title: Optimizing resource allocation in United States AIDS drug assistance programs.
abstract: BACKGROUND
  US acquired immunodeficiency syndrome (AIDS) Drug Assistance programs (ADAPs) provide medications to low-income patients with human immunodeficiency virus (HIV) infection/AIDS. Nationally, ADAPs are in a fiscal crisis. Many states have instituted waiting lists, often serving clients on a first-come, first-served basis. We hypothesized that CD4 cell count-based ADAP eligibility would improve ADAP outcomes, allowing them to serve more-diverse patient populations and to prioritize persons who are at greatest risk of HIV-related mortality.
  
  
  METHODS
  We used Massachusetts ADAP administrative data to create a retrospective cohort of Massachusetts ADAP clients from fiscal year 2003. We then used a model-based analysis to apply potential eligibility criteria for a limited program and to compare characteristics of patients included under CD4 cell count-based and first-come, first-served eligibility criteria.
  
  
  RESULTS
  In fiscal year 2003, Massachusetts ADAPs served 3560 clients at a direct cost of 10.3 million dollars. With use of CD4 cell count-based eligibility (with an eligibility criterion of a current or nadir CD4 cell count < or = 350 cells/microL), it would have served 2253 clients (37% fewer than in fiscal year 2003) and appreciated savings of 2.7 million dollars. Given the same budget constraint and using first-come, first-served eligibility, Massachusetts ADAPs would have served 2406 clients (32% fewer than in fiscal year 2003). The first-come, first-served approach would have excluded patients with median CD4 cell count of 257 cells/microL (interquartile range, 124-377 cells/microL) in favor of serving patients with median CD4 cell count of 659 cells/microL (interquartile range, 511-841 cells/microL). In addition, a CD4 cell count-based scheme would have served a greater proportion of nonwhite individuals (65% vs. 55%; P<.0001), non-English speakers (24% vs. 19%; P=.03), and unemployed people (69% vs. 61%; P=.0009), compared with the population that would have been served by a first-come, first-served policy.
  
  
  CONCLUSIONS
  With limited resources, ADAPs will serve more-diverse populations and patients with significantly more advanced HIV disease by using CD4 cell count-based enrollment criteria rather than a first-come, first-served approach.
authors.affiliation: Division of General Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA. blinas@partners.org
authors.forename: Benjamin P
authors.initials: BP
authors.lastname: Linas
authors.forename: Hui
authors.initials: H
authors.lastname: Zheng
authors.forename: Elena
authors.initials: E
authors.lastname: Losina
authors.forename: Annette
authors.initials: A
authors.lastname: Rockwell
authors.forename: Rochelle P
authors.initials: RP
authors.lastname: Walensky
authors.forename: Kevin
authors.initials: K
authors.lastname: Cranston
authors.forename: Kenneth A
authors.initials: KA
authors.lastname: Freedberg
mesh_terms: D019380:Anti-HIV Agents / Q000627:therapeutic use; D018791:CD4 Lymphocyte Count; D006078:Government Programs; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology; D017320:HIV Protease Inhibitors / Q000627:therapeutic use; D006801:Humans; D011203:Poverty; D040841:Resource Allocation; D014481:United States
chemical_list: D019380:Anti-HIV Agents; D017320:HIV Protease Inhibitors