State Medicaid Reimbursement for Routine HIV Screening

Segment Description: Physician experts in infectious diseases discuss state Medicaid reimbursement policies for routine HIV screening.

Interview Transcript (modified slightly for readability):

Colleen Kelley, MD, MPH: States that expanded Medicaid under the Affordable Care Act were required to adopt routine HIV testing. Those states that did not, some of them still have only medically indicated HIV testing. And that becomes problematic when we talk about how important screening and early diagnosis is. If someone is just being screened, is that a medically indicated test, or is it not? And so the issue of Medicaid reimbursement can become an issue. I know in the state of Georgia it certainly has been, where at times we’ve not even been able to test pregnant women because at some point it was considered not medically indicated if they were not symptomatic. I think everyone would disagree with that practice. I think it is something that we need to pay attention to and to understand how essential HIV testing on a routine basis is for everyone.

Joseph Eron, MD: In North Carolina, the availability of free STD [sexually transmitted disease] testing actually varies by county, and the county health department.

Colleen Kelley, MD, MPH: Absolutely.

Joseph Eron, MD: If you have someone on PrEP [pre-exposure prophylaxis] who’s supposed to be tested for STDs and should be, it may or may not be covered. It’s really a state-by-state issue, which also factors into the cost….

Julia Marcus, MD, MPH: Yes, absolutely.

Joseph Eron, MD: Additional testing. We’re going to transition now a little.

Ian Frank, MD: I want to remind folks that if you’re worried about acute HIV infection, or you have somebody you’re considering as a candidate for PrEP and they have perhaps a recent sexual exposure, you need to do an HIV RNA [genetic material] test. You need to do a viral load test because you can occasionally miss a diagnosis with a serologic test. I just want to remind folks about that.

Joseph Eron, MD: I know. It’s probably worth taking a minute to remind people that, I think most everyone now probably uses a fourth-generation test for HIV testing, which tests both for antibody and antigen, or protein. And that gets almost everybody, including many of whom we missed in the bad old days who had acute infection.

But as Ian points out, it will miss some people, because you become RNA positive before you become antigen positive. The test is more sensitive, the PCR [polymerase chain reaction] test. And occasionally that can be quite important.

Colleen Kelley, MD, MPH: Rapid testing and screening are essential for public health and expanding access to screening using rapid tests. Those actually don’t detect as well as that antigen antibody test, that blood test that most of us use in a clinical setting. So if someone has had a rapid test in the community, we’ve got to follow up with an antigen antibody test, and sometimes a viral load for people who are seeking PrEP or who may have had a recent exposure.

Joseph Eron, MD: Or if they had a febrile illness.