A lack in affordable care may lead to HIV resurgence

National Women and Girls HIV/AIDS Awareness Day on March 10 provides an important opportunity to mark the progress that has been made in the fight against HIV/AIDS among women in America.

In just five years, from 2011 to 2015, the number of new HIV diagnoses among women in the U.S. fell by 16 percent and HIV-related mortality continues to decline due to the availability of high-quality treatment and prevention tools.

{mosads}But this progress is being jeopardized as women are losing access to affordable health insurance and necessary services. Recent actions by the Trump administration to dismantle the Affordable Care Act of 2010 (ACA) will reduce access to health care for many, and has placed dangerous restrictions on women’s reproductive rights. Additionally, proposed budget cuts to federal health programs will put women’s health at risk.

While there have been promising declines in new overall HIV cases in America, racial and geographic disparities persist, and the U.S. opioid epidemic has increased HIV risk in many communities.

African-Americans continue to bear a disproportionate burden of HIV. Although representing only an estimated 12 percent of the U.S. population, they accounted for 44 percent of HIV diagnoses in 2016. Black women account for 60 percent of new HIV diagnoses among all women. Whereas HIV is the fourth leading cause of death for black women aged 35−44, HIV does not even rank in the top 10 causes of death for any other female racial group.

African-Americans are hit hardest by HIV in the South, accounting for almost 51 percent of all people living with HIV, and black women accounted for 71 percent of all HIV diagnoses among women in the South.

Exacerbating this risk, federal funding for HIV care and prevention continues to lag in this region as most states in the South have not expanded Medicaid, further limiting access to comprehensive health care. As a result, fewer people living with HIV in the South are aware that they are HIV positive than in any other region in the country.

What’s more, the burden of HIV is compounded by the opioid epidemics significant impact on women. According to the CDC, 68 percent of counties vulnerable to an HIV or hepatitis C (HCV) outbreak among people who inject drugs are found in the South. Opioid addiction increases the risk of future drug injection, making women vulnerable to blood-borne viruses including HIV. In 2016, women represented 46 percent of people over the age of twelve who misused opioids and 27 percent of HIV diagnoses among individuals who inject drugs. If current trends continue, 1 in 23 women and 1 in 36 men who inject drugs will be diagnosed with HIV in their lifetime.

The causes of HIV among women in the U.S. and contributing factors extend far beyond biological risk and include many social determinants of health that create barriers to obtaining affordable, quality care.

Gaps in insurance coverage due to unemployment or underemployment, lack of access to affordable housing and transportation, stigma, discrimination, and intimate partner violence are common barriers that make obtaining vital health care services more challenging for women who need these interventions the most.

The ACA: moving forward

A key component to ending the HIV epidemic among women is addressing gaps in health coverage. Health insurance is crucial for accessing preventive services as well as lifesaving HIV treatment.

As of 2016, the number of women in the U.S. with individual coverage doubled under the ACA, and 15 percent more women gained Medicaid coverage. For African Americans, the uninsured rate decreased by over one-third between 2013 and 2016, from 18.9 percent to 11.7 percent.

Since its enactment, the ACA has also increased access to coverage for people living with HIV by expanding Medicaid in 32 states and the District of Columbia, eliminating discriminatory practices such as denying health insurance coverage to people with pre-existing conditions including HIV/AIDS, and providing parity for treatment of mental and substance use disorders, as well as clinical preventive services without patient cost-sharing including HIV testing.

And yet, the administration’s efforts to destabilize the ACA’s healthcare marketplaces, reverse Medicaid expansion, and restrict access to reproductive health services are placing those most impacted by HIV at even greater risk.

As many as 40 percent of people living with HIV today reside in states that have not yet expanded Medicaid. Furthermore, some of the nation’s most underserved populations — including people living with HIV and those with opioid addiction — could lose their Medicaid coverage as a result of recent state proposals that require work-related activities as a condition for Medicaid eligibility.

Kentucky, Indiana, and Arkansas recently received Centers for Medicare and Medicaid Services (CMS) approval for waivers that require those who are eligible for Medicaid to work in order to keep their coverage.

Several other states are currently seeking these approvals as well. Beyond the administrative burden of proving that one has satisfied the Medicaid work requirement, many people with opioid addiction must pass drug tests in order to secure a job. These work requirements create an additional barrier to accessing substance abuse treatment for unemployed people.

Additionally, an estimated 5.5 million people — many of whom are women — could lose their health care coverage with the introduction of new “short-term” plans proposed by the Trump administration in the individual health insurance marketplaces.

These cheaper insurance plans are not required to offer comprehensive care and may allow insurers to deny coverage for pre-existing conditions such as HIV or breast cancer, providing coverage for just one year. They also typically do not provide clinical preventive care without patient cost sharing or mental health services.

An important provision of the ACA is the Prevention and Public Health Fund, which supports HIV education campaigns and other community-based services. But the administration has proposed cuts to the Centers for Disease Control and Prevention (CDC) budget that has put this critical funding in jeopardy.

Preventive interventions have dramatically reduced mother-to-child HIV transmission, increased HIV testing,  expanded access to condoms, syringe exchange programs, and pre-exposure prophylaxis (PrEP) for women.

The continuing efforts to dismantle the ACA and undermine access to health care threaten the health of millions of women and could derail decades of progress that has been made in eliminating HIV/AIDS in the U.S.

We must raise our voices to reverse these adverse actions, work to strengthen the ACA, increase federal funding for HIV/AIDS research and programs, as well as advocate for evidence-based policies that can move our country from peril to progress in ending the HIV/AIDS epidemic among women and girls in America.

Rear Admiral Susan J. Blumenthal, M.D., M.P.A. (ret.) is the senior policy and medical advisor at amfAR, The Foundation for AIDS Research and a Clinical Professor at Tufts and Georgetown University Schools of Medicine. She served as the first Deputy Assistant Secretary for Women’s Health in the US Department of Health and Human Services and Assistant Surgeon General of the United States. Ijeoma A. Egekeze, M.P.H., serves as an Allan Rosenfield Public Policy Fellow with amfAR, The Foundation for AIDS Research in Washington, DC. Egekeze, earned her Master of Public Health degree from the Milken Institute School of Public Health at The George Washington University.