Association Between Changes in Socioeconomic Status Before and After Human Immunodeficiency Virus Infection Diagnosis and Mortality Rates in Korea

Abstract

BACKGROUND: This study investigated changes in medical insurance status as a surrogate marker of socioeconomic status after human immunodeficiency virus (HIV) infection, and their association with mortality among people living with HIV in Korea. METHODS: This study included 13,112 individuals newly diagnosed with HIV between 2004 and 2018, identified from the claims data of the National Health Insurance System-National Health Information Database. Participants' medical insurance status was categorized into National Health Insurance (NHI) and medical aid (MA). Using the Cox proportional hazards model, the association between mortality and changes in medical insurance status before and after HIV infection diagnosis was assessed using hazard ratios (HRs) and confidence intervals (CIs). RESULTS: The insurance coverage rates before HIV diagnosis were 95.1% and 4.9% for NHI and MA recipients, respectively. After diagnosis, the insurance coverage rates were 13.4% and 86.6% for MA and NHI recipients, respectively, demonstrating a threefold increase in the proportion of MA recipients. The conversion rate from NHI to MA was highest in the 35-44 and 45-54-year age groups at HIV infection diagnosis (32.9% and 29.4%, respectively). Compared with NHI recipients, the HR was significantly higher among individuals that transitioned from NHI to MA (HR, 1.66; 95% CI, 1.39-1.97) and individuals that remained on MA (HR, 1.74; 95% CI, 1.40-2.18), suggesting a higher mortality rate in these groups. CONCLUSION: In Korea, where highly active antiretroviral therapy is essentially free of charge, a significant association was observed between a decline in medical insurance status following HIV diagnosis and increased mortality.

연구목적: 본 연구는 인간면역결핍바이러스(HIV) 감염 후 사회경제적 지위의 대체 지표로서 건강보험 자격 변화를 조사하고, 이러한 변화가 HIV 감염인(PLWH)의 사망률과 어떤 관련이 있는지를 분석하였다. 결과: HIV 진단 전후의 보험 자격 변화와 사망률 간의 연관성을 Cox 비례위험모형(Cox proportional hazards model)을 사용하여 추정하였다. PLWH에서 HIV 감염 진단 전 보험 자격은 건강보험(NHI) 95.1%, 의료급여(MA) 4.9%이었으나, HIV 감염 진단 후에는 의료급여 수급 자 비율이 13.4%로 증가하여 의료급여 수급 자 비율이 약 3배 증가하였다. 건강보험에서 의료급여로 전환된 비율은35–44세(32.9%), 45–54세(29.4%) 그룹에서 가장 높게 나타났다. 특히, 건강보험 수급자에 비해, 건강보험에서 의료급여로 전환된 그룹은 사망률이 유의하게 높았으며 (HR: 1.66, 95% CI: 1.39–1.97), 지속적으로 의료급여를 수급한 그룹도 사망률이 건강보험 수급자에 비해 높았다 (HR: 1.74, 95% CI: 1.40–2.18). 결론: 한국에서는 고활성 항레트로바이러스 치료(HAART)가 사실상 무료로 제공됨에도 불구하고, HIV 진단 이후 건강보험 자격의 하락과 사망률 증가 간에 유의한 연관성이 관찰되었다.