Doing Prevention in the ACA Era: CBOs in the Midwest Finding Their Way

Background: Implementation of the Affordable Care Act (ACA) creates new opportunities for engaging HIV-positive and high-risk negative persons into evidence-based prevention and treatment strategies.  Community-based organizations (CBOs) are well positioned to reach individuals whom these interventions might benefit most.  Many structural and philosophical barriers confront CBOs in the rapidly evolving world of HIV-prevention and sexual health politics.

Methods: In-depth interviews were conducted with executive administrators of 11 different CBOs in the Midwest.  Interviews explored how each CBO has integrated behavioral and biomedical prevention methods, as well as the challenges and opportunities presented by the ACA.  Thematic transcript analysis was conducted to identify common insights and challenges experienced by respondents.

Results: Most interviewees indicated that their prevention efforts were not directly facilitated by ACA.  Many identified challenges with integrating biomedical interventions. Cited challenges included lack of frontline staff knowledge and ethical concerns regarding PrEP and PEP.  Interviewees also described a prevention environment where acceptable interventions are prescribed by funders, who place heavy emphasis on “test and treat” strategies over other behavioral and biomedical approaches.

Conclusions: The ACA offers a potential opportunity to curb the tide of HIV within high-risk populations.  To be successful, new frameworks must be developed for strategically integrating interventions and for evaluating their combined effect. Future research in this area should explore how expanded access to healthcare provided by the ACA will impact acceptability and uptake of biomedical prevention strategies, and work with CBOs to determine effective strategies for engaging and retaining high-risk individuals in these interventions.