HIV in Houston: A Study on the Potential Impact of Medicaid Expansion and ART/PrEP

HIV rates in Houston, Texas could decrease significantly with the expansion of Medicaid and increased use of preventive and antiviral medications, according to a new study.

Houston is facing a serious HIV crisis, according to a recent report from the CDC. The fourth most populous city in the U.S. ranks ninth in the nation for rates of new HIV diagnoses. Compared to the rest of the United States, Houston also has lower rates of people remaining in HIV care and achieving viral suppression. The highest burden is among younger, Black men who have sex with men (YBMSM), who make up 19% of all new diagnoses.

A new study, led by researchers from the Brown University School of Public Health, the University of Texas Health Science Center and the University of Chicago suggests that expanding Medicaid under the Affordable Care Act and increasing the use of preventive and antiviral medications, like PrEP, could lead to a significant decrease in the number of new HIV infections, particularly among YBMSM in Houston.

The study, published in the journal Medical Care, used an “agent-based network model” to evaluate the effects of Medicaid expansion on HIV transmission. The results indicate that by the tenth year of implementation, Medicaid expansion could lead to about a 15% reduction in the total number of new infections. Additionally, increased engagement in the HIV care and prevention continua—among the most effective tools in preventing and treating HIV—along with successful Medicaid expansion, could result in about  a 44% decrease in the number of new infections within ten years. 

“This study extrapolates information from states that have expanded Medicaid and investigates how effective this similar expansion in Medicaid services is likely to be in Houston,” said Aditya Khanna Ph.D., assistant professor of behavioral and social sciences in the Brown University School of Public Health and co-author of the study. “However, doing this successfully will require mitigation of social and structural barriers that people face, and more needs to be done to dismantle these barriers.”

Houston’s diverse population makes up the largest city in Texas, one of only 11 states that has not yet adopted Medicaid expansion under the Affordable Care Act. This is causing “massive coverage gaps that disproportionately burden people of color,” the authors write, limiting access to medical care and contributing to the high rate of HIV transmission among YBMSM. 

To address these issues, Khanna recommends confronting stigma and racism, as well as barriers like substance use that impede access to HIV prevention strategies. “There is also the issue of mass incarceration, which disproportionately impacts the very population we are studying in this paper,” Khanna said. “These barriers need to be acknowledged and addressed in any policy and healthcare practice reforms.”