At the Intersection of HIV and COVID-19: Medicaid Data as a Complement to Cohort Studies

ABSTRACT The Coronavirus Disease 2019 (COVID-19) pandemic has had an unprecedented impact on the lives of people worldwide. Yet, the effect on persons living with HIV (PLWH) is not known. Emerging evidence suggests that PLWH have a similar or modestly higher risk of COVID-19 acquisition, and higher risk for worse COVID-19 outcomes, including hospitalization and death. However, the data has been mixed as several studies have suggested no difference in clinical outcomes. Several studies also found that outcomes are worse among those without viral suppression and those with lower CD4 counts, highlighting the importance of continued HIV care. Yet, early reports suggest that COVID-19 has disrupted services across the HIV care continuum. As the pandemic continues to unfold, it is critical to better characterize the relationship between COVID and outcomes among PLWH. In addition, we need to identify how the pandemic and the public health strategies to combat the pandemic impacted the provision of care for PLWH, as well as whether any adverse effects are lasting. Approximately 40% of PLWH are enrolled in Medicaid. The proposed project will include Medicaid beneficiaries from 27 states and Washington, DC between 2018 and 2024 with a conservative estimate of 25 million beneficiaries and 275,000 PLWH enrolled annually. Medicaid is an important complement to HIV cohort studies as it affords us the breadth of data to evaluate differences by geographic location, social determinants of health at the community level, as well as among important sub-populations. We will assess the relationship between HIV and COVID-19 disease, including on hospitalization due to COVID-19 and adverse conditions due to COVID like post-acute sequala of COVID-19 (PASC). We will also evaluate the impact of the COVID19 pandemic on the provision of care for prevention of HIV and HIV care. We will assess care across the HIV care continuum including PrEP prescription, HIV testing, and annual HIV care visits, viral load tests, and ARV medication possession ratio. We will also evaluate impacts on the provision of care for non-HIV conditions, including annual wellness visits, preventive screenings and health condition management. We will compare care rates during the pre-COVID period (2001-2019), acute COVID period (2020-2021), and post-acute COVID period (2022-2024) overall and by geographic location (state, urban/rural, local government area [LGA], smallest government region e.g. county, city, town, etc.) and regional severity of COVID-19 cases and COVID- 19 policies. Findings from the proposed study will help inform and target interventions to improve care for PLWH in the future.