Building the Case for Localized Approaches to HIV: Structural Conditions and Health System Capacity to Address the HIV/AIDS Epidemic in Six US Cities

Abstract

Since the discovery of the secondary preventive benefits of antiretroviral therapy, national and international governing bodies have called for countries to reach 90% diagnosis, ART engagement and viral suppression among people living with HIV/AIDS. The US HIV epidemic is dispersed primarily across large urban centers, each with different underlying epidemiological and structural features. We selected six US cities, including Atlanta, Baltimore, Los Angeles, Miami, New York, and Seattle, with the objective of demonstrating the breadth of epidemiological and structural differences affecting the HIV/AIDS response across the US. We synthesized current and publicly-available surveillance, legal statutes, entitlement and discretionary funding, and service location data for each city. The vast differences we observed in each domain reinforce disparities in access to HIV treatment and prevention, and necessitate targeted, localized strategies to optimize the limited resources available for each city’s HIV/AIDS response.

Appendix: Estimating Enrollees Per Funding Agency

State-level estimates for Ryan White, ADAP, CDC, SAMHSA and HOPWA funds were reported by the Kaiser Family Foundation, and sourced from a special data request to the National Alliance of State and Territorial AIDS Directors (NASTAD) [39].

To estimate the state-level number of Medicaid enrollees in NY, CA, MD, and FL, we adjusted the published 2011 number of enrollees with HIV, as reported by the Centers for Medicare and Medicaid Services, by applying city-specific estimates from Berry and colleagues for the adjusted relative risk of Medicaid coverage for HIV provider visits post-ACA (first half of 2014) versus coverage before (2011–2013) [96]. For GA (non-adopter of ACA) and WA (adopter of ACA), we used the adjusted relative risk of Medicaid Coverage provided by Berry and colleagues.

For city-level Medicare enrollees, we calculated the average spending per HIV positive beneficiary by dividing the national level expenditure data (reported via the Kaiser Family Foundation) by the estimated number of beneficiaries living with HIV. Since there was no publicly available data on the number of beneficiaries, we multiplied the number of beneficiaries by the local HIV prevalence rate to obtain to approximate the number of state-level beneficiaries and assumed the distribution of Medicare enrolled PLHIV matched the distribution of all diagnosed within the state.