Improving outcomes in state AIDS drug assistance programs.
BACKGROUND
State AIDS Drug Assistance Programs (ADAPs) provide antiretroviral medications to patients with no access to medications. Resource constraints limit the ability of many ADAPs to meet demand for services.


OBJECTIVE
To determine ADAP eligibility criteria that minimize morbidity and mortality and contain costs.


METHODS
We used Discrete Event Simulation to model the progression of HIV-infected patients and track the utilization of an ADAP. Outcomes included 5-year mortality and incidence of first opportunistic infection or death and time to starting antiretroviral therapy (ART). We compared expected outcomes for 2 policies: (1) first-come first-served (FCFS) eligibility for all with CD4 count <or=350/microL (current standard) and (2) CD4 count prioritized eligibility for those with CD4 counts below a defined threshold.


RESULTS
In the base case, prioritizing patients with CD4 counts <or=250/microL led to lower 5-year mortality than FCFS eligibility (2.77 vs. 3.27 deaths per 1,000 person-months) and to a lower incidence of first opportunistic infection or death (5.55 vs. 6.98 events per 1,000 person-months). CD4-based eligibility reduced the time to starting ART for patients with CD4 counts <or=200/microL. In sensitivity analyses, CD4-based eligibility consistently led to lower morbidity and mortality than FCFS eligibility.


CONCLUSIONS
When resources are limited, programs that provide ART can improve outcomes by prioritizing patients with low CD4 counts.
Linas
Benjamin P
BP
Divisions of General Medicine, Massachusetts General Hospital, Boston, MA 02115, USA. blinas@partners.org
Losina
Elena
E
Rockwell
Annette
A
Walensky
Rochelle P
RP
Cranston
Kevin
K
Freedberg
Kenneth A
KA
D000163:Acquired Immunodeficiency Syndrome / Q000188:drug therapy* / Q000191:economics / Q000276:immunology; D000328:Adult; D019380:Anti-HIV Agents / Q000191:economics / Q000627:therapeutic use; D018791:CD4 Lymphocyte Count; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D017063:Outcome Assessment, Health Care; D011632:Public Assistance; D040841:Resource Allocation; D013221:State Health Plans; D013997:Time Factors; D014481:United States
D019380:Anti-HIV Agents