regimens may be slowed by delayed QHP coverage and benefit design.

Investigating the Association Between a Risk-Directed Prophylaxis Protocol and Postoperative Nausea and Vomiting: Validation in a Low-Income Setting.

BACKGROUND: The efficacy of postoperative nausea and vomiting (PONV) prevention protocols in low-income countries is not well known. Different surgical procedures, available medications, and co-occurring diseases imply that existing protocols may need validation in these settings. We assessed the association of a risk-directed PONV prevention protocol on the incidence of PONV and short-term surgical outcomes in a teaching hospital in Rwanda. METHODS: We compared the incidence of PONV during the first 48 hours postoperatively before (April 1, 2019-June 30, 2019; preintervention) and immediately after (July 1, 2019-September 30, 2019; postintervention) implementing an Apfel score-based PONV prevention strategy in 116 adult patients undergoing elective open abdominal surgery at Kigali University Teaching Hospital in Rwanda. Secondary outcomes included time to first oral intake, hospital length of stay, and rate of wound dehiscence. Interrupted time series analyses were performed to assess the associated temporal slopes of the outcome before and immediately after implementation of the risk-directed PONV prevention protocol. RESULTS: Compared to just before the intervention, there was no change in the odds of PONV at the beginning of the postintervention period (odds ratio [OR], 0.23; 95% confidence interval [CI], 0.05-1.01). There was a decreasing trend in the odds of nausea (OR, 0.60; 95% CI, 0.36-0.97) per month. However, there was no difference in the incidence of nausea immediately after implementation of the protocol (OR, 0.96; 95% CI, 0.25-3.72) or in the slope between preintervention and postintervention periods (OR, 1.48; 95% CI, 0.60-3.65). In contrast, there was no change in the odds of vomiting during the preintervention period (OR, 1.01; 95% CI, 0.61-1.67) per month. The odds of vomiting decreased at the beginning of the postintervention period compared to just before (OR, 0.10; 95% CI, 0.02-0.47; P = .004). Finally, there was a significant decrease in the average time to first oral intake (estimated 14 hours less; 95% CI, -25 to -3) when the protocol was first implemented, after adjusting for confounders; however, there was no difference in the slope of the average time to first oral intake between the 2 periods ( P = .44). CONCLUSIONS: A risk-directed PONV prophylaxis protocol was associated with reduced vomiting and time to first oral intake after implementation. There was no substantial difference in the slopes of vomiting incidence and time to first oral intake before and after implementation.

Geographic Accessibility of COVID-19 Test to Treat Sites by Race, Ethnicity, Age, and Rurality.

This cross-sectional study explores geographic disparities in antiviral access by quantifying the accessibility of COVID-19 Test to Treat sites for subpopulations by race, ethnicity, age, and rurality.

A Missed Opportunity: Extragenital Screening for Gonorrhea and Chlamydia Sexually Transmitted Infections in People With HIV in a Southeastern Ryan White HIV/AIDS Program Clinic Setting.

Background: Guidelines recommend annual screening for gonorrhea/chlamydia in sexually active people with HIV at multiple sites (urogenital, oropharyngeal, rectal). In the first year of multisite screening at our Ryan White HIV/AIDS Program clinic, we studied (1) sexual history documentation rate, (2) sexually transmitted infection (STI) screening rate, (3) characteristics associated with STIs, and (4) the percentage of extragenital STIs that would have been missed without multisite screening. Methods: Participants were ≥14 years old with ≥1 in-person medical visit at our clinic in 2019. Descriptive analyses were performed, and adjusting for number of sites tested, a log-binomial model was used to estimate the association between characteristics and STI diagnosis in men. Results: In this cohort (n = 857), 21% had no sexual history recorded. Almost all STI diagnoses were among males (99.3%). Sixty-eight percent (253/375) received appropriate urogenital testing, 63% (85/134) received appropriate oropharyngeal testing, and 69% (72/105) received appropriate rectal testing. In male participants with ≥1 STI test (n = 347), Hispanic ethnicity and having a detectable HIV viral load were associated with an STI diagnosis. Of those diagnosed with an STI who had multisite testing, 96% (n = 25/26) were positive only at an extragenital site. Conclusions: Screening rates were similar across all anatomical sites, indicating no obvious bias against extragenital testing. In males, STIs were more frequently diagnosed in people who identify as Hispanic and those with detectable viral loads, which may indicate more condomless sex in these populations. Based on infections detected exclusively at extragenital sites, our clinic likely underdiagnosed STIs before implementation of multisite screening.

Confederate monuments and the history of lynching in the American South: An empirical examination.

The present work interrogates the history of Confederate memorializations by examining the relationship between these memorializations and lynching, an explicitly racist act of violence. We obtained and merged data on Confederate memorializations at the county level and lynching victims, also at the county level. We find that the number of lynching victims in a county is a positive and significant predictor of the number of Confederate memorializations in that county, even after controlling for relevant covariates. This finding provides concrete, quantitative, and historically and geographically situated evidence consistent with the position that Confederate memorializations reflect a racist history, one marred by intentions to terrorize and intimidate Black Americans in response to Black progress.

Worsening Disparities in State-Level Uptake of Human Immunodeficiency Virus Preexposure Prophylaxis, 2014-2018.

Retrospective analysis of human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) use among individuals with PrEP indications demonstrates worsening disparities in uptake between early- and late-adopting states from 2014 to 2018. To end the HIV epidemic, federal and state governments must close gaps by translating successful policies from early-adopting states to late-adopting states.

Medicaid Expansion's Impact on Human Immunodeficiency Virus Outcomes in a Nonurban Southeastern Ryan White HIV/AIDS Program Clinic.

BACKGROUND: Although the Ryan White HIV/AIDS Program supports high-quality human immunodeficiency virus (HIV) care, Medicaid enrollment provides access to non-HIV care. People with HIV (PWH) with Medicaid historically have low viral suppression (VS) rates. In a state with previously high Qualified Health Plan coverage of PWH, we examined HIV outcomes by insurance status during the first year of Medicaid expansion (ME). METHODS: Participants were PWH ages 18-63 who attended ≥1 HIV medical visit/year in 2018 and 2019. We estimated associations of sociodemographic characteristics with ME enrollment prevalence and associations between insurance status and engagement in care and VS. RESULTS: Among 577 patients, 151 (33%) were newly eligible for Medicaid, and 77 (51%) enrolled. Medicaid enrollment was higher for those with incomes <100% federal poverty level (adjusted prevalence ratio, 1.67; 95% confidence interval [CI], 1.00-1.86) compared with others. Controlling for age, income, and 2018 engagement, those with employment-based private insurance (adjusted risk difference [aRD], -8.5%; 95% CI, -16.9 to 0.1) and Medicare (aRD, -12.5%; 95% CI, -21.2 to -3.0) had lower 2019 engagement than others. For those with VS data (n = 548), after controlling for age and baseline VS, those with Medicaid (aRD, -4.0%; 95% CI, -10.3 to 0.3) and with Medicaid due to ME (aRD, -6.2%; 95% CI, -14.1 to -0.8) were less likely to achieve VS compared with others. CONCLUSIONS: Given that PWH who newly enrolled in Medicaid had high engagement in care, the finding of lower VS is notable. The discordance may be due to medication access gaps associated with changes in medication procurement logistics.

Regional Disparities in Qualified Health Plans' Prior Authorization Requirements for HIV Pre-exposure Prophylaxis in the United States.

Importance: With the goal of ending the HIV epidemic in the United States, access to HIV pre-exposure prophylaxis (PrEP) is essential to help curb new HIV infections. There has been differential uptake of PrEP by region, with the South lagging behind other regions. Discriminatory benefit design (benefit design that prevents or delays people with complex or expensive conditions from obtaining appropriate treatment) through prior authorization requirements could be a systemic barrier that contributes to the decreased PrEP uptake in the South. Objectives: To investigate whether there are regional disparities in prior authorization requirements for combined tenofovir disoproxil fumarate and emtricitabine for qualified health plans (QHPs) and to assess whether any QHP characteristics explain the disparities. Design, Setting, and Participants: This design was a cross-sectional study of QHPs offered in the 2019 Affordable Care Act Marketplace. The QHPs studied included all Affordable Care Act-compliant individual and small-group market plans in the United States. Exposures: The primary exposure was the 4 census regions (Northeast, West, Midwest, and South). Additional covariates included other plan characteristics. Main Outcomes and Measures: Prior authorization requirement for combined tenofovir disoproxil fumarate and emtricitabine at the QHP level. Results: In total, 16 853 QHPs were analyzed (18.2% in the Northeast, 19.5% in the West, 25.0% in the Midwest, and 37.3% in the South). Overall, 18.9% of QHPs required prior authorization for combined tenofovir disoproxil fumarate and emtricitabine. This percentage varied by region, with 2.3%, 6.2%, 13.3%, and 37.3% of plans requiring prior authorization in the Northeast, West, Midwest, and South, respectively. Compared with QHPs in the Northeast, QHPs in the South were 15.89 (95% CI, 12.57-20.09) times as likely to require prior authorization, whereas the Midwest and West were 5.69 (95% CI, 4.45-7.27) and 2.65 (95% CI, 2.02-3.47) times as likely, respectively. Other plan characteristics did not account for the regional variation. Conclusions and Relevance: Compared with QHPs in the Northeast, QHPs in the South were almost 16 times as likely to require prior authorization for PrEP, and the reasons for these disparities are unknown. The prior authorization requirement is a possible barrier to PrEP access in the South, which is the region of the United States with the most annual new HIV diagnoses. There is limited regulation of QHPs' prior authorization requirements. Federal- or state-level health policy laws may be necessary to remove this system-level barrier to ending the HIV epidemic in the United States.

Trends in burden and risk factors associated with childhood stunting in Rwanda from 2000 to 2015: policy and program implications.

BACKGROUND: Rwanda has made substantial economic progress over the past two decades. However, evidence suggests that malnutrition among children remains high in spite of this progress. This study aims to examine trends and potential risk factors associated with childhood stunting from 2000 to 2015 in Rwanda. METHODS: Data for this study come from the 2000 to 2015 Rwanda's Demographic and Health Surveys (DHS), a cross-sectional, population-based survey that is conducted every 5 years. Following prior work, we define stunting based on age and weight as reported in the DHS. We assess the overall prevalence of stunting among children under the age of 5 in Rwanda and then conduct bivariate analyses across a range of policy-relevant demographic, socioeconomic, and health variables. We then incorporate key variables in a multivariable analysis to identify those factors that are independently associated with stunting. RESULTS: The prevalence of stunting among children under the age of 5 in Rwanda declined from 2000 (47.4%) to 2015 (38.3%), though rates were relatively stagnant between 2000 and 2010. Factors associated with higher rates of stunting included living in the lowest wealth quintile, having a mother with limited education, having a mother that smoked, being of the male sex, and being of low-birth weight. CONCLUSIONS: Though overall stunting rates have improved nationally, these gains have been uneven. Furthering ongoing national policies to address these disparities while also working to reduce the overall risk of malnutrition will be necessary for Rwanda to reach its overall economic and health equity goals.