The Affordable Care Act (ACA) is federal legislature that aims to increase the number of people with health insurance and to improve health outcomes. People living with HIV (PLWH) are often uninsured or underinsured, and therefore are positioned to theoretically benefit from the ACA. Providing HIV medications to PLWH is beneficial to the individual for his longevity and to the public in terms of reduced HIV transmission. Before the ACA passage, state AIDS Drug Assistance Programs (ADAPs) were the safety net resource responsible for providing key medications, including antiretroviral therapy and opportunistic infection prophylaxis, to uninsured or underinsured PLWH. While called a safety net, state ADAPs serve over 193,000 PLWH nationally, and in 2013, it was estimated that about one-third of PLWH receiving HIV care accessed medications through ADAP. Approximately 80% of Virginia ADAP clients were eligible for ACA insurance plans, and with this opportunity, Virginia ADAP shifted its role to help enroll its clients in ACA insurance plans, and it is paying ACA monthly premiums, medication copayments, and deductibles, as this is the new avenue for its clients to receive key medications. The ACA needs to be examined to see how it is being implemented and to ensure that it is having its intended effects. Moreover, given that federal and state funding supports ADAP, it needs to be assessed whether good outcomes are achieved. This work will (1) characterize the demographic and systems-level differences between Virginia ADAP clients who were enrolled in ACA insurance plans and those who were eligible but were not enrolled during the 2013- 2014 enrollment process and (2) define the relationship between months enrolled in an ACA insurance plan and HIV outcomes. This research will utilize Virginia Department of Health statewide data to provide important information for state and federal policy. In addition to addressing these research aims, this fellowship will also include a rigorous training program of didactic course work and close research mentoring by senior health services researchers, health economists, clinical epidemiologists and biostatisticians. This NRSA fellowship training plan will allow me to advance as an investigator and successfully compete for a K series career development award. Findings about the implementation of ACA insurance enrollment and the ACA's effects on HIV outcomes will be significant contributions to the fields of health services research, health policy and HIV care. The research generated with this NRSA fellowship opportunity will inform state and federal level discussions of ACA enrollment and outcomes achieved with this new policy. In a time of constrained budgets, funds need to be allocated in a way to optimize enrollment and achieve the best health outcomes. Good HIV health outcomes have benefits to the individual as well as to society.