Financial Barriers and Lapses in Treatment and Care of HIV-Infected Adults in a Southern State in the United States

Abstract

Antiretroviral (ARV) adherence has largely been considered from the perspective of an individual's behavior with less attention given to potential structural causes for lapses in treatment, such as the cost of medications and care. HIV medication expense is typically covered by third party payers. However, private insurance premiums and deductibles may rise, or policies terminated such as with a change in employment. Likewise, a patient's eligibility for publicly funded coverage like state AIDS Drug Assistance Programs (ADAP) or Medicaid can also be lost. We conducted a one-time survey of a sample of 300 patients receiving HIV care at a single large academic center in the south of United States to examine lapses in HIV therapy due to financial reasons. We found that during the prior year, financial issues including medication cost or coverage led to a lapse in ARVs in 10% (n = 31) of participants. However, of the 42% (n = 125) participants who had been enrolled in ADAP at any time during the prior year, 21% (n = 26) reported an ARV lapse due to problems with ADAP or medication cost. Respondents cited ADAP's required semi-annual renewal process and other administrative issues as the cause of ARV lapses. The median duration of missed ARVs was 2 weeks (range of <1-23 weeks). Non-HIV medication and transportation to and from clinic costs were also identified as financial burdens to care by respondents. In conclusion, although conducted at a single medical center and one state, this study suggests that a significant minority of HIV-infected patients encounter financial barriers to ARV access, and this is paradoxically more common among those enrolled in the state ADAP. Streamlining, supporting, and simplifying ADAP renewal procedures will likely reduce lapses in ARV adherence and persistence.

Keywords: access to care; antiretroviral; drug cost; patient care.

FIG. 1.

Study participant selection and recruitment. ID, Infectious Diseases; UNC, University of North Carolina at Chapel Hill.

FIG. 2.

Reported financial barriers to HIV and Non-HIV care. *Of 270 asked about transportation barriers. **Of 185 participants reporting being prescribed non-HIV medications.

FIG. 3.

Lapses in ART among overall cohort (n = 300) and proportion of those experiencing ART lapse who ADAP receipients. ADAP, AIDS Drug Assistance Programs; ART, antiretroviral therapy.