China’s free ART policy has developed into a mature standard and practice after 20 years of implementation, development, and refinement. No matter in the past or now, free ART is the most important ART security policy for PLWH. Medical insurance policies including AIDS outpatient specific disease, dual channel, and separate payment are improving in China as HIV prevention and control enters a phase of high-quality development, which encourages some PLWH to switch to medical insurance ART [24]. The study found that 17.3% (273/1371) of PLWH switched to medical insurance ART, indicating the attractiveness of medical insurance ART. In the future, medical insurance ART will be an important supplement to free ART to meet the diversified ART needs of PLWH in China.
There were differences in the general characteristics between PLWH who switched to medical insurance ART and those who did not. Specifically, there were differences in knowledge level, occupation, social status and economic status between those who switched to medical insurance ART and those who did not. This may be because those with more education, steady employment and decent incomes, and a higher social status are more knowledgeable about medical insurance ART and have the financial means to cover the out-of-pocket costs associated with it. As a result, a larger percentage of these patients switch to medical insurance ART.
There were differences in the ART status between PLWH who switched to medical insurance ART and those who did not. The earlier the year of initiating ART, the higher the level of the ART hospital, and the closer the distance to the ART hospital, the higher the proportion of switching to medical insurance ART. The reason why PLWH who switched to medical insurance ART had lower rates of adverse medicine reactions than free ART is likely that medical insurance ART medicines were mostly single-tablet combinations that had just hit the market in recent years, and these medicines had fewer side effects compared to free ART medicines [21, 22].
For factors associated with switching to medical insurance ART, compared with unemployed/retired patients, government agency/public institution/state-owned enterprise employees were more willing to switch to medical insurance ART. Compared with those whose average annual income of family members were ≤ $6,985, those whose average annual income of family members were ≥ $13,972 were more willing to switch to medical insurance ART. Compared with those whose personal annual income were ≤ $6,985, those whose personal annual income were ≥ $13,972 were more willing to switch to medical insurance ART. When deciding whether to switch to medical insurance ART, income is a significant aspect. The first thing that changes when PLWH switch to medical insurance ART is the expense. Free ART medicines are provided by the state at no cost, while medical insurance ART medicines cost about $42–70 every month. Patients with stable jobs, high social class, and decent incomes are more willing to switch to medical insurance ART after comparing the cost and advantages of medical insurance ART medicines. Paying $42–70 every month for ART is also a significant financial strain for low-income patients [26, 27]. As a result, these patients are less likely to switch to medical insurance ART.
Compared with the basic medical insurance for urban and rural residents, basic medical insurance for urban employed were more willing to switch to medical insurance ART. In China, the basic medical insurance is mainly divided into basic medical insurance for urban employed and basic medical insurance for urban and rural residents. The basic medical insurance for urban employed is for urban workers, who have stable and well-paid jobs, while the basic medical insurance for urban and rural residents is for rural residents or urban residents without jobs. And the reimbursement ratio of basic medical insurance for urban employed is higher than that of basic medical insurance for urban and rural residents [28]. In one Chinese city, for example, the reimbursement rate is 70% for basic medical insurance for urban employed and 60% for basic medical insurance for urban and rural residents. PLWH with basic medical insurance for urban employed have better economic status and need to pay less out-of-pocket for medical insurance ART than those with basic medical insurance for urban and rural residents, so they are more willing to switch to medical insurance ART.
Compared with those who initiated ART in 2018–2022, those who initiated ART before 2012 were more willing to switch to medical insurance ART. PLWH who initiated ART before 2012 were on ART for a longer duration, so they were more likely to experience ART failure, medicine toxicities, comorbidities, and medicine resistance than PLWH on ART for a shorter duration [29,30,31]. Therefore, these patients are more willing to switch to medical insurance ART on the advice of their physicians or on their own initiative, in order to lessen or mitigate the negative effects of long-term ART on their health.
Compared with the county hospitals or below, PLWH receive ART in provincial hospitals were more willing to switch to medical insurance ART. Provincial hospitals are generally located in the provincial capital, and the implementation of national AIDS insurance security policies such as AIDS outpatient specific disease, dual channel, separate payment are better than county hospitals or below. Patients are able to switch to medical insurance ART more easily and efficiently at provincial hospitals. In addition, PLWH in provincial hospitals are richer than county hospitals or below generally, so they are more willing to switch to medical insurance ART.
The source of information for switching was mainly from physicians, indicating that physicians were important for patients to switch to medical insurance ART. In the future, training for physicians on medical insurance ART should be strengthened, so that they can guide PLWH to switch to medical insurance ART correctly and reasonably. The reasons for switching were mostly less adverse medicine reactions, more convenient to take medicines, and better treatment effect. It is evident from this that PLWH who switch to medical insurance ART with the expectation that ART medicines will not only control HIV in the body but also to simplify and improve their quality of life [32]. They also hope that the medicines will not negatively impact their bodies and will be easier to take (Free ART medicines are generally taken twice a day, taking 2–3 pills at a time, while medical insurance ART medicines are generally taken once a day, taking 1 pill at a time).
The biggest worries of PLWH regarding medical insurance ART are privacy disclosure and high cost of medicines and tests. Patients with AIDS generally do not want their HIV status to be known since it is a sensitive disease and they are susceptible to discrimination [33, 34]. The primary worry of PLWH who have switched to medical insurance ART is privacy disclosure, which is a danger associated with the multiple departments involved in the auditing and reimbursement of medical insurance ART. In the future, the privacy protection system should be improved to reduce the risk of privacy disclosure. Although the economic status of PLWH who switch to medical insurance ART is better than those who receive free ART, money is a major concern for them. Whether to further increase the reimbursement rate of medical insurance ART and reduce the out-of-pocket payment rate to alleviate their financial burden need to be further studied.
There are some limitations in this study. Firstly, there are many provinces and cities involved in this study, and the sampling standards are difficult to be completely consistent, so there are sampling errors. Secondly, this study lacked data on treatment, such as CD4 cell count, viral load, and drug resistance. Therefore, it is impossible to compare the treatment effect of PLWH who switched to medical insurance ART and those who did not. And more studies can be carried out in the future to make up for this deficiency.
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