The Role of Government-Funded Assistance Programs on HIV Testing among Poor Adults in the US

November 5,
2019
2019 APHA - Philadelphia,
PA
Session 4037.0: Politics of
HIV Prevention and Care
The Role of Government-Funded
Assistance Programs on HIV Testing
among Poor Adults in the US:
Findings from the National Health
Interview Survey 2016-2018
Emeka Oraka; Iddrisu Abdallah; Tamara Carree; Peter Dakutis;
Fengjue Shu; Nixon Arauz
1ICF
*No conflicts of interest to disclose

ICF proprietary and confidential. Do not copy, distribute, or disclose.ICF proprietary and confidential. Do not copy, distribute, or disclose.
HIV in Economically Challenged Communities
More than 1.1 million Americans are currently living with HIV and even
more at risk
 Nearly 40% of PLWH do not know they have HIV or know but are not in care account
for 80% of new diagnoses
Within communities hardest hit by HIV infection, impoverished
neighborhoods are more affected than affluent areas
 3rd leading cause of death among Black men and women between ages 35 and 44
 4th leading cause of death among Latinos of the same age group
 Nearly half of all people living with HIV residing in ten metropolitan areas
2
The Role of Government-Funded Assistance Programs and HIV Testing Among Poor US Adults

Health Disparities Framework for HIV Infection
Social-
Economic
Status (SES)
Education
Occupation
Income
Social Capital
Psychological
Influences
Negative
Expectations
Lack of
Resilience
Perceived
Discrimination
Adverse Health
Behaviors
HIV Health
Outcomes
Mortality
Disease
Trajectory
Comorbidities
10/29/2019
3

Ending the HIV Epidemic: A Plan for America
(EHE)
National plan for reducing the number of new HIV infections by 90% by
2030
Calls for increasing investments in programs that serve economically
disadvantaged persons at risk of getting HIV
HIV screening is the most important step to accomplishing the EHE goals
Despite higher testing rates, socioeconomically disadvantaged are among
the hardest-to-reach populations in need of HIV treatment and care
4

US Government-Funded Assistance Programs
Government-funded/Public assistance programs may play an important
role in HIV prevention
In 2016, 52% of people ages 18 or older in the US resided in households in
which one or more persons received benefits
Most common assistance programs include:
 Medicaid
 Supplemental Nutrition Assistance Program (SNAP)
 Human Services (housing assistance, job training/placement, childcare,
transportation)
 Temporary Assistance for Needy Families (TANF)
5

Public Assistance Beneficiaries
Overlap between population of public assistance beneficiaries and
population at-risk for HIV infection
Population of beneficiaries is mostly comprised of:
 Children under age 18
 Minority groups (mainly African American and Hispanic)
 Female heads of household
 Non-high school graduates
 The unemployed
6

Study Objectives and Rationale
Study Objectives:
–Government-funded assistance programs provide
services to low-income communities and may play an
important role in preventing the spread of HIV
–Our objective was to assess the impact of government
funded assistance programs on HIV testing among poor
adults in the US
Rationale:
–Study findings can support future HIV prevention efforts
that support the goals of the EHE
7

National Health Interview Survey (NHIS)
One of the major data collection programs of the
National Center for Health Statistics (NCHS)
Used to monitor trends in illness and track progress
toward achieving national health objectives
Data collected annually from a nationally
representative sample of US residents
8

Analysis Methods – Study Sample
Respondents [N = 61,654 (72.4%) out of 85,187 respondents]
Adults (18-64) living in households in the United States
Non-institutionalized
Sub-analysis restricted to adults living in poverty according to standards
set by Census Bureau
–Poor (< 100% US Federal Poverty Threshold [FPL])
–Near Poor (100% - 250% FPL)
–Not Poor (> 250% FPL)
Average response rate from 2016–2018: 54%
9

Analysis Methods – Classifying Public
Assistance Enrollment
Survey Participants provided yes/no responses when asked if
they were a beneficiary of any of the following publicly-
provided programs:
 Medicaid
 Human Services (e.g. job-placement/training, transportation, or childcare)
 Temporary Assistance for Needy Families (TANF)
Respondents who answered “Yes” were coded as being a
beneficiary of the respective program
 A composite variable of “Any Public Assistance” used to classify respondents receiving
benefits from 1 or more programs
10

Independent Variables
11
 Age
 18 – 29; 30 – 49; 50 – 64
 Race/Ethnicity
 Hispanic; Non-Hispanic White; Non-Hispanic
Black; Non-Hispanic Other Race
 Education Level
 < High School; High School Graduate; Some
College; College Graduate or More
 Sexual Identity
 Gay/Bisexual; Straight
 Gender
 Male; Female
 Marital Status
 Married; Not Married
 Region
 Northeast; Midwest; South; West

Statistical Analysis
Outcome variable
Ever tested for HIV, not including blood donation (Yes/No)
Multivariable logistic regression model design
Yielded adjusted prevalence ratios (aPR) and 95% confidence
intervals (CI)
Assessed associations of receiving government assistance with
ever tested for HIV as outcome
12

HIV Testing Prevalence And Associated
Factors
47% of US adults 18 years to 64 have ever tested for HIV
13% were living in poverty of those 50% have ever tested
Government-Funded Assistance Programs Enrollment
–Medicaid: 44%; Human Services (e.g. job-placement/training, transportation,
or childcare): 3%; Temporary Assistance for Needy Families (TANF): 4%;
Any Assistance: 45%
13

HIV Testing Prevalence by Poverty Level
10/29/2019 14
50%
49%
46%
40
42
44
46
48
50
52
54
Ever Tested for HIV
Prevalence(%)
Prevalence of US adults aged 18 - 64 ever tested for HIV by
poverty level: National Health Interview Survey 2016-2018
Poor (< 100%FPL) Near Poor (100% - 250%FPL) Not Poor (>250% FPL)

HIV Testing Prevalence by Selected Government Assistance
Program
10/29/2019 15
58% 58%
65% 67%
43% 44%
50% 49%
0
10
20
30
40
50
60
70
80
Any Public Assistance Medicaid Human Services TANF/Welfare
Prevalence%
Prevalence of ever testing for HIV among various forms of
government assistance received by US adults living in poverty;
National Health Interview Survey 2016 - 2018
Receives Govt
Assistance and
Tested for HIV
Does not Receive
Govt Assistance
and Tested for HIV

Summary of Results
Study findings highlight the impact of public assistance
programs on HIV prevention efforts
Beneficiaries tend to test more than those who are not
regardless of program
Despite elevated testing rates, program beneficiaries were
still not testing at the 90% threshold proposed by the EHE
16

Summary of Results (cont.)
Differences in HIV testing rates among public assistance
programs highlight pathways to improve HIV prevention
efforts among historically hard-to-reach populations
 African American women
 The homeless or those with transient housing
 Young African American men who have sex with men
Elevated testing among Human Services beneficiaries
indicates possible direct and indirect benefits of public
assistance programs on enrollees.
 Pathways to improved health outcomes warrant further study
17

Public Health and Policy Implications
Federal funding for public assistance programs is vital in
order to achieve the objectives of the EHE
Continued research needed to understand how program
enrollment results in higher likelihood of testing and how this
association can be improved
Some factors that may increase testing include perinatal
services, Medicaid expansion, and provider incentives
18

Limitations
19
Potential recall bias
Unable to account for duration of time that respondents
received government assistance or behaviors that may
increase risk of HIV
Unable to determine causal pathway of association due to
cross-sectional data

Discussion
Public assistance programs may have unintended benefits
that impact other dimensions of health
Proposed federal budget cuts for safety net programs are
counter-productive to current and proposed HIV prevention
efforts
Public assistance programs should be funded at full capacity
and incorporated into future EHE efforts
20

Questions?
Contact Information:
Emeka Oraka, MPH
Data Analytics Specialist IV
Emeka.Oraka@ICF.com
Eoraka@cdc.gov

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