Abstract:
Background: The global push to achieve the 90-90-90 targets designed to end the HIV
epidemic has called for the removing of policy barriers to prevention and treatment, and ensuring
financial sustainability of HIV programs. Universal health insurance is one tool that can be used
to this end. In sub-Saharan Africa, where HIV prevalence and incidence remain high, the use of
health insurance to provide comprehensive HIV care is limited. This study looked at the factors
that best predict social health insurance enrollment among HIV positive pregnant women using
data from the Academic Model Providing Access to Healthcare (AMPATH) in western Kenya.
Methods: Cross-sectional clinical encounter data were extracted from the electronic medical records
(EMR) at AMPATH. We used univariate and multivariate logistic regressions to estimate the predictors
of health insurance enrollment among HIV positive pregnant women. The analysis was further
stratified by HIV disease severity (based on CD4 cell count <350 and 350>) to test the possibility of
differential enrollment given HIV disease state. Results: Approximately 7% of HIV infected women
delivering at a healthcare facility had health insurance. HIV positive pregnant women who deliver
at a health facility had twice the odds of enrolling in insurance [2.46 Adjusted Odds Ratio (AOR),
Confidence Interval (CI) 1.24–4.87]. They were 10 times more likely to have insurance if they were
lost to follow-up to HIV care during pregnancy [9.90 AOR; CI 3.42–28.67], and three times more
likely to enroll if they sought care at an urban clinic [2.50 AOR; 95% CI 1.53–4.12]. Being on HIV
treatment was negatively associated with health insurance enrollment [0.22 AOR; CI 0.10–0.49].
Stratifying the analysis by HIV disease severity while statistically significant did not change these
results. Conclusions: The findings indicated that health insurance enrollment among HIV positive
pregnant women was low mirroring national levels. Additionally, structural factors, such as access to
institutional delivery and location of healthcare facilities, increased the likelihood of health insurance
enrollment within this population. However, behavioral aspects, such as being lost to follow-up
to HIV care during pregnancy and being on HIV treatment, had an ambiguous effect on insurance
enrollment. This may potentially be because of adverse selection and information asymmetries.
Further understanding of the relationship between insurance and HIV is needed if health insurance
is to be utilized for HIV treatment and prevention in limited resource settings.
