Colombian antenatal HIV testing rates reveal health insurance paradox

The introduction of subsidized health insurance for poor people in Colombia resulted in decreased access to HIV tests in antenatal care, research shows.

The study results also highlight that levels of antenatal HIV testing remain low in the country, despite it being introduced as standard into national insurance programs in 2000 as part of a strategy to prevent mother-to-child transmission of the virus.

The study included 10,596 women who received antenatal care between 2000 and 2005. Overall, 26% had contributive insurance (for salaried citizens above the poverty threshold), 34% had subsidized insurance, and 31% were uninsured. The remaining 8% had other forms of insurance.

Survey results indicated that only 35% of women had an HIV test ordered during their most recent pregnancy, the authors report in Health Policy and Planning.

After adjustment for healthcare provider, mother, and child characteristics, women in the subsidized insurance program were 18% less likely to have an HIV test ordered than uninsured women. Additionally, these women were also significantly less likely to see a doctor during their antenatal visit than uninsured women or women in the contributory program.

"Although this finding may initially appear unlikely - the insurance reform introducing the subsidized regime was intended to increase access to essential health services - there is evidence to suggest that there are structural and institutional barriers to accessing health services by those in the subsidized regime," say authors Allison Ettenger (Jacaranda Health, Nairobi, Kenya) and colleagues.

These include mechanisms that limit the use of services, such as the need for health insurance providers to approve diagnostic tests, the fragmented contracting of services at different sites, and disagreement about what benefits are included in the subsidized program.

The authors also note that women with subsidized insurance are often required to give written consent to the HIV test in person at the Health Management Organization that enrolled them in the scheme, which may require travel - adding additional expense and time - while uninsured women are not.

Ettenger and colleagues say that further research is needed to examine how enrollment in the subsidized program affects access to primary and preventive services.

"A more comprehensive understanding of mechanisms and structural barriers posed by the subsidized regime may suggest ways to both reduce costs and increase access to health care and prevention services," they conclude.

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