Improvement Still Needed in Sexually Transmitted Disease Testing Among HIV-Positive Medicaid Enrollees

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To the Editor:
The report by Landovitz and colleagues1 provides detailed analyses on the poor testing rates among HIV-positive, Medicaid and Medicare recipients in California and provides ideas on how to improve these rates. We have found similar sexually transmitted disease (STD) testing rates among other states for persons who are HIV positive and insured by Medicaid only, a population of people who may be more vulnerable than those who are dually covered.
Our data contain Medicaid claims files for 22 states during 2 periods (2009–2010 and 2012–2013). These data are the most comprehensive data available at this time. Our 2 study populations included Medicaid fee-for-service enrollees who were at least 15 years of age, who had an HIV diagnosis code in 2009 or in 2012, who had an HIV viral load test conducted within the same year as diagnosis, and who were continuously enrolled for a period of 13 months after diagnosis. We used 13 months as our follow-up period to allow a 1-month lag in claims to demonstrate compliance with yearly recommended screening. The Centers for Disease Control and Prevention recommends regular STD screening among HIV-positive patients,2 and we examined claims for evidence of STD testing for 13 months during 2 periods (Table 1).
There are 3 noteworthy findings in these analyses. First, syphilis testing rates were typically much higher than those for chlamydia and gonorrhea in almost all states across both periods. Second, all 3 testing rates increased for most, but not all, states between the 2 periods. Third, even with improvement over time, STD testing rates were still low and varied among states. A limitation of these analyses is that administrative data may not fully capture procedures patients receive,3 and this may especially be true in an outpatient setting.
These findings suggest inadequate adherence to guidelines for Medicaid fee-for-service enrollees. They are similar to those of Landovitz and colleagues and support the idea that HIV-positive persons who are publicly insured potentially receive poor quality of care. This idea is further supported by our previous work looking at these same testing rates among HIV-positive persons who were commercially insured and who had higher rates of STD testing compared with the testing rates found in the Medicaid populations studied in the article by Landovitz et al. and our current analyses presented here.4
It is widely believed that Medicaid expansion will facilitate better health among more people, and studies that have shown better access to care and utilization of services through expansion for some populations and some specific diseases have been conducted.5 However, simply expanding Medicaid coverage does not necessarily mean that providers will be more likely to offer screening. As of January, 2017, 32 states had expanded their Medicaid programs.6 Therefore, we believe that it is important to closely follow up this vulnerable population to ensure that they receive the benefits of improved access to care.

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