HIV Care May Have Slipped During the Pandemic HIV Care May Have Slipped During the Pandemic

HIV care suffered setbacks during the first year of the COVID-19 pandemic, and Black patients may have been disproportionately affected, according to an analysis by tech company Komodo Health.

The company analyzed insurance claims and reported drops in HIV screening, new diagnoses, and new preexposure prophylaxis (PrEP) prescriptions, as well as changes in PrEP adherence.

It called for urgent action to step up screening and improve preventive care outcomes in communities of color.

“Getting your patients tested for HIV is really important,” said Tabby Khan, MD, MPH, Komodo Health’s medical director, in an interview with Medscape Medical News. “Our data really underscores that a lot of patients were missed in this during the COVID pandemic, and we need to catch up.”

The findings of less screening, fewer diagnoses, and fewer new PrEP prescriptions as the pandemic got under way made sense to Philip A. Chan, MD, MS, associate professor, Department of Medicine, Brown University, Providence, Rhode Island. Chan was not involved in the study.

“Many clinics moved to telemedicine. A lot of them closed. A lot of staff went to address the pandemic shortages and health care. [Komodo’s data are] consistent with data that I’ve seen in the literature, including some of our own,” said Chan, who also serves as medical director of Rhode Island’s only publicly funded sexually transmitted diseases clinic and the state’s only dedicated PrEP program.

However, he added, to accurately interpret the results would require transparency into the company’s data source.

“To interpret any outcome, whether it be this study or other similar studies, you really have to know what the data is they’re pulling from,” he said. The study results were not published in a peer-reviewed journal, and were released on a Komodo web page.

Pandemic-Era Changes in HIV Care

The company used insurance claims data to compare outcomes during the pandemic’s first year, from March 2020 to March 2021, with those occurring the year before, from March 2019 to March 2020.

The analysis covered approximately 100,000 people in all 50 states, each of whom was continuously enrolled during the timeframe of the analysis, according to Khan. Patients’ mean age was approximately 38 years.

Company researchers found that, compared with the year before the pandemic, HIV screenings fell by 14.9% during the first year of the pandemic. In addition, new HIV diagnoses fell by nearly 31.5% and new PrEP prescriptions fell by 12.6%.

Black people, who comprise 13% of the United States’ population, accounted for 44% of new diagnoses during the pandemic versus 45% the year before, according to the analysis. This community made up 35% of those tested for HIV during the pandemic versus 34% before, the researchers found.

As for adherence, the researchers reported that the only group to experience a drop was the Black population. Some 80% of total prescribed Black patients adhered during the pandemic versus 83% before.

Hispanics’ adherence was reported at 87% during the pandemic versus 85% before, while Whites’ was 88% during both periods. 

The researchers did not calculate confidence intervals, Khan said. In addition, she told Medscape Medical News, peer review is “not in the works right now.”

Despite Limitations, Concerns About Missed HIV, Racial Disparities

The study did not control for how stay-at-home orders may have affected rates of sexually transmitted infection. But the results suggest many people are infected without knowing it, Khan said.

“Maybe people weren’t engaging in high-risk behavior quite as much, or maybe people weren’t socializing, so they weren’t being infected as much [during the pandemic]. I think that can contribute a little bit [to the drop in new diagnoses]. But 31.5% is pretty staggering,” she said.

Khan also cited the use of commercial claims data as an important limitation. These data do not capture care delivered in free clinics, for example.

“It’s likely that this gap in Black patients versus white patients is even more staggering, because there are a significant number of uninsured Black patients,” she said.

Further Questions Remain

Chan, too, worries that the pandemic has exacerbated race-based disparities in HIV care.

“We know that African American/Black and Hispanic/Latinx communities are disproportionately impacted,” Chan said.

But as to how the pandemic has affected these disparities, he said, “we have very limited data about that.”

Insurance claims generally do not require information on race and ethnicity, so that information is often missing, he explained.

“I don’t know how you can look at race and ethnicity [in] insurance claims and come to any meaningful data, in my opinion, unless they have a data set that I’m unaware about,” he said.

According to Komodo, the company’s proprietary Healthcare Map database, from which the study population was drawn, comprises deidentified data on over 330 million patients. These data come from payers, providers, electronic health records, and other sources.

When asked in an email what percentage of the study’s claims data included information on race and ethnicity, Khan responded that “Komodo’s data experts carefully review and evaluate the methodology to ensure findings are representative and in line with the broader patient population within the Healthcare Map.”

Regarding adherence, Chan noted that prescriptions may have been missed and that the reported results did not include error bars.

“I would say it’s a preliminary result that needs to be explored further,” he said.

HIV Remains a Live Issue

Racial and ethnic disparities in HIV care are worrisome, Chan said.

“These populations have been and are disproportionately impacted by HIV prevention outcomes,” he said. “I do think it’s a worry that the pandemic has exacerbated that. And I think one of the gaps is that we don’t know how bad it’s been, and we don’t know if it’s improving now.

“Much more needs to be done to address disparities in general and specifically as they relate to pre-exposure prophylaxis and other HIV prevention approaches,” he added.

Bottom line for doctors, Khan said: “Ask a patient if they know their HIV status. And if they say no, start that conversation about getting tested.

“If you have patients that are HIV positive, that have been reluctant to start prep, that is another conversation that needs to be had,” she added. “HIV is something that is still very much a problem.”

The study was conducted by Komodo Health. Chan reports no relevant financial relationships.

Jenny Blair, MD, is a journalist, writer, and editor in Vermont.

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